How a cardiovascular patient education system can be improved: Introducing 1 a novel model for identifying hospital educational challenges and solutions

1 Background: Cardiovascular diseases (CVDs) have always been considered by healthcare 2 specialists for different reasons, including extensive prevalence, high cost, chronicity, and high risk of 3 death. the recovery from CVDs is highly influenced by the behavior and lifestyle. As a result, it seems 4 necessary to train and develop special abilities for patients and their companions, the development of 5 efficient and effective training systems should be considered by healthcare specialists. 6 Methods: Hence, in this study, an existing training system for cardiovascular patients is reviewed, 7 and using field observation and targeted interviews with hospital experts, all aspects of its training process, 8 including involved components, inputs, outputs, processes and interactions are extracted. Then the process 9 maps of the training system are drawn up through the BPMN (Business Process Model and Notation) 10 methodology. Next, its challenges and difficulties are identified with the aid of semi-structured interviews 11 with experts, and due to the importance and different influence of the identified problems, these challenges 12 are prioritized using the Multi Criteria Decision Making method (MCDM). 13 Results: The most important identified challenges included high nursing workload and shortage of 14 time, lack of understanding of training concepts by patients, lack of attention to training, disruption of 15 training process by the patients’ companions, and patient's weakness in understanding the standard 16 language. In identifying the root causes, learner, educator, and educational tools are the most effective in 17 the training process; therefore, the improvement scenarios were designed accordingly. 18 Conclusions: In the present study, a novel framework for cardiovascular patients' education has been 19 designed and presented based on the analysis of the results of ranking the challenges and their root causes.

Many researchers have attempted to identify the challenges and obstacles in the process of 10 patient education. Some regard these challenges as systematic failures, and others find them related 11 to the patients' personal characteristics and behaviors. For example, age is one of these factors 12 because in their old ages are exposed to variety of health-education problems. Recently, co-13 morbidity has also become more prevalent as aging, makes self-care and patient education 14 increasingly complex [7]. Maloney and Weiss [8] claim that roots of these phenomena are patients' 15 lack of attention when transmitting information, difficulty of confronting the disease, sense of fear, 16 and large amount of information. Due to the importance of education in the treatment and control 17 phases of chronic diseases such as CVDs, it is important that educational processes lead to a series 18 of care and self-care activities that can change the patients' lifestyle in the long run [9]. 19 Abandoning and changing habits like smoking, inappropriate food habits, and lack of sufficient 20 exercise that have become a part of patients' behaviors and lifestyle in the long term, are very 21 challenging. Dickson and Riegel [10] showed that doctors' recommendations for continuous 22 jugging or participation in sports clubs seem strange and illogical to most of cardiovascular 1 patients, who had no regular exercise program before. 2 On the other hand, according to Riegel and Carlson [11] and Dickson and Riegel [10], 3 misconception and lack of awareness among cardiovascular patients are very common. Dickson 4 remarked that many scholars believe that a significant number of patients consider sport as 5 something harmful and forbidden for their health. But education is a necessary response to this 6 lack of knowledge and awareness in patients. Health literacy is recognized as a factor, which is 7 very effective in patients' ability of understanding and using health information and guidelines. 8 The Institute of Medicine Committee on Health Literacy has stated that patients with inadequate 9 health literacy have less partnership in decision making and low adherence to their doctors' 10 treatment plan.

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Physicians play a very influential role in the education process of their patients. However, 12 challenges such as lack of enough time and fear of risking on the doctor-patient relationship 13 prevent them from developing patient education processes [12]. Arian  In previous studies, there were shortcomings such as the lack of a complete and 4 comprehensive categorization of the challenges of patient education and engagement, and 5 evaluating their effectiveness on the education process. In addition, researchers that have 6 addressed the root causes of these challenges, just have provided solutions for improving the 7 education system and paid less attention to the root causes in the overall system. The challenges 8 of patient education identified in previous researches, are illustrated in Table 1. Every challenge 9 is marked with a code from CH1 to CH29 (CH is abbreviation of "Challenge"). Also, the Table 1 10 shows supporting evidence (citations) for all challenges.

