2.1 Introduction
The Metro Mapping method uses visualizations to create an overview of a care pathway. The metaphor and visual language of the metro (subway) is used to create that overview.
The Metro Net outlines all diagnostic and treatment options for a condition.
The Metro Map is a detailed visualization of a care path within the Metro Net.
The Metro Net and Metro Map are tools to gain insight into existing and future care pathways. They also contribute to the (re)design of care pathways. This module of the manual explains the Metro Net and the Metro Map. Module 3 explains how to create the overviews in Microsoft Visio.
Example Metro Net
This example describes the Metro Net of prostate cancer.
Example Metro Map
This example describes the Metro Map of prostate cancer.
2.1.1 Terms
The following terms are used in this manual:
- Metro Net: a visual overview that outlines all diagnostic and treatment options for a specific condition and their mutual relationship.
- Metro Map: a detailed visualization of a care path within the Metro Net.
- Care path: a collection of sequential diagnostic and treatment phases for a specific condition (based on https://e-p-a.org/care-pathways/).
- Phase: a phase is a part of the care pathway with a specific goal, such as diagnosis or treatment.
- Metro Line: A Metro Line is a combination of a number of successive steps (stations) within a phase. The line and the stations have the colour that matches the type of treatment.
- Station: this is a step in a Metro Line. This can be, for example, a decision moment, consultation, treatment, examination or multi-disciplinary consultation.
2.2 Metro Net
The Metro Net is a visual overview that outlines all diagnostic and treatment options for a specific condition and their mutual relationship.
Creating a Metro Net requires insight into all diagnostic and treatment options for a condition and how they are interrelated, the phases of the care path and the type and stage of the condition. This information is often included in the guideline(s) for a particular condition. The guidelines are therefore a good starting point for a first version of the Metro Net.
The Metro Net is a visualization that uses the following elements:
- Phases
- Diagnostic and treatment options
- Transfer stations
- Connecting lines
Diagnostic and treatment options per phase
The diagnosis and treatment of a condition consists of several phases. In the case of an oncological disorder, after an initial diagnosis, there are curative and palliative treatment options. After treatment, restaging and possibly other treatment options can follow.
The Metro Net shows the diagnostic and treatment options per phase as Metro Lines. Only the transfer stations are shown in the Metro Net. The other stations are not shown in this overview. Connecting lines show how tests and treatments are related.
NB! The phases of the Metro Net are also used in the Metro Map.
Phase names
When naming the phases, consider whether it is clear to users. If one treatment is possible in a phase, this can be the name of the phase; for example: 'Chemotherapy'. If multiple treatments are possible, choose a different name, for example 'Initial treatment'.
Use of colours
Each phase is shown with its own color. When one treatment is possible in a phase, the phase will be given the colour that matches the type of treatment. The Metro Line and the stations in this phase will have the same colour. The name of the stage is listed in the title bar. When multiple treatments are possible in a phase, the title bar gets a different colour than the colours of the Metro Lines. The Metro Lines and stations are coloured according to the type of treatment.
2.3 Metro map
The Metro Map is a detailed visualisation of a specific care path within the Metro Net.
2.3.1 Layers
A Metro Map consists of five layers.
- Layer Experience: in this layer the experiences of patients and relatives with the care path are described.
- Layer Metro: this is a visualisation of the phases, Metro Lines and stations within the care path. This is supplemented by the experiences of care providers.
- Layer Information: this layer records what information is exchanged with the patient and relatives at what time.
- Layer Companions: in this layer the caregivers and their role are described per phase.
- Layer Context: this layer shows where each step takes place and what (medical) devices the patient uses.
The layers are explained in the following chapters.
Metro Map
2.3.2 Columns
The Metro Map has a fixed grid of columns.
The columns provide the connection between the layers of the Metro Map. Within a column, the information in the different layers belongs together.
A fixed width of the columns ensures a clear visual rhythm. This contributes to the clarity of the Metro Map.
Each column has a code. It's at the bottom of the Layer Metro. This makes it easy to refer to a column. The code consists of a combination of letters and numbers. The letters refer to the name of the stage. For example, the phase 'operation' has the following code: OP1, OP2, OP3 etc.
Metro Map columns
2.3.3 Layer Metro
In the Layer Metro, the phases, Metro Lines and steps of the care path are mapped.
