Shadowing: Aim for the Heartand Backfill with the Data Pamela K. GreenhouseExecutive Director, PFCC Innovation Center firstname.lastname@example.org
Disclosure StatementI have no affiliation, financial or otherwise, withany commercial or other industry interest withregard to the PFCC Methodology and Practiceor this presentation.Pamela K. Greenhouse, MBAExecutive Director, PFCC Innovation Center
Learning Objectives• Understand Shadowing as a tool to view care through the eyes of patients and families• Understand how Shadowing creates a sense of urgency to drive change• Understand that Shadowing allows us to identify redundancies and opportunities to reduce waste and cost• Understand the 6 steps of Shadowing and Care Experience Flow Mapping
UPMC: Who are We?• UPMC is a $10 billion integrated global health system headquartered in Pittsburgh, PA• Named one of the nation’s Top 10 Hospitals on the U.S. News & World Report’s Honor Roll of America’s Best Hospitals• Pennsylvania’s largest employer with 55,000 employee.• Operates more than 20 academic, community, and specialty hospitals and 400 outpatient sites, employs more than 3,200 physicians, and an array of rehabilitation, retirement, and long- term care facilities
The Patient and Family Centered Care Methodology and Practice• A simple, replicable and sustainable six- step methodology to deliver exceptional care experiences and improve clinical outcomes while decreasing waste and cost.• Developed for health care, the PFCC M/P is based on the Design Sciences in which the goal is always to make things better for the end user
The PFCC Methodology and Practice Provides the Steps to Success Ideal Experience 6. PFCC Project Teams to Close the Gap 5. Shared Vision of the Ideal 4. Working Group thru Touchpoints 3. Shadow, Current State, Urgency 2. Guiding Council 1. Define Care ExperienceCurrent State
Let’s define our terms! Care GiverAny person within a care setting whose work touches a patient’s or family’s experience Touchpoints Key moments and places in any care settingwhere patient and family care experiences are directly or indirectly affected by any care giver.
Hospital Hurdles Care Delivery Valet Techni- cian DietaryScheduler Nurse/ Doctor
PFCC At UPMC PFCC is a grassroots effort to improve care and outcomesover 60 different Care Experience Working Groups and care settings of all kinds. In 2012, more than 180 PFCC Project Teams & Over 440 Completed Projects. PFCC Working Group Membership 60 1400 55 50 1200 45 1000 40 35 800 30 25 600 20 400 15 10 200 5 0 0 2006 2007 2008 2009 2010 2011 2012 # Total Working Groups
The PFCC Community of Practice is Growing• Baptist Memorial, Collierville - Tennessee• Nemours, A Children’s Health System, Delaware & Orlando• National Health Service, UK• Korean Health System, Korea• Atrius/Vanguard/Harvard, Boston• WellSpan Health, Pennsylvania• Rochester General Hospital, New York• UNC Healthcare, North Carolina• Aneurin Bevin Health, Wales
Three Keys for the PFCCMethodology and PracticeKey #1: Viewing all care as experiencesthrough the eyes of patients and families.Key #2: Engaging patients and families asfull partners in co-designing care with us.Key #3: Providing simple solutions in acomplex system in order to overcomehurdles and break down barriers toproviding exceptional care experiences.
The Key We’re Focused on Today View All Care as an Experienceand Through the Eyes of Patients and Families
What is Shadowing? Shadowing is the direct, real- time observation of patients and families as they move through each step of a Care Experience, over the full cycle of care.
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 – isthat it’s everywhere and it’s free.”“This enlightened perception reveals theexperience, not just the process. “ Tim Brown “Change by Design
Shadowing Shadowing Empathy Insights PFCC Actions andImplementation Through Working Groups
Shadowing and Care Experience Flow Mapping• Walk the walk of patients and families…feel what they feel• Shadow patients and families through the selected care experience, record subjective and objective observations and insights• High impact for the $’s and effort
Who Can Shadow?…Anyone!• Guiding Council and care givers• Shadowing for new hires and light duty staff• Students, volunteers, summer interns, patient advocates
“Being a nurse for 25 years I thought Ihad a good understanding of what ourpatients and families wanted because Ilive it and work it every day. But I foundout that there are some things that aremore important to the patients than Ithought they were. For example, I didn’trealize how many people were having ahard time just finding my unit. Or thatparking was such a big issue.”