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It seems that comprehensive identification and prioritization of the process of educating 12 cardiovascular patients and engaging them, as well as presenting a new framework and the 13 approach to improve the education process are the very topics that have not received enough 14 attention in the past researches. Different research works have been done to identify, prioritize and 15 then analyze the challenges of patient education process in various health care systems; however, 16 no similar study has been conducted in terms of prioritization, addressing the root causes, and also 17 performing simultaneously the four actions of identifying challenges, prioritizing them, rooting 18 them out, and providing a comprehensive framework to improve the implementation of educating 19 cardiovascular patients.  A misconception or lack of awareness (CH4) [10,11] Difficulty of changing lifestyle (CH5) [10,11] Patients' lack of understanding about the severity and of the disease Difficulty in memorizing information (CH7) [8] Confusion because of conflicting information (CH8) [10] Difficulties in facing the disease (CH9) [8,11] Age-related cognitive disorder (CH10) [11] Lack of patients' cooperation (CH11) [11,13] Patients' general unfavorable status (CH12) [8,13] Medical personnel related Lack of personnel's time and long duration of education classes (CH13) [7,12,13] Lack of nurses' awareness about patient education principles (CH14) [13] Risk of weakening patient-doctor relationship (CH15) [12] Society-related challenges Different culture and language (CH16) [7] Old papulation (CH17) [7] Limited health literacy (CH18) [3] Comorbidity outbreak (CH19) [7] System-related Health centers focus on their own desired content (not patients' needs) (CH25) [8,13] Lack of recognition the patients' educational needs (CH26) [13] Lack of nursing human resources (CH27) [13] Lack of written educational sources (CH28) [13] Lack of funding for patient education (CH29) [13] In addition, there are several methods for prioritizing the challenges. However, in previous 1 researches in this area, just the questionnaire tool has been used to survey and rank the experts' 2 opinions. To deal with this problem, the present research uses one of the multi-criteria decision-3 making methods for prioritizing challenges after identifying them. Obviously, the identified 4 challenges must be prioritized because there are too many of them, and they have various 5 backgrounds. Furthermore, not all challenges are important equally, and not all of them have equal 6 impact on the education system, so their importance must be prioritized. Therefore, to identify the 7 most important challenges and provide improvement scenarios of the education system, 8 prioritization must be performed.

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In industrial engineering, studying the process of patient education falls into qualitative  It is noteworthy that this applied research has been done by studying a particular case. The 16 implementation steps of this research have been designed based on a structured, step-by-step 17 problem-solving system to answer the following research questions:

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The methodology used in the present research is based on a problem solving structured step-by- 12 step system that has been a generalization of the business process management method presented  In the first stage, the required data were collected through the hospital documentation, field 3 observation, and interviewing the hospital experts about the education process of cardiovascular 4 patients. In other words, it is directly focusing on the subject and field observation, questions and 5 answers, and interviewing experts to identify the challenges of education process and engaging the 6 cardiovascular patients. In this phase, we employed the BPMN standards and cross-functional 7 chart to document the education process [14]. 8 In the second stage, the challenges of the patients' education system were extracted and 9 classified through semi-structured in-depth interviews [15] with experts at the hospital under study 10 and then coded by the researchers.

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Prioritizing the identified challenges is important because there are too many challenges with 12 varying degrees of importance in this process. As a result, in the third stage, prioritizing the 13 challenges of patient education system was performed using the PROMETHEE method. 14 In the fourth stage, for the top ten prioritized challenges, the root causes analysis was 1 performed to detect their root causes by the hospital experts, and then improvement scenarios for 2 the education system based on them were suggested.