It is a visualization based on the metaphor and visual language of the metro (subway).
Phases
The Metro Map is a representation of a care path that consists of several phases.
The phases and use of colour are defined when creating the Metro Net. Copy this into the Metro Map.
Metro Line
In the Layer Metro, the patient's journey is represented by a 'Metro Line'.
The Layer Metro displays the steps a patient encounters. By displaying the care path from the patient's point of view, it is easier to optimize the care path for the patient.
A Metro Line is a combination of a number of successive steps (stations) within a phase. The line and the stations have the colour that matches the type of treatment.
When there are multiple options, the Metro Line splits. See below: "Optional steps in a Metro Line."
Line
The patient's journey is shown with a continuous line.
Split Metro Line
The Metro Line splits when there are multiple options.
Station
A station is a step in the care path and is shown as a circle on the Metro Line.
A station is shown as a circle on the Metro Line with textual explanation. Only the steps relevant to the goal are displayed.
At each station it is stated what is happening and which care providers are involved. A brief explanation can be given below.
Only the steps relevant to the goal of the Metro Map are displayed. Depending on the goal, you can, for example, choose to display the administration of medication, but not to display the ordering, preparation and checking of the medication.
Textual explanation of a step
- What: what happens in this step?
- With whom: who is involved in this step?
- Explanation + possibly enumeration
Treatment step (no consultation)
Consultation with patient (always possible to adjust route)
Consultation with patient and planned shared decision-making moment: choice of patient required
Step without participation or presence of patients (e.g. multi-disciplinary consultation)
Stations and columns
When patients go through several care steps in one day, these are shown in one column.
Patients sometimes go through several care steps in one day, for example when a patient first has a blood test on one day, then has a consultation and then receives chemotherapy. The stations that take place on one day are placed in one column. The stations are placed next to each other in chronological order. The textual explanation is placed below each other.
Multiple care steps in one day
Optionele stappen op een Metrolijn
Not every patient encounters all stations on a Metro Line.
There are three types of optional situations. These are visualized in their own way.
- Choice: two or more treatments are possible, for example surgery or radiotherapy. After the moment of choice, the Metro Line splits into two or more Metro Lines. These run parallel. The patient follows one of these Metro Lines. At the moment shared decision making moment before the split, it is indicated on the basis of which criteria a choice is made.
Splitting of the Metro line into two or more Metro lines
- Exception: a station that does not apply to all patients, only with certain criteria. The text below the station states that this station is optional and what the criteria are for this station.
Optional station
- Skip: Sometimes patients can skip stations, for example when certain exams have already been performed elsewhere. To skip stations, the Metro Line is split and a continuous line is drawn above one or more stations. Then the lines come together again.
Skipping a station
Transfer
During a journey, a patient has to transfer several times to another Metro Line.
An example of a transfer is the transfer from diagnosis to treatment or from chemotherapy to radiotherapy. The patient then often has to deal with other care providers and the patient enters a different environment.
At the end of a phase, the patient is faced with the choice of how to proceed. This may be a subsequent treatment. In addition, not every patient follows the standard route, for example, because metastases have been detected during treatment. Then the patient may make a jump to another Metro Line or to another Metro Map.
The Metro Map provides insight into the transfer options. This is important information because a switch often means a change in the care providers, information or environment involved.
Transfer between phases
Transfer to another station on the care path
Jumps in the care path can be caused by choices made by the patient, the course of the disease, the development of the condition and/or the effects of the treatment. This can be both forward and backward in the care path. It can also be a jump to a different care path. Such transfers are represented by a block on a vertical line. The block contains the number of the column to which the patient switches. The block has the color of the phase to which the patient is switching. A short explanation can be written next to the block.
Repetitions
Some steps are repeated a number of times before continuing on the Metro Line, for example during chemotherapy. This is indicated by a receding line with an arrow.
By displaying a repeat with a symbol, the stations do not have to be displayed several times.
A repeating station or series of stations is shown with a curved left arrow. Below the step, an explanation is given about how often and under what conditions recurrence takes place.
Repeating step
A repeating step is shown with a curved left arrow..
A repeating sequence of steps
A repeating series of actions or moments of care are shown with a line that wraps around the stations and connects to an earlier station on the Metro Line.
