Learning Objectives Use shadowing to define value and what patients - - PDF document

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Learning Objectives Use shadowing to define value and what patients - - PDF document

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IHI National Forum: Go Shadow 12/10/2013 D17 & E17 This presenter has nothing to disclose Go Shadow: See Patients Wants and Needs While Lowering Cost Anthony M. DiGioia III, M.D. December 11, 2013 9:30am-10:45am 11:15am-12:30pm

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IHI National Forum: Go Shadow 12/10/2013 1

D17 & E17

This presenter has nothing to disclose

Go Shadow: See Patients’ Wants and Needs While Lowering Cost

Anthony M. DiGioia III, M.D.

www.pfcc.org/IHIGoShadow

December 11, 2013

9:30am-10:45am 11:15am-12:30pm

Learning Objectives

Use shadowing to define value and what patients want and need while engaging them in the redesign of care delivery Shadowing is the standardized, simple tool to improve care experiences and

  • utcomes, remove waste, and decrease

cost Establish the connection with patients that generates urgency to change

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Value = Health Outcomes

Value in Health Care

Cost

We All Define Value Differently

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The Patient and Family are the

  • nly way for all of us to

understand and deliver value…

3 Keys to Delivering Value

  • 1. View All Care

Through the Eyes

  • f Patients and

Families

  • 2. Co-Design
  • 3. Implementation
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  • 1. Define Care Experience
  • 2. Guiding Council
  • 3. Shadow, Current State, Urgency
  • 4. Working Group thru Touchpoints
  • 5. Shared Vision of the Ideal
  • 6. PFCC Project Teams

to Close the Gap

The PFCC Methodology and Practice Provides the Steps to Success

Ideal Experience Current State

More Info: www.pfcc.org

Value and Care Experience

  • Defined through the eyes of patients and

families and includes everything that impacts their journey toward wellness.

  • Examples include outcomes,

interactions with and among care providers, transitions in care, safety, costs, and everyone they are impacted by along the way.

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  • 1. Define Care Experience
  • 2. Guiding Council
  • 3. Shadow, Current State, Urgency
  • 4. Working Group thru Touchpoints
  • 5. Shared Vision of the Ideal
  • 6. PFCC Project Teams

to Close the Gap

Shadowing

Ideal Experience Current State

Shadowing

Shadowing is repeated and independent

  • bservation of patients and

families as they move through each step of their health care journey

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It’s Easy

We watch what people do (and do not do) and listen to what they say (and do not say). The easiest thing about the search for insight – in contrast to the search for hard data – is that it’s everywhere and it’s free… …This enlightened perception reveals the experience, not just the process. Change by Design, Tim Brown

Shadowing

Determines Your Current State Accurately and Efficiently Continuously Engages End Users in Real Time: Patients, Families and Care Givers (called Co-Design)

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Clinical Outcomes, Quality and Safety True $ Cost $ Patient Reported Outcomes and SDM Patient and Family at the Center

Value and Accountable Care

Care Experiences

True Costs = TDABC Time Driven Activity Based Costing

Robert S. Kaplan and Michael E. Porter “How to Solve the Cost Crisis in Health Care,” HBR 2011

Identifies true cost to deliver care and for any care experience:

  • Personnel
  • Space
  • Equipment
  • Consumables
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The Value “Chain”

TDABC Results TJR Care Experience 30 Days Prior to 90 Days Post-Op

Total Hip Replacement Total Knee Replacement Consumables 54% 45% Personnel 43% 51% Space/Equipme nt 3% 4%