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In the final step, focusing on the challenges affecting the education system and the outcome 4 of the root cause analysis, a novel framework for improving the education processes was proposed 5 with the help of the hospital experts. In recent decades, more precise comparing and choosing options, analyzing the effective 8 qualitative and quantitative attributes, and investigating their mutual effects have been provided 9 by the access to computing equipment and decision-making methods. In MCDM methods, several 10 criteria are used instead of one optimality evaluation criterion. We chose the PROMETHEE II 11 method for prioritizing the challenges due to the type of item scoring, lack of need for paired 12 comparison, simple scoring and powerful ranking mechanism, as well as too many challenges of 13 this case study. PROMETHEE decision support method is one of the multi-attribute decision 14 support techniques that uses two terms of 'performance' and 'indifference' to look for the best 15 option among many other options. Figure 2 [16] illustrates the steps of implementing this method. 16 Briefly, it can be expressed that PROMETHEE includes three main steps:    In the PROMETHEE II used in this research, there is another more step, called the absolute 3 superiority calculation (the pure flow of external priority, step 4). It is to be noted that in each of 4 proposed preference functions in step1, one or two parameters must be defined (p and/or q) in 5 which q is the threshold of indifference and p is the threshold of excellence. The indifference 6 threshold is the biggest difference that is negligible in decision making, while the excellence 7 threshold is the smallest difference that is sufficient to allocate perfect advantages between two 8 options. The total score of each option (net outranking flow) is shown with Փ. In this research, the V-1 shape function with indifference area (Figure 3) was selected for the preference function of step 2 1. Amount of p and q was determined with the help of a MCDM expert. In the following, the executive stages of the proposed approach and the obtained results are 6 presented.  10 In the first stage, we employed the BPMN standards and cross-functional charts to identify 11 and document the current situation of the education processes of cardiovascular patients (the as-is 12 processes) at the hospital under study. BPMN is one of the most complete languages of modeling 13 the business processes; for this reason, this symbolic modeling language was used for documenting 14 the education processes in the current study.

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In the hospital under study, there are three main processes of education in the inpatient ward, 16 surgical inpatient ward, and angiography. They include a lot of sub-processes that some of which are not necessarily in the same ward and might be performed by different persons in different 1 stages of patient flow in the hospital.

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In the present study, a big challenge in presenting the maps of the processes to their owners 3 was the lack of familiarity with the BPMN standards. In this regard, cross-functional charts were 4 used to simplify the process maps. These charts incorporate all information of the processes 5 including activities, events, and flow sequences. Hence, the cross-functional charts of the 6 processes of the three educational groups (angiography, surgical inpatient ward, and inpatient  are asked similar questions about the subject under study, but they are free to provide their answers 16 in any way they wish. In this interview, the researcher is responsible for coding and classifying the 17 answers.

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The experts were asked to express the obstacles and challenges of educating and engaging

E13
The nurse emphasizes the clinical practices more than education.

HR19
The patients, who do not attend the educational classes due to their specific conditions or period of the treatment will lose group education.

M6
Oral education is not presented by the medical team during the discharge.

HR20
There is no rule for disambiguation and pre-procedure education for noninvasive procedures..

M7
In the surgery department, there is less bedside educational communication between the surgeon or her/his assistants and patient.

HR21
The focus of the evaluation system is more on writing reports and literature than on clinical practice and communication between nurses and patients.

M8
The experience & educational skills of doctors are different and, in some cases, inadequate .

HR22
There is no sufficient plans for the patients' other diseases.

M9
Being too busy, the doctor cannot allocate enough time to talk with the patient.

HR23
The education of preventing frequent disorders in ICU is not sufficiently considered. Figure 4 shows the challenges identified in the hospital under study for cardiovascular 1 patients. As indicated they have been grouped into three main categories and several sub-2 categories after interviewing the hospital experts. In fact, the categorization given in Figure 4 3 reveals which of the challenges extracted from interviewing the experts falls into which of the 4 categories in Table 1. After identifying the challenges, their prioritization is important because there are too many 3 challenges with varying degrees of importance, so considering them as equal is irrational. As a 4 result, in the next step, prioritizing the challenges of patient education process is done. several factors involved in the education process were simultaneously considered, and making use 12 of different mathematical relationships, their total impact on the options was determined. Thus, a 13 collection of criteria involved in the education process were extracted from the previous articles. 1 Next, asking the hospital experts, some extracted criteria were removed, and some were modified 2 and adjusted to be tangible to the hospital scores.