Lead time
Lead time provides information about the time between stations or the length of time at a station.
Lead time between stations
Lead times between stations are indicated by a gray line running from station to station. The lead time is indicated in the text.
Lead time at a station
Lead times at a station are described in the explanatory notes, for example a chemotherapy treatment takes 2 hours.
Example of the Layer Metro
2.3.4 Layer Information
The Information Layer records which information is exchanged with the patient and relative and when this is exchanged.
It is important that the patient is well informed throughout the entire care pathway. For example, to understand what a treatment entails or who to contact in case of questions or complications. It is also important to inform a patient in a timely manner about side effects or practical matters, such as the times and locations of appointments or preparations at home. By displaying this directly below the Layer Metro, it becomes clear that a change in the care path, the Layer Metro, also means a change in the information that the patient needs.
The Layer Information contains 3 types of information:
This is information that the patient needs to have an overview of the care path. This can be information about the different phases of the care path, the steps within a phase and the treatment options (as described in the Layer Metro). This may also include information about the healthcare providers involved and who the patient can turn to with questions (as described in the Layer Companions). And may include information about locations and medical devices encountered by the patient (as described in the Layer Context).
This is information that is specific to the individual patient, such as blood test results or (treatment) recommendations. The Metro Map describes in general terms what information the patient receives, for example that the patient receives information regarding the type of cancer and the location where the tumor is located.
These are 'tools' that are important for the patient and loved ones to prepare for the next steps in the care path. These can be decision aids, but also questionnaires in preparation for a consultation.
Example of the Layer Information
Part of the Metro Mapping method is a tool that provides insight into the information needs that patients and relatives may have at the start of a care path and at the start of a phase of the care path. This tool will be made available on this site soon.
2.3.5 Layer Companions
The Layer Companions determine who is responsible for what in the care pathway.
Patients and loved ones deal with many different care providers and functions and sometimes do not know who to turn to for which question.
The following four companions are recorded in the Metro Map:
this is the practitioner who is ultimately responsible for the patient's care
this employee is the first point of contact for patients and relatives with questions about care and health.
this is the employee that the patient can contact regarding the planning of appointments.
this is the care provider that the patient can contact in case of an emergency (also outside office hours).
When a patient transfers to the next Metro Line, for example because the chemotherapy treatment has been completed and the operation follows, the companions often also change. By mapping this out, care providers can plan the transfers together and inform the patient and relatives properly.
In the Layer Information it can be recorded how and when the patient and relative are informed about the companions.
Example of the Layer Companions
Part of the Metro Mapping method is a tool to identify with care providers and patients who are part of the companions. This makes it clearer who has what role and responsibility. This tool will soon be available on this site.
2.3.6 Layer Context
The Layer Context shows where each step takes place and which (medical) devices the patient has to deal with.
For patients and relatives, finding the right location at the right time can be a burdensome, stressful task. This layer shows the location of each station, for example a specific department in the hospital or at home. If the patient can choose the location or whether a treatment takes place at home or in the hospital, this can also be recorded in this layer.
The (medical) devices that the patient has to deal with can lead to confusion. In this layer, it is possible to record for each station which aids a patient will be dealing with, such as an MRI scanner or an IV for chemotherapy.
The Layer Experience describes the experiences of the patient, relatives and care providers with the relevant care path.
Example of the Layer Context
Part of the Metro Mapping method is a tool that provides insight into the information needs that patients and relatives may have at the start of a care path and at the start of a phase of the care path. This tool will be made available on this site soon.
2.3.7 Layer Experience
The Layer Experience describes the experiences of the patient, relatives and care providers with the relevant care path.
Mapping the experiences on the Metro Map provides insight into bottlenecks and opportunities for improvement.
Experiences of patients and relatives are displayed in the Layer Experience, this layer is at the top of the Metro Map.
In the Layer Experience, experiences are represented by:
- Themes: at the beginning of each phase, the themes that are important to patients and relatives in that phase are listed.
- Quotes: quotes and ideas can be displayed per station. With each quote is can be indicated whether it is a positive or negative experience. An ascending triangle represents a positive experience, and a descending triangle represents a negative experience.
Experiences of caregivers are displayed in the Layer Metro at the relevant station. This is shown with a red text frame.
Example of the Layer Experience