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Ma p #

Care Segment

THR Total TKR Total 1 New Patient Scheduling Visit 0.1% 0.2% 1a Pre-Surgical Office Visit (30 days pre surgery) 2% 3% 1b Renaissance Billing 0.3% 0.3% 1c Administration Support - Surgery 3% 4% 2 Pre-Op Testing 2% 2% 3 Day of Surgery 3% 3% 3a Operating Room 57% 48% 3b Central Sterile 0.6% 1% 4 PACU 2.6% 3% 5a Inpatient Post-Op Day Zero 4.5% 5% 5b Inpatient Post-Op Day 1 6.9% 8% 5c Inpatient Post-Op Day 2 5.9% 7% 5d Inpatient Post-Op Day 3 3.5% 5% 6 Home Therapy & 4 week Follow-Up 5.2% 6% 7 3 Month Follow-Up (90 days Post-Op) 2.6% 3%

PFCC Shadowing TDABC Helps Providers

Process Improvement Personnel and Resource Utilization

  • Redesign processes
  • Eliminates steps
  • Reduce waste and idle time
  • Optimize cycle of care
  • Who should be doing the

work? Where?

  • Reduce unused staff time,

equipment, facilities

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PFCC Shadowing TDABC A Common Platform

  • Generate conversations between clinical,

administrative and financial leaders

You can develop:

  • Bundling, RBP
  • PCMH’s
  • ACO’s
  • “Care Experience”

Based Homes

PFCC Shadowing TDABC is the “How To”

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If Any Doubts…Go Shadow

  • Engages patients and

families as full partners in care delivery redesign

  • Opens eyes and creates

urgency to drive change

Lisa L. Schraeder, MS

  • Sr. OD Consultant

PFCC Innovation Center of UPMC

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Ready…Set…Go Shadow

Start here …

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  • Gloss

ssary y of Terms ms

  • How

w to Shadow w a Patient t and Fami mily

  • Shadowi

wing Preparati tion Checklist st

  • Requesti

ting to Shadow a Pati tient

  • What

t to Obse serve and Note te While Shadowi wing

  • Obse

servati tion Temp mplate te

  • Samp

amples es Obs bser ervati tion

  • nal Repo

port

  • Care Experi

rience Flow w Map

  • Samp

mple Time me Stud tudy

  • Samp

mple Final Shadowi wing Report

  • Shadowing FAQ’s
  • Shadowi

wing Thank You Card

Shadowing ing Resour

  • urces

ces

Care Giver Touchpoints

Key moments and places within the care setting where patient and family care experiences occur. Any person within a care setting whose work touches a patient’s or family’s experience whether directly or indirectly.

Some Terminology…

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‘Go Shadow’ 101:

The Before, During and After

What to Know Before You Go

 Not a Secret Shopper  Beginning and End  # of Shadowers  Map CURRENT flow  How to approach

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Cynthia Rasmussen, MD

Harvard Vanguard Medical Associates

Overcoming Hurdles

“We started Shadowing a year ago… Our challenge was cold calling patients over the phone to ask them about Shadowing but once we got

  • ver that, we found Shadowing to

be extremely powerful and got so much feedback.” Shadowing ing Resour

  • urces

ces

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FAQ:

Won’t Care Givers change their behavior if they know they are being Shadowed?

Do you view care differently now?

“I have gained a completely new perspective for how hard each of my colleagues work--their tireless dedication is awe-inspiring. I have become a better listener, more empathetic, and look for

  • pportunities to connect people,

processes, and ideas for improvement.”

Pat Fustich

Administrative Assistant Pediatric Surgery

A Care Giver’s Perspective

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During Shadowing: In the Field

Note:

 Care Givers  Touchpoints  Time  Patient Comments  Your Observations  Anxiety Anxiety  Action

After Shadowing: Sharing Findings

 Care Experience Flow Map  Report in Order of Experience  Tell the Story  Type of Report

  • Detail
  • Summary
  • Time Study

 Include Recommendations

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After Shadowing: Sharing Findings

 Tell the Patient’s Story  Report in Order of

Experience

 Share Observations &

Recommendations

 Include Care Experience Flow Map

Care Experience Flow Map

  • Transitions in care issues
  • Communication gaps
  • Bottlenecks
  • Inefficiencies in process
  • Amount of time spent

