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Designing for Doctor and
Patient Interactions in the
Leave-taking Experience
A Project Report




      Cleveland Clinic Office of Patient Experience
Designing for Doctor & Patient Interactions           1
Motivation and context of this project                                             Table of contents
This project report captures the work of our team for a capstone class at the      Executive summary                                     5
Weatherhead School of Management - Design in Management: Concepts,
Methods of Practice & Products.                                                    Introduction: the strategic imperative
                                                                                   Founding principles                                   8
This class was a one-year studio course with various sponsors across               Healthcare innovation                                 9
several teams. Our team collaborated with Cleveland Clinic’s Office of                  Service innovation & Cleveland Clinic           12
Patient Experience from Fall of 2010 to Spring of 2011.                                 Office of Patient Experience & HCAHPS           14
                                                                                   Caregiver & patient communication                    16
This project report was created and provided as a deliverable to the Office
of Patient Experience and complements the oral presentation given at               Problem
Cleveland Clinic on April 26, 2011.                                                Strengths of Cleveland Clinic                        18
                                                                                   A challenge for Cleveland Clinic                     19
A separate document captures our design process with detailed photos of
our brainstorm sessions and ideation. If you are interested in getting a copy      Hypothesis
of this, please let us know.                                                       Patient journey                                      22
                                                                                   Why focus on discharge?                              23
Thank you,
                                                                                   Design research
Kipum Lee, Ph.D. candidate in Design, Management & Information Systems             What we did                                          26
Timothy Anderson, M.B.A. candidate in Marketing & Strategy                             Conference participation                         27
Emeka Mbanefo, M.B.A. candidate in Marketing                                           H.E.A.R.T.™ Service Recovery Program             28
Nicole Ujadughele, M.B.A./M.P candidate in Healthcare Systems Mgmt
                              .H.                                                      Brainstorming with Office of Patient Experince   29
Jalak Vyas, M.B.A. candidate in Finance                                                Observations                                     30
                                                                                       One-on-one interviews                            31
                                                                                   	         Interview tools & methods                  32
Please contact kipumlee@gmail.com for any inquiries about this work.               Analysis of the discharge experience                 36
                                                                                   Synthesis of reseach: generation of themes           40

                                                                                   Product: an interaction guide
                                                                                   Ideation using actions, words, and props             42
                                                                                   Concepts: scenarios                                  43
                                                                                   Thoughts on implementation                           55
                                                                                   Business case
                                                                                       Cost & benefits                                  56
                                                                                       Risk                                             58

                                                                                   Final thoughts                                       59

                                                                                   Appendix                                             60




2                                                                 Project Report   Designing for Doctor & Patient Interactions           3
Special thanks to                                         Executive summary
Prof. Dick Buchanan                                       This project report consists of six main parts: introduction, identification of
Prof. Fred Collopy                                        a pressing problem in the area of patient experience within Cleveland Clinic,
                                                          our hypothesis on how to explore the problem, design research, our product,
Dr.   Kurt Stange                                         and concluding thoughts.
Dr.   Eugene Blackstone
Dr.   Randall Starling                                    Although Cleveland Clinic possesses much strength in being a physician-
Dr.   Scott Endsley                                       led organization, it is facing challenges in providing world-class, doctor-
Dr.   Bob Hostoffer                                       to-patient communication because it is difficult to change the behaviors of
Dr.   Charles Mbanefo                                     these leaders. To make the problem manageable as a project, our group has
Dr.   Samir Thaker                                        focused primarily on physician and patient interactions during the discharge
Dr.   Dustin Yoon                                         period of in-patients. This is a critical moment in the patient journey that
Dr.   Jonathan Ahn                                        currently does not provide patients with quality communication moments
Dr.   Philip Choe                                         with their doctors.
Dr.   Anna Irwin
                                                          To address this problem, we propose an interaction guide – composed of
Ms. Fran DiDonato                                         actions, words, and props – to help physicians and their team say goodbye
Ms. Patricia Jurca                                        to patients and families during leave-taking. This service guide embodies
Ms. Anderson                                              ideas synthesized from themes that emerged during our team’s research
Mr. Johnson                                               process. The interactions are depicted in the form of short sketches and
Ms. Huda Alawadhi                                         demonstrate scenarios that support the conditions for conversation and
Ms. Natalie Hong                                          connection between doctors and patients.
Mr. Vinod Shah
                                                          The project report concludes with some thoughts on how these ideas have
From the Office of Patient Experience:                    the potential to have impact for the organization as a whole. A short section
Ms. Donna Oliver                                          at the end captures thoughts on how the interaction concepts could be
Ms. Toya Gorley                                           implemented as well as their financial implications.
Ms. Angela Costello
Ms. Laura
Mr. Robert Moreno
Ms. Carole Vincent
Ms. Mary Swierka
Ms. Mary Linda Rivera