Examples: Assumed vs. TrueAssumed True• Counter 1 • Parking Garage• Counter 2 • Counter 1 • Counter 2• Main Waiting Area • Main Waiting Area• Patient Room • Vitals Room• Small Waiting Area • Patient Room • Small Waiting Area • Discharge Desk • Pay Station
Outpatient Office Visit Care Experience Flow MapTouchpoints: Care Givers:• Call Center • Scheduler• Parking Garage • Valet attendant• Dr.’s Office • Receptionist• Exam Room • CRNP• Ultrasound • Technician• Transport • Transporter• Inpatient Unit/Room • Unit Director • Nurse
Patient and Family Shadowing Actual ExperienceSix Steps to 6. Report Your FindingsShadowing 5. Observe the Patient’s and Family’s Care Experience 4. Connect with the Patient and Family 3. Gather Information for the Shadowing Project 2. Select the Patient and Family Shadower 1. Define the Care Experience for ShadowingPresumed Flow
Six Steps to Patient and Family Shadowing Step 1 Define the Care Experience for ShadowingWhich care experience do you want to shadow?Broad vs. narrow care experience?
Step 1 Defining the Care Experience Segments of Care Emergency Room Care Experience ER Admitting DeskRegistration/Triage Registration/TriageER Exam Room ER Exam RoomCheck Out/Discharge
Step 1 Defining the Care Experience Segments of Care Discharge Care ExperienceDischarge Notification Preparation for D/C Nurse Arrival for Discharge Instructions Transport for Exit Check Out/Discharge
Example of Discharge Touchpoints and ObservationsInitial Discharge Notification• Was the notification within a reasonable time of discharge?Preparation for Discharge• Was the patient ready for discharge?Nurse Arrival for Discharge• Did the nurse arrive in a timely fashion?
Example of Discharge Touchpoints and ObservationsInstructions• Were the instructions presented in a way the patient could understand?Transportation for Exit• Did the patient need transportation upon discharge?Exiting Facility• Were there any issues for the family members with valet or parking?
Examples of Ways to SegmentShadowing for Other ExperiencesMorning Rounds• Physician and nurse communication to patient• New nurses coming on duty• Medication delivery“Adopt-a-Patient”• Can be at various time intervals• Conversations will allow you to gain insight about the patient experience
Six Steps to Patient and Family Shadowing Step 2 Select the Patient and Family Shadower• Be a good observer and listener• Have a positive, open and supportive attitude• Approach Shadowing with open eyes and no biases• Be empathic, compassionate, reliable and trustworthy
Six Steps to Patient and Family Shadowing Step 3 Gather Information for the Shadowing• Which patients and families should be Shadowed?• What is the current pathway of the care experience to be Shadowed?• When is the ideal time for Shadowing to occur, based on patient volume, activity, type of procedures involved, or other considerations?
Patient and Family Shadowing Preparation Checklist• When will you notify care givers about the Shadowing that is about to take place?• Shadowers are Not Secret Shoppers• Tip: It is always helpful for the Shadower to take a quick tour of the area to be Shadowed in advance.
Patient and Family Shadowing Preparation ChecklistPrepare for Reporting• How will you report information back to the care givers who are requesting the Shadowing?Closing• Provide your contact information to the patient, family and care givers• Confirm the date for Shadowing and patient information
Steps to Patient and Family Shadowing Step 4 Connect and Coordinate with the Patient and Family• Make arrangements in advance with patients and family members• Explain that your role as Shadower is to observe, record and evaluate their care experience
Request to Shadow the Patient and Family: Sample Dialogue Presenting the Concept of Shadowing• Make phone call at least 24 hours prior to appointment –Tool 4 for guidance and scripting purposes• Arrangements with patients and family members in advance will reduce their anxiety• Emphasize your role in improving their experience• Defuse any “secret shopper” impressions that they may have
Tool 4. Request to Shadow Patient and Family: Sample Dialogue36
PFCC Methodology and Practice Website• www.pfcc.org• Click on Go Shadow• Click on Shadowing Resources
Steps to Patient and Family Shadowing Shadow: Observe and Record the Step 5 Patient’s and Family’s Care Experience The overall flow of Patients, Families, and Care Givers…• Care Experience Flow Mapping• Record Touchpoints and care giver roles• Record who enters and leaves and where they go• How long they are gone and when they come back• What they do…and how they say and do it