What it will reveal…

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Touchpoint Care Giver/Time

Parking Lot Reception Desk Exam Room Lab Patient/Family park car trouble finding right garage 7:15 A Checked in with front desk receptionist 7:28 - 7:35 A Assessment by physician assistant and doctor 9:15-9:30 Patient /Family sent to desk to get Rx for lab work 9:37 A Patient/Family stop at parking window to pay for parking; cashier 10:42 A lab technician performs blood draw 10:14 A Patient/Family exit garage after finding car 11:02 A Get lost on way to lab; no clear signage; Shadower intervenes and assists them with wayfinding 9:49 A Hallway Parking Pay Window Patient /Family back to desk to check out from appointment 10:26 A Doctor's Office Suite Entrance to clinic 7:27 A Waiting Room 60 minute wait ; called back by medical assistant, 8:35 A

Sample: Office Visit Care Experience Flow Map

Touchpoints:

Parking Lot

  • Clinic Suite
  • Reception Desk
  • Waiting Room
  • Exam Room

Reception Desk Main Hallway Lab Clinic Suite/Desk Pay Station Parking Lot

Sample Care Experience Flow Map

Care Givers:

  • Parking Attendant
  • Housekeeper
  • Registrar
  • Medical Assistant
  • Nurse
  • Physician Asst./Dr.
  • Greeter
  • Phlebotomist
  • Lab Tech
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Touchpoints:

  • Parking Lot
  • Clinic Suite
  • Reception Desk
  • Waiting Room
  • Exam Room
  • Reception Desk
  • Main Hallway
  • Lab
  • Clinic Suite/Desk
  • Pay Station
  • Parking Lot

Sample Care Experience Flow Map

Care Givers:

  • Parking Attendant
  • Housekeeper
  • Registrar
  • Medical Assistant
  • Nurse
  • Physician Asst./Dr.
  • Greeter
  • Phlebotomist
  • Lab Tech

Touchpoint Care Giver/Time

Parking Lot Reception Desk Exam Room Lab Patient/Family park car trouble finding right garage 7:15 A Checked in with front desk receptionist 7:28 - 7:35 A Assessment by physician assistant and doctor 9:15-9:30 Patient /Family sent to desk to get Rx for lab work 9:37 A Patient/Family stop at parking window to pay for parking; cashier 10:42 A lab technician performs blood draw 10:14 A Patient/Family exit garage after finding car 11:02 A Get lost on way to lab; no clear signage; Shadower intervenes and assists them with wayfinding 9:49 A Hallway Parking Pay Window Patient /Family back to desk to check out from appointment 10:26 A Doctor's Office Suite Entrance to clinic 7:27 A Waiting Room 60 minute wait ; called back by medical assistant, 8:35 A

Sample: Office Visit Care Experience Flow Map

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PFCC Shadowing Field Journal

Your turn! Your on the go resource for Shadowing Available online www.pfcc.org

The “Don’t Quit Your Day Job Players” production of…

Jenny’s Jarring ring Jour urne ney

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The Scene of the Accident ED Waiting Area

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Patient Room Inpatient Room, Day of Discharge

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Creating Your Shadowing Report

What to Include

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  • Review the raw notes captured in your

journal

  • Report, in the order in which the patient

and family moved through the Care Experience, the events, timing, Care Givers, and Touchpoints they encounter

  • Tell the patient’s story
  • Include your Care Experience Flow Map

Writing and Presenting Reports

Writing and Presenting Reports

Offer suggestions made by patient and family Include your own observations and recommendations Deliver tactfully and include positive

  • bservations

Remember to note any anxiety as that could become a priority project Pictures are worth a thousand words

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1,000 Words

Care Experience: Date: Shadower: Request:

Shadowing Summary Report

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Care Experience: ED Care Experience Date: December 11th, 2013 Shadower: Me-Myself Andi Request: To Shadow an ED patient from Arrival thru Discharge