4                                        Project Report   Designing for Doctor & Patient Interactions                                  5
01. Introduction
                     Founding principles • Healthcare innovation • Caregiver/patient communication




6   Project Report   Designing for Doctor & Patient Interactions                                 7
Founding principles                                                                       Innovation

     “Cleveland Clinic was founded in 1921 by four                                        Celebrating its 90th year this year, the organization has deliberately branded
     renowned physicians with a vision of providing                                       the celebration under the guiding principle of “Patients First.” As the Clinic
                                                                                          reflects upon its 90 years of success and growth and considers its vision for
     outstanding patient care based upon the principles of                                the future, CEO and President, Dr. Delos (Toby) Cosgrove, evokes one of the
     cooperation, compassion and innovation.”1                                            three founding principles - innovation.


                                    Cleveland Clinic still upholds its original                “The future belongs to those who seize the opportunities
                                    mission statement - “To provide better care of             created by innovation.”
                                    the sick, investigation into their problems, and                                                 - Dr. Delos M. Cosgrove
                                    further education of those who serve.”

                                    The vision is captured by “Striving to be the         Innovation is a theme that is at the core of what the Weatherhead School
                                    world’s leader in patient experience, clinical        of Management is exploring. We have called this theme of innovation and
                                    outcomes, research and education.”                    entrepreneurship, “Managing as Designing.”4

                                    Cleveland Clinic holds these values: Quality,         Therefore, our project group took this theme of innovation very seriously for
The Founders (clockwise from        Innovation, Teamwork, Service, Integrity,
upper left): Doctors Frank E.                                                             the past year and questioned what is meant by “healthcare” or “medical
Bunts, George E. Crile, John        Compassion.2                                          innovation.” After examining the landscape of healthcare, we propose four
Philips, and William E. Lower                                                             kinds of healthcare innovation:

Cleveland Clinic’s group practice model - which means that the doctors                    	         •   Quality & safety innovation
on staff are salaried employees and are not in private practice - is a                    	         •   Biomedical innovation
unique structure and has also been formed by the principles of teamwork                   	         •   Technological/device innovation
(collaboration/cooperation) and innovation.3                                              	         •   Service innovation

In 2007, the various practices of the Clinic were restructured to                         The visual mapping on the next page shows how various healthcare
complement the group practice model. By combining specialties                             institutions in the United States fall into one of the four areas.
surrounding a specific organ or disease system into practice units called
“institutes,” Cleveland Clinic believes it is better equipped to provide
integrated patient-centered care along with an easy-to-understand structure
for patients and families.

Furthermore, in 2004, the former CEO, Dr. Floyd D. Loop, unified the idea
of providing great care under the umbrella of “World Class Service,” and this
has more recently been captured by the guiding principle of “Patients First.”             Crile Forceps designed by and named after
                                                                                          founder Dr. George E. Crile



1 Cleveland Clinic Facts & Figures handout, Revised 5.2010.                               4 See R. J. Boland, and F. Collopy, ed., Managing as Designing (Palo Alto, CA:
2 Cleveland Clinic Experience booklet.                                                    Stanford University Press, 2004).
3 http://my.clevelandclinic.org/about/overview/mission_history.aspx.