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For instance, in Table 3, the first criterion (patient knowledge) and the second criterion 4 (patient's attitude and belief) were derived from Boyde et al [6]. The third, the fourth and fifth 5 criteria were determined based on the hospital experts' opinion. Eventually, the experts' points of 6 view on these five criteria were aggregated, and using the five final criteria presented in Table 3, 7 the challenges were prioritized with the help of the PROMETHEE II method. In this MCDM method, to obtain the decision matrix points, scoring forms were filled-out 10 with the aid of 17 hospital experts and 15 patients from the same hospital. The experts included 11 20 nurses and doctors working in different internal and surgical departments with at least six months 1 of experience in that ward who were interested in participating in this study. They included three 2 general practitioners, one quality manager, seven head nurses, and six nurses.

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After extracting information from the collected forms, the decision matrix was created, and 4 for simplicity, the weight of all criteria was assumed to be the same (w=0.2). Due to the large 5 content of the decision-making matrix and computational complexity, they were discarded. Then, 6 using the decision-making matrix and the weight of criteria, the PROMETHEE II method was 7 applied according to the V function (as mentioned in section 2.3, this research uses V-shape 8 function with indifference area), indifference threshold (q=5), and absolute excellence (p=1.5).

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It is to be noted that MATLAB software was used to code and prioritize the challenges. The 10 values of Փ and the ranking of the challenges are presented in Table 4. The first five items of 11 prioritizing the challenges were as follows: 12 1. The nurse is too busy to allocate enough time to educational affairs.       Table 4, among the top 10 challenges, most challenges are related to human 3 recourses (80%), and in this group, the biggest proportion goes to patients (50% of the whole 4 challenges). After that, nurse-related challenges are the second human factor with a share of 20%.

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The environment and condition group, having two options in the 8th and 9th ranks, is the second  After clarifying the priority of the challenges of educating cardiovascular patients and 5 selecting top ten challenges, it is necessary to detect their root causes by hospital experts to be able 6 to suggest improvement scenarios for the education system.

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To accomplish this step, after selecting ten risky challenges out of the prioritization operation, separate in-depth semi-structured interview sessions were held in the hospital's meeting room to 10 discuss and identify the root causes of these challenges.

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The experts participating in this phase included 8 nurses, 3 physicians, and 1 hospital manager. 12 In the interviews, each interviewee was asked two basic questions about each challenge:

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• What are the reasons for these challenges (depending on their area of expertise)?

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• Which actor in the education system is the main cause of each challenge?

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The interviews were conducted separately in the meeting. Then all answers to the above 16 questions were collected and then coded. Similar responses were assigned the same codes. Then, 17 for each challenge, with the help of content analysis, ten cause-and-effect diagrams (Ishikawa 18 diagram) were drawn. Finally, these diagrams were verified by all the interviewees, and corrective

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• Root causes related to educational tools, including lack of simplicity, diversity and 12 attractiveness, inaccessibility, and lack of interactive multimedia tools.

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Examining the challenges and their root causes shows that in the challenges that the patient is 14 the main factor, other factors are effective as well. Many patients refuse education, but it is clear 15 that the causes of disorders related to patients are largely out of their control. Accordingly, it seems 16 that solving any of these challenges alone would not be sufficient and effective to improve the 17 whole system. On the other hand, implementation of some improvement suggestions may affect 18 other conditions due to the complex causal relationship, which makes it necessary to develop a 19 more general framework. As shown in Figure 6, while providing improvement solutions, these 20 factors (educator, learner and educational tools) need to be taken into account interactively.

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Consequently, in this research, it is tried to provide a suitable and practical framework by 22 combining different prioritization based ideas by considering the condition of the studying system 1 and the existing facts. Accordingly, and based on five top challenges analyses (root causes), a set of improvement 5 suggestions for these challenges were presented. For the first challenge (HR13) in which "heavy 6 nursing workload" prevents allocating enough time to patient education, employing new experts 7 and experienced personnel called "tutors" was suggested; they can follow and evaluate both 8 learners and educators. In this way, the nursing workload will be reduced, and together with the 9 routine and implicit training done through patients-staff conversations, the education classes will 10 be managed by the tutor in appropriate manner and on time. In addition, according to the root 11 causes of the second and third challenges (HR2 & HR1), which refer to their inability in 12 understanding the education content, a few shared solutions were presented as follows: 13  Designing and implementing in-service training to promote organizational culture, 14 expression skills, and effective communication.  Finally, for the fifth challenge (HR5) that again refers the patient's weakness in understanding 11 the standard language, the suggestion is that the presence of a companion should be mandatory for 12 these patients, or a person who understands the patient's language completely (translator) should 13 be quickly called. Nurses should also be advised during the in-service training courses to speak 14 slowly and fluently with the patients.