Mom’s MelodramaPlaceholder for PFCC Live Video Skit
Heart Care Experience Flow Map Reaches scheduler Call Center to make an appointment Parking Parked car in wrong Touchpoints and Care Givers lot per attendant Call transferred to Dr.’s Office office takes info and Front desk receptionist receptionist makes checks patient in appointment Transport Returned to Exam Physician assesses room Physician patient and orders updated pt. Ultrasound tests Escorted to Escorted to Exam Escorted to Inpatient Ultrasound byCardiac Unit Room by Unit by Transporter Transporter Transporter Technician Information performs test; test Desk takes 45 minutes Greeted by Unit ClerkHousekeeping Moved to Room by Clinical Manager; Lab waits 40 minutes for room Dietary Phlebotomist draws blood Home Clinical Manager made follow-up phone call
Heart Care Experience Flow Map Touchpoints: Care Givers:• Call Center • Scheduler• Parking • Parking Attendant• Doctor’s Office • Physician• Transport • Transporter• Ultrasound • Technician• Cardiac Unit • Unit Clerk• Information Desk • Greeter• Housekeeping • Housekeeper• Lab • Phlebotomist• Dietary • Dietary Aide• Pharmacy • Pharmacist
Shadowing Results Segment of Heart Care Experience:Begins: With phone call to schedule appointmentEnds: With follow-up phone call post discharge
First Contact & Parking• Automated phone greeting – Not caller friendly – Misleading• Receptionist friendly• Same day appointment• Texted directions to phone• Parking long way from clinic
Registration Experience• Questions repeated from phone call• No wheelchair for patient• CRNP comes out to greet patient
Exam Room Experience• Nurse –Uses medical jargon –Patient/family anxious –Orders ultrasound• 30 minute wait for transport
Ultrasound Experience• Daughter told to stay behind• Transport leaves patient in hallway• Daughter alone in exam room for 45 minutes w/o updates• Results ready quickly; delivered by CRNP
Inpatient Admission Experience• Patient arrives on floor – Staff is unprepared• Waits for room in hallway – 40 minutes – Shadower intervenes• Blood work not taken• Cafeteria closes early
Discharge and Follow-up• Confusion on time of D/C• 7 hour wait• Patient and Daughter present for instructions• Medications not explained• Patient looking for prescription• Follow-up call from nurse
Recommendations• Improve automated recording• Confirm information once• Wheelchair access in garage• Clearer signage in garage and to unit• Improve Care Giver handoffs• Room service options• Discharge process
Another Kind of Shadowing“Reality TV for Care Givers”
Number of Visits (1 )A ne st he (2 sio )C lo 0 10 20 30 40 50 60 70 80 ar gi (3 dio st )C lo h gy (4 apla (5 )D in )E ie KG tar y (6 Tec )F h lo (7 rist )H (8 U C )I (1 (9 nte (1 ( 0) )L rn 4) 1 3 (1 M ias O )O 2) as o cc c N (1 seu n u c ur 1 s (1 pat u pa sin )N e (1 5) io ti g urs 6) Pa na on St e Pa ti l T al ud tie ent he Th e n r e t (1 nt S C ar ap r a (1 P 7) up e y S py 8) hy po Tec t...Avg Number of Visits Pr si rts h im cia A nic ar n ss ia y s is n Ca As ta (2 re sis nt (2 P 1) (2 P t Staff Type 2) hy 0)P (1 9 hy an t Ph si h )P sic ys ca l ysi ha ia ica T ca r m n (2 l T he r l Th a c 3) he ap e y R ec rap y S rapy o v y tud er Te e y c n (2 Ro h ici t 4) o m anAvg Time per Visit R es S p ta (2 ir at ff (2 5)S ory 6 o Staff Contacts/Time Analysis (22 patients) (2 )Su cia 7) rg l (2 Tra eon 8) ns Vo p lu ort nt ee r 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Time/Visit (min) Reality TV for Care Givers
Hand washing - Top 5 Care Giver Groups 57 That Interact with Patients28 Staff Types Top 5 Care Givers# of contacts = 4034 # of contacts = 3221 Account for 81% of contacts 19% Nurse 39%5% Patient Care Technician 26% 39%5% PT and OT 6%6% Patient Support Assistant 5% 26% PT Technician 5% Others 19% (23 Staff Types)
Shadowing Changes Your Perspective“I can’t tell you how impactful Shadowing is; once people Shadow, they talk about PFCC differently—getting to view care through the eyes of patients and families truly provides Care Givers with a different perspective.” --Susan P. Ferguson Chief Nursing Officer,59 Baptist-Collierville
A Physician Becomes a Patient"So now, on the other side of the fence, I have alsobeen able to think about being a patient, and onewhose life is threatened. I have come to regret howmuch better a doctor I might have been, had I been atthe receiving end of medical care earlier in mycareer. In the past eighteen months I have learnt asmany lessons from sometimes unwittingly insensitivedoctors and nurses as from many otherswhose patience, encouragement andquiet humor have sustained me throughdark times." -Elizabeth Bryan Singing the Life