8                                                                        Project Report   Designing for Doctor & Patient Interactions                                      9
Kinds of healthcare innovation

                                                                            Humanistic care                                                                                                        specific parts of the body are usually
Quality & safety innovation                                                                                                                              Service innovation                        considered to find an innovative solution.
                                                                                                                                                                                                   The top part captures care that can be
                                                                                                                                                                                                   described as being “holistic/humanistic”:
      University of Pittsburgh Medical Center                                                                                                  Kaiser Permanente (Garfield Center)                 this type of care has the potential to also
      (Center for Quality Improvement & Innovation)
                                                                                                                                                    Mayo Clinic (SPARC)                            describe care that focuses on the “well-
                                                                                                                                                                                                   being” of people. The dots represent
                                                                                                                                                                                                   where each institution gravitates toward in
                                                                                                                                                                                                   terms of how the organization’s innovation
                                                                                                                                                                                                   initiative may be perceived by others.
              Reagan UCLA                                                                          Arizona State University
              (Center for Health Quality & Innovation)                                             (Herberger Institute)
                                                                                                                                                                                                   If an institution is in one part of the four
                                                         Massachusetts General Hospital                                                                                                            quadrants, it should not be interpreted
 Johns Hopkins Hospital                                  (Stoeckle Center for Primary Care Innovation)
 (Center for Innovation in Quality Patient Care)
                                                                                                                                                                                                   that it is limited to having only that kind
                                                                                                                                                                                                   of innovation. For example, Johns Hopkins
      Discovery                                                                                                                                                  Invention                         Hospital has a strong research arm as well
                                                                                                                                                                                                   as a Center for Bioengineering Innovation
                                                                                                               Cleveland Clinic
                                                                                                                                                                                                   and Design that is a joint effort at the
                                                            University Hospitals - Ohio                                                                                                            university level between the medical and
                                                            (Research & Innovation Center)
                                                                                                                                                                                                   engineering schools (Technological/device
     Barnes - Jewish/Washington University                                                                                                                                                         innovation).
                                                                                                                    Duke University - Medical & Business School
                 Mount Sinai Hospital                                                                               (Center for Entrepreneurship & Innovation)                                     However, since only the Center for
                                                                         University of Washington                                                                                                  Innovation in Quality Patient Care is
                                New York - Presbyterian                  Medical Center                                                                                                            a part of both the medical school and
                                                                                                                                                                                                   hospital, the primary or dominant type of
                                                                                                                           University of Michigan Health System
 Hospital of the University of Pennsylvania                                                                                (Medical Innovation Center)                                             innovation at Johns Hopkins Hospital has
                                                                                                                                                                                                   been designated in the Quality & safety
Biomedical                                                                                                                                                   Technological/                        innovation quadrant.
research innovation                                                                                                                                       device innovation
                                                                            Mechanistic care                                                                                                       Out of the four kinds, service innovation
                                                                                                                                                                                                   is the nascent, “innovation frontier.” The
                                                                                                                                                                                                   model for this kind of innovation is the
                                                                                                                                                                                                   hospitality industry where the notion of
The mapping above depicts some of the major healthcare institutions or
                                                                                                                                                                                                   designing for services has been around for
healthcare-related organizations in the United States.
                                                                                                                                                                                                   more than 80 years.5
The left side of the mapping indicates healthcare institutions that have
strong research capabilities and consider “discovery” (finding and fixing
problems) as the primary goal. The right side of the mapping is a place for
healthcare institutions that consider “invention” (novelty) as the primary                                                                               5 See J. W. Marriott, Jr., and Kathi Ann Brown, The Spirit to Serve: Marriott’s Way (New York,
goal. The bottom of the mapping emphasizes “mechanistic care” where                                                                                      NY: HarperCollins, 1997).