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In the present study, a framework for cardiovascular patients' education and engagement has 21 been designed and presented based on analysis of the results of ranking the challenges and their 22 root causes. The framework consists of five steps, which are shown by A-E Latin letters in Figure   23 7. In these steps, the effort has been made to cover completely the process of receiving educational 1 services by cardiovascular patients. Solutions are also given for the overwhelming challenges of 2 this process, which were recognized as important in the prioritization operation. At first, the patient 3 enters the department and experiences the first encounter with the nurses. As mentioned, in human Meanwhile, the tutor will pay due attention to the patients with special conditions and will focus 7 on their education according to the nurses' primary screening list. tools. In some studies of this area, due to the lack of such preliminary studies, utilization and 21 adherence of the tools suggested for improving the system may decrease over time due to a lack 22 of proper understanding of system challenges. In addition, using this framework, hospitals can 23 continuously be informed of the bottlenecks of their education system and also significantly raise 1 their awareness about the as-is processes to support the educational system improvement.
2 Furthermore, the applicability of this framework is one of its greatest advantages over others. In As shown in Figure 5, the first challenge refers to the nurses' lack of time, which the lack of 6 enough personnel, and inefficient methods are its root causes. In this regard, two solutions are 7 presented: 1) grouping education and dividing the various education points that should be 8 presented by the nurses between different intervals, for modifying inefficient methods and 2) 9 introducing a new educational assistant named tutor who has enough expertise and experience in 10 education; this will eliminate the cost of hiring a new nurse. Therefore, it can be seen that with the 11 arrival of a low-cost assistant we can solve this challenge. 12 On the other hand, the second, third, and fifth challenges point to the patient's understanding, 13 his/her ability to communicate with the educator, and follow the education respectively. The methods' represents nowadays a rapidly developing field of health science methodology. 12 In other words, we have used this valuable capability to create a framework for cardiovascular 13 patients' education system and maximize improvement in the educational processes of chronic 14 patients. In practice, most researchers agree that "mixed-methods" produces a richer and more would be valuable if we could also try it out in the educational system of some other hospitals, so 1 that the proposed frameworks could be compared, and finally, generalized. Especially one of the 2 areas that can differ is the solutions for improvement in different hospitals. Some of the solutions 3 suggested in this framework might seem impossible to be fulfilled in other hospitals, but these can 4 be customized and adapted to a specific hospital's atmosphere. In this study, a framework for improving cardiovascular patients' education processes and 7 their engagement was presented. Initially, the education processes were identified through a case 8 study in Tehran Heart Center and drawn up based on the BPMN standard. Next the challenges of 9 the education system were extracted through semi-structured interviews with the process owners 10 and then classified in the form of a taxonomy. In the next step, the challenges were prioritized 11 using the PROMETHEE method, and based upon the criteria identified in the research literature. 12 Then their root causes were explored using cause-effect charts. Finally, the framework was 13 proposed to improve the top 10 challenges and evaluated with the help of hospital experts.  In future research, the scenario of adding new workforces (both nursing and non-nursing) can 20 be simulated and the results can be compared. It is also possible to do process-mining, and 21 determine the possible causes of the disorders by focusing on more detailed components of the 1 education process.

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As the processes that are drawn up using the BPMN standard are easily understandable for 3 process designers and developers, they can be the basis for powerful IT activities in health-related 4 areas. From another perspective, the challenges can be considered using a fuzzy cognitive 5 mapping, an effective method in modeling decision-making problems that can model the elements 6 and factors of decision and provide an opportunity to discover the relative power and direction of 7 relationships using algebraic operators.