Table 5.

Value exchanges of care pathway model design phase 4.

No.	Involved actors	Transaction content	Value attribute
1	Nurse, Informal caregiver	The nurse phones the informal caregivers to inform them that the patient has returned to the ward. Any questions the informal caregivers have are answered.	Nurse: quality Informal caregiver: reliability
The following transactions are not listed in a strict successive order, but strong dependencies exist.
2	Nurse, Patient	continuous The nurse is the main contact person for the patient and supports him or her at the ward by checking in regularly, asking questions and monitoring the patient's health. In turn the patient provides information to the nurse and both asks and answers questions. This transaction is dynamic and occurs multiple times (blue colour). The nurse handles the discharge of the patient, informs him or her about do's and don'ts and arranges all the needed paperwork at discharge.	Nurse: safety Patient: comfort
3	Nurse, Physiotherapist	The nurse informs the physiotherapist when the patient has returned to the ward. Relevant medical patient data and information about how the patient feels is exchanged to determine when mobilisation of the patient could take place. At a later point in time the physiotherapist informs the nurse regarding progress in mobilisation. Both actors inform each other to track progress and coordinate whether the patient can be safely discharged.	Nurse: quality Physiotherapist: quality, insight
4	Physiotherapist, Patient	(twice) The physiotherapist supports the patient’s mobilisation on two separate occasions, providing advice and reassurance. The patient asks questions and gives feedback on mobilisation. The patient uses a walker for support during the first mobilisation. During the second, the patient uses crutches to meet the functional discharge criteria.	Physiotherapist: satisfaction, safety Patient: mobility, comfort
5	Doctor, Patient	The doctor visits the patient twice after surgery to check progress. The doctor explains how the surgery went and asks the patient how he or she is doing. The patient provides information on how he or she feels and asks any questions he or she still might have. Lastly the doctor reassures and motivates the patient. If the patient meets the functional discharge criteria and both the physiotherapist and nurse agree, the patient is discharged.	Pharmacist: safety Patient: comfort
6	Doctor, Nurse	The doctor asks the nurse how the patient is doing and whether the patient is able to go home. The nurse bases the response on medical data and information about the patient. Finally, the doctor notifies the nurse when patient discharge is approved.	Nurse specialist: quality Patient: comfort, insight
7	Doctor, Physiotherapist	The physiotherapist exchanges information with the doctor, and the doctor asks questions to discuss the state of health of the patient in order to determine whether it is safe to discharge the patient.	Informal caregiver: satisfaction Patient: comfort
8	Informal caregiver, Patient	continuous The informal caregivers are (generally) present at all value exchanges involving patients. They reassure the patient, while the patient provides information to the informal caregivers about the care pathway.	Informal caregiver: satisfaction Patient: comfort
9	Patient information application, Patient	continuous The patient information application informs the patient throughout the entire pathway about his or her journey, preparing the patient for what to expect and when. The patient can ask urgent questions via the application. The date of surgery is scheduled via this application.	Patient information application: quality, efficiency Patient: insight, comfort