10                                                                                               Project Report                                          Designing for Doctor & Patient Interactions                                                11
Service innovation & Cleveland Clinic

                                                                        Humanistic care                                                                                                        (including the Global Cardiovascular
Quality & safety innovation                                                                                                                          Service innovation                        Innovation Center) continues the legacy
                                                                                                                                                                                               of technological innovation at the Clinic.
                                                                                                                                                                                               Beginning with a pressurized rubber suit
     University of Pittsburgh Medical Center                                                                                               Kaiser Permanente (Garfield Center)                 for surgical patients (1903) and the first
     (Center for Quality Improvement & Innovation)
                                                                                                                                                Mayo Clinic (SPARC)                            successful blood transfusion method
                                                                                                                                                                                               (1906), Cleveland Clinic continues to
                                                                                                                                                                                               engage in innovating devices/technologies
                                                                                                                                                                                               and creating spin-off ventures. Hence,
 Quality and Patient                                                                                                                             Office of Patient                             Cleveland Clinic’s positioning on the map
        Reagan UCLA                                                                            Arizona State University
 Safety Institute Quality & Innovation)
        (Center for Health                                                                     (Herberger Institute)                             Experience                                    is supported by its strong emphasis on
                                                                                                                                                                                               technological innovations.
                                                     Massachusetts General Hospital
 Johns Hopkins Hospital                              (Stoeckle Center for Primary Care Innovation)
 (Center for Innovation in Quality Patient Care)
                                                                                                                                                                                               The Office of Patient Experience (see next
                                                                                                                                                                                               section) is the group that has been formed
     Discovery                                                                                                                                               Invention                         to explore “service innovation.” There is
                                                                                                                                                                                               great desire for the organization to start
                                                                                                           Cleveland Clinic
                                                                                                                                                                                               moving into this emergent space.
                                                        University Hospitals - Ohio
                                                        (Research & Innovation Center)
                                                                                                                                                                                               At Cleveland Clinic, experts from
 Lerner Jewish/Washington University
  Barnes -
           Research                                                                                                                     Cleveland Clinic                                       organizations such as the Ritz-Carlton,
 Institute                                                                                                      Duke University - Medical & Business School GCIC
                                                                                                                                        Innovations &                                          Disney Institute, Lincoln Center for the
                 Mount Sinai Hospital                                                                           (Center for Entrepreneurship & Innovation)                                     Performing Arts, Siegfried & Roy (i.e.
                                                                     University of Washington                                                                                                  Empathy & Innovation Summit), and also
                                New York - Presbyterian              Medical Center                                                                                                            Four Seasons have been invited to begin
                                                                                                                                                                                               conversations around service innovation.
                                                                                                                       University of Michigan Health System
 Hospital of the University of Pennsylvania                                                                            (Medical Innovation Center)
                                                                                                                                                                                               The idea of performance (i.e. Disney refers
Biomedical                                                                                                                                               Technological/                        to their employees as cast members)
research innovation                                                                                                                                   device innovation                        may begin to shift and challenge parts of
                                                                        Mechanistic care                                                                                                       Cleveland Clinic, which at this time can be
                                                                                                                                                                                               characterized as an “engineering culture.”

Cleveland Clinic has all four kinds of healthcare innovation represented in
its organization.                                                                                                                                            “Patients today ar savvy healthcare customers.
                                                                                                                                                             They judge healthcare providers not only on clinical
The Quality and Patient Institute explores innovative ways to enhance                                                                                        outcomes, but also on the courtesy of their personnel,
quality metrics and safer environments and processes for patients and                                                                                        the convenience of their facilities and their ability to
families. The Lerner Research Institute specializes in translational and
clinical research. Its mission is to understand the underlying diseases and                                                                                  deliver excellent service.”6
to develop new treatments and cures. The Cleveland Clinic Innovations                                                                                                                                 - Dr. Delos M. Cosgrove

12                                                                                           Project Report                                          Designing for Doctor & Patient Interactions                                        13
Office of Patient Experience & HCAHPS                                                        Parts and wholes of the HCAHPS