Shadowing Summary Report

Patient and Family Bio

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Patient and Family Bio

“Jodi” High School Cheerleader Arrived alone Unsure of what has happened Frightened Concerned mom anxious to see her

ED Care Experience Flow Map

Touchpoints:

  • Care Givers:
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ED Care Experience Flow Map

Touchpoints:

  • Ambulance
  • (Waiting Area)
  • Exam Room
  • Hospital Room

Care Givers:

  • EMT/Command
  • Ctr. Dr.
  • Registrar
  • Nurse

ED Care Experience Flow Map

Touchpoints:

  • Ambulance
  • Triage
  • (Waiting Area)
  • Testing
  • Exam Room
  • Transport
  • Hospital Room

Care Givers:

  • EMT, Radio Doc
  • Physician, Nurse
  • Registrar
  • Technologist
  • Radiologist
  • Orthopaedist
  • Neurologist
  • Transporter
  • Housekeeper
  • Dietary
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Accident Scene/Transport Accident Scene/Transport

“Jodi” sustained threatening fall Paramedics reported to scene to stabilize her Paramedic gave update enroute to receiving hospital Patient sounded frightened; asked questions which were eventually answered Patient traveling unaccompanied

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Waiting Area

Registrar performed as per policy re HIPPA and visitor identification Lack of expressed empathy for mom’s situation Spoke about operational challenges

– “There’s no one here to cover for me.”

Did not proactively unite family member with patient Reunion took 3 hours to happen

Waiting Area

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Exam Room Exam Room

Nurse

– Compliments patient on getting through testing – Tells patient mom would be there soon – Uses medical jargon (anxiety) – Makes comment about cheerleaders needing

helmets

– Hand hygiene – Acknowledges neck braces

are uncomfortable

  • 3 hour wait for patient/family

reunion

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Testing

Jodi needed multiple tests; we did not see each one Clinical jargon used to describe tests Sounded like physician couldn’t be reached to clear cervical spine collar Could radiologist clear?

Testing

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Inpatient Room: Day of Discharge

Mom and Jodi heard conflicting reports from ortho and neuro about recovery time Large packet of info given to mom; not reviewed Could not go home with medication because pharmacy was closed; nurse offered list of local pharmacies

Discharge

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Opportunities/Suggestions Opportunities/Suggestions

Clearer handoffs b/w Care Givers

– B/W Attending and Radiologist – Conflicting reports b/w Ortho and Neuro (same patient)

Patient/Family Reunion protocol needs clarification Could radiologist read scan to expedite removal of collar? Possibility of weekend pharmacy hours or starter dose medications Reduce jargon to reduce anxiety Continue but enhance educational materials re: concussion Establish comforting environment and responses to concerned family members

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Impact Projects

Real World Results from Shadowing

Cervical Spine Clearance

Process Change 24/7 Attending

  • Decreased time

from admission to clearance of the c-spine with collar removal

  • Previous attempts to

address issue

  • Results showed 50%

decrease compared to 2007 and a 70% decrease by 2009

Hours

Average Time Spent in Collar

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Impact of Shadowing: Going Home with Meds in Hand

  • Increased

compliance

  • Reducing

readmission rates

  • Improving health
  • Improve Safety
  • Satisfaction
  • Reduce Re-Admission Rates

Impact of Shadowing: Medication Card

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Impact of Shadowing: Private “Roomer”

Shadowing shed light on rumor of “private room” Care Givers would still be puzzled

  • therwise

Shadowing...

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Shadowing…

Engages Care Givers in designing improvement

Shadowing…

Is a means of partnering with patients and families in the co-design of those improvements

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Shadowing…

Is a terrific onboarding tool

Shadowing…

Highlights inefficiencies and waste

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Shadowing…

Can be used as a measurement tool

Shadowing…

Can be used as a means of time study

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Remember…pfcc.org

~ Free Webinars ~

GoShadow.org

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Thank You

Q & A