Anthony M. DiGioia III, M.D. November 9, 2011 Yes we can! Transforming patient and staff experiences: A view from the frontline

We are not delivering the basics in a very complex system We must focus on providing a full cycle of care Real value? Transitions of care and communications Why change? Just ask our patients and families

No industry has survived without focusing on the needs, wants and desires of their end users... in health care? Lost along the way… We must begin to listen to our patients and families (and Care Givers) as our end users…and actually engage all in the design of new approaches Word of warning on the current state…

If you ran this hospital…where would you start and what would you do?

You could develop the system to deliver better outcomes, safety, quality, reduce waste and develop high performance teams while delivering great care experiences for patients and their families… Would you be interested if…

Design Science Clinical Process The new third pillar for health care Experience-Based Design: From Redesigning the System Around the Patient to Co-Designing Services with the Patient by Bate and Robert, Quality Safety Health Care 2006;15:

The first two sciences Clinical and Process Evidence-based medicine Clinical pathways Re-engineering, process improvement, Lean, TPS, CMI Quality and safety efforts

What are the Design Sciences and Experience-Based Design ? Designing services, interactions, processes and environments for the complete experience Making it better for the end user Expanding on but not replacing the concept of clinical sciences and process Provides tools for first understanding and then acting Strength: Implementation

Sciences of the Artificial By Dr. Herb Simon Natural Science Study of a Forest Study of the Human Body Design Science Farming Health Care Delivery

What does Experience-Based Design teach us in health care? We should never just try to be a “service line” because the value is that we stage experiences and we guide transformations for our patients and their families.

When the patient is partner With transformations patients are engaged and changed Forces us to look at the whole experience i.e. full cycle of care Nothing is more important than the knowledge required to transform care and comes from “co-design”

PFCC and EBD: The updated model for care delivery

The three keys to success

View all care as an experience and through the eyes of patients and their families Key #1

Key #2: Co-Design with patients and families (and care givers) engagement to partnerships Giving information Listening and responding Consulting and advising.. Complaining Experience Based Co-Design (Adapted from Bate and Robert Quality Safety Health Care 2006;15: )

Most efforts were successful because they focused on the patient and family care experience…but can’t explicitly explain how they got there…“no methodology” Will solutions from one region work somewhere else and isn’t everyone starting at a different current state? The difficulty is to teach others how to get there and to have widespread and rapid adoption… Key #3: There are individual success stories but how can we all get there?

Current state Ideal experience Simple solutions in a complex system Key #3: Implementation - Methodology - Co-Design - Overcome hurdles

The way to get started “PFCC…amazingly simple. Simply amazing.” An Experienced Based Design for health care: Patient and family centered care methodology and practice (PFCC M/P)

The PFCC methodology and practice is our new system for health care Singular goal to provide exceptional care experiences for patients and their families Which also delivers better outcomes and quality, safety and reduces waste Re-focus existing resources…not new ones You will identify, solve and implement the solutions with the help of patients and families

Process improvement = manage objects or things Performance improvement = people AND processes Performance is the engine to Change the Culture PFCC M/P is all about performance

Care giver PFCC Methodology and Practice Any person within a care setting whose work touches a patient’s or family’s experience. Touchpoints Key moments and places in any care setting where patient and family care experiences are directly or indirectly affected by any care giver.

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams Six steps to transform care

Inpatient example of step 1 Transplant Inpatient care experience Begins: When the patient receives a call that they may have a donor Ends: When the patient is transferred to critical care

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams

Step 2 real world example: Transplant PFCC Guiding Council Administrative Champion = Program Administrator, Transplant Services Clinical Champion = Clinical Director, Transplant and Dialysis Services PFCC Coordinator = Data Quality Reviewer, United Network for Organ Sharing

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams

27 Touchpoints & Care Givers Exam Room Transport Ultrasound Transport Patient is called back to exam room by CRNP who orders an ultrasound and begins admission process Transport arrives after patient has been admitted for testing and observation After waiting several minutes outside Radiology the patient is finally greeted by technician to complete ultrasound A second transporter is called and arrives several minutes after the test is completed to transport patient to inpatient unit The patient is greeted by the Unit Director upon arrival and the RN assigned to patient does thorough review Call Center Patient arrives early for appointment and checks in with Registrar Office/ Registration Patient calls number to schedule an appointment Scheduler Inpatient Unit/Room CURRENT STATE: Shadowing and heart center care experience flow map

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams

Touchpoints: Call Center Dr.’s Office Exam Room Ultrasound Transport Inpatient Unit/Room Care Givers: Scheduler Receptionist CRNP Technician Transporter Unit Director Nurse Care experience flow map and working group invitation list Care Giver “TEAM List” Pat Smith Chris Kelly Sam Jones Al Very Sue Grade Lou Simon Deb Unger

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams

“Stories are the creative conversion of life itself into a more powerful, clearer, more meaningful experience. They are the currency of human contact.” — Robert McKee Award-winning film and television writer

Current State PFCC Methodology and Practice Ideal Experience 1. Define Care Experience 2. Guiding Council 3. Current State, View Care, Urgency 4. Working Group thru Touchpoints 5. Shared Vision for the Ideal 6. PFCC Projects and …Improvement Teams

Use the same six steps to form PFCC project improvement teams 1.Select care experience 2.Co-leaders 3.Evaluate the current state 4. Project team based on Touchpoints 5. Shared vision of the ideal 6. PFCC improvement projects

Function drives structure Care Experience Guiding Council and Working Group Project Team 1 Project Team # Project Team 2 Project Team 3

Cycle within a cycle and never ending continuous performance improvement PFCC Project Teams PFCC Working Group PFCC Project Teams

PFCC is making a difference PFCC is a grassroots effort to change the culture... Over 35 Working Groups Over 156 Project Teams Over 403 Completed Projects in 5 years

Shadowing and care experience mapping Patient and family advisory councils Patients and families on working groups and project teams Patient, family and care giver stories Informal surveys HCAHPS and “satisfaction” surveys Voice of Experience and Adopt a Patient Programs PFCC Tool Kit and Co-Design: Partnerships (…and there is no one right answer for everywhere)

Point of Care (PoC): Experienced Based Co-Design In-depth face-to-face interviews Discovery interviews carried out by clinical staff Focus groups Web-based free text comments Comment cards or suggestion boxes (on-site) Video boxes (on-site) Complaints and compliments Patient diaries Mystery shopping and observation Customer journey mapping

A PFCC must: shadowing and care experience flow mapping Walk the walk of patients and families… Shadow patients and families throughout the selected care experience, as well as for recording observations and insights High impact for the $’s and effort

Viewing care experiences and flow Shadowing “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.” - Tim Brown Change by Design

Shadowing and PFCC M/P Observations Empathy Insights PFCC Actions and Implementation Thru Working Groups

Patient and family shadowing Sets the stage for urgent change Care experience flow mapping Comparison of True vs. Assumed Follow the patient and family to look behind the curtain…

The first steps towards Co-Design… Shadowing continuously engages and partners with patients, families and care givers Creates real-time patient and Family Advisory Councils Shadowing is one of the best ways to assess your current state and the way to get started

Delivering exceptional care experiences is simple… the complexity is largely a reflection of the environment in which we find ourselves Focusing on the patient and family is a transformational approach for your organisation…which means there are “special” challenges There will be hurdles and a BIG one: Our organisations and…artificial silos

PFCC cuts across your organisation and breaks down silos and changes the culture… Hospital care delivery Care Experience WG #2 Experience WG #3 Care Experience WG #1 Care

PFCC cuts across silos and creates care experience based teams* Home Silos and PFCC M/P Health Insurance Pharmacy Home Health Outpt Therapy Rehab or Skilled Nursing Facility Physician Office Acute Hospital *Follow the Patient and their Family

OK….now let’s talk about us! Before PFCC… 47

PFCC M/P improves care givers’ experiences too....

…is us! We are care givers and: Patients Family members of patients The untapped Co-Design resource

Customised for health care and why we are in health care, i.e. care of patients and their families Simple to learn and builds care teams Generates a sense of urgency Breaks down silos Drives transformational change Sets the stage for focused care centers PFCC M/P on the practical side: Doing more with less

The PFCC methodology and practice as EBD/Design Science You, along with patients and families will determine the opportunities for improvement, propose and test solutions and then implement changes that will transform care

Sample PFCC success Stories Hip and knee total joint replacement experience Level I trauma experience

PFCC impact… The Bone and Joint Center at Magee Highest inpatient surgical volume Discharges to home over 90% of the time …and with lowest length of stay The best outcomes: ─Readmission rates, transfusion rates, infection rates and SCIP compliance The most efficient OR and the best care teams The lowest cost per case All while having the highest HCAHPS and …best patient loyalty anywhere

The Bone and Joint Center at Magee Named to the US News and World Report Top 50 Best Hospitals for 2011 Magee Orthopaedic Program began 2006 From start-up to Top 50 in just five years!

Emergency Department Physical Therapy Occupational Therapy Trauma MDs Orthopedics Pharmacy Nursing Staff EMS Communications Center Social Work Case Management Neurosurgery OMFS Ophthalmology Cardiology Operating Room PACU Patient Transportation Security Parking ISD Environmental Services Registration Radiology Patient Relations CCM Administration Acute Pain Service Dietary Trauma Patient But what about an unexpected care experience?

Cervical spine clearance Process Change 24/7 Attending Goal to decrease 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 since 2003 Hours

Restructure of Level I Trauma Services Created Three “Primary Care” Teams for Trauma Results showed: -Improved continuity of care -Improved communication -Improved patient & family satisfaction -Improved resident work hour compliance The Trauma Restructure was associated with improvement in time of discharge

Bariatric surgery Total Hip and Knee Joint Replacement Women’s Cancer Services Home Health Care Pediatric and Adult Emergency Room Many different care experiences and types of hospital - big and small, tertiary to community Pediatric Outpatient Surgery Rehabilitation Rheumatology Day of Surgery Transplant Level I Trauma Urgent Care Centers

So updated care delivery: The Design Sciences and PFCC M/P Place the care experiences of patients and families at the center and on the same footing as process and clinical goals and we can transform the system by DESIGN… We may not know the final answers but approaches like the PFCC M/P can get us heading in the right direction and adapt to our changing environment.

You! The PFCC M/P and You Ideal You can do this too….

PFCC is the way to proceed as we develop new models of care delivery

Clinical Process Thank you! PFCC M/P …any questions?