     “I was invited to Harvard Business School to discuss                                    Totality of hospital experience
     a case study on Cleveland Clinic. After a very positive
     and stimulating first session, a student at the second                                           Parts of patient experience
     session raised her hand and said, ‘Dr. Cosgrove, my
                                                                                                             Communication                                                Services
     father needed mitral valve surgery. We knew about
     Cleveland Clinic and the excellent results you had. But                                                  1               Information              14
     we decided not to go because we heard you had no                                                                 2                                                   4
                                                                                                                               7           17           11
     empathy there. We went to another hospital instead.’                                                                          3                                          13
                                                                                                                                                  19
                                                                                                                                   20   16
     The student then asked me: ‘Dr. Cosgrove, do you teach                                                       5
     empathy at Cleveland Clinic?’ The question left me                                                                   6

     speechless.”6                                                                                                                                                   8
                                                                                                                                                                              9        21
                                                                                                                                                Environment
                                          - Dr. Delos M. Cosgrove                                                                                                                     22

                                                                                                                                Safe Zone (positive scores)

In 2007, Dr. Cosgrove created the new position of Chief Experience Officer
and soon afterwards, the Office of Patient Experience.                                                                                                      e.g. successful surgery

The Office of Patient Experience has played a pivotal role in raising the                    one way is to organize the questions into parts and wholes. In the above
level of awareness of patient experience at Cleveland Clinic, starting various               visualization, the green outer rings capture all the HCAHPS questions except
initiatives such as the H.U.S.H. Quiet at Night program to address the issue                 21 and 22 and they have been grouped into categories of communication,
of nocturnal noise levels, and importantly, facilitating conversations around                information, services, and environment.
the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey (please refer to Appendix A for details about the HCAHPS                     Communications captures questions that deal with empathy and behaviors
and why they are important).                                                                 between caregivers and patients (e.g. “Did doctors treat you with courtesy
                                                                                             and respect?”). Information envelops straightforward questions that deal
To assist the Office of Patient Experience, our group investigated the nature                with “knowledge” and are not necessarily tied to emotions and empathy
of the HCAHPS survey and discovered an interesting paradox between                           (e.g. “Did hospital staff tell you what the medicine was for?”). Information
the above-the-national-average scores that measure overall satisfaction                      is inside the domain of communication since it is a form of communication.
(questions 21 & 22) and the less-than-national-average (or well below                        Services deal with staff responsiveness and pain management. Environment
the targeted 90th percentile) scores that measure parts of the patient                       provides a place for questions that ask about cleanliness and noise levels of
experience.                                                                                  the stay area.

While there are many ways to interpret and organize the HCAHPS survey                        The blue area is the totality of the patient experience.
(see Appendix B for more details and a breakdown of the survey questions),
                                                                                             One of the important questions when looking at this visualization is, “Can
6 D. M. Cosgrove, “A Better Patient Experience,” Cleveland Clinic Magazine, Summer 2007,     service innovation begin to bridge the gap between the parts and the whole
p. 3.                                                                                        and also raise the quality of the parts to match the whole?”


14                                                                          Project Report   Designing for Doctor & Patient Interactions                                                    15
Caregiver & patient communication

Totality of hospital experience

         Parts of patient experience

               Communication                                             Services

                1               Information           14
                        2                                                4
                                 7        17           11
                                     3                                       13
                                                 19
                                     20   16
                    5
                            6


                                               Environment
                                                                    8
                                                                             9               21

                                                                                            22
                                                                                                                            02. Problem
                                  Safe Zone (positive scores)
                                                                                                                Strengths of Cleveland Clinic • Challenges for Cleveland Clinic

                                                           e.g. successful surgery

When looking at the HCAHPS this way, it is glaring that a bulk of the
questions deal with issues of communication between caregivers (doctors,
nurses, staff) and patients (and families).

As mentioned in the previous section, communication captures emotional
and behavioral types of communication as well as straightforward
information that is exchanged between caregivers and patients.7

Setting the scope of our interest to communication between caregivers and
patients was an important first step in the process and would eventually
form into our problem statement.




7 For more information about communication theory that informed our work, please see
C. D. Mortensen, ed., Communication Theory: Second Edition (New Brunswick, NJ:
Transaction Publishers, 2009).

16                                                                                   Project Report   Designing for Doctor & Patient Interactions                                 17
Strengths of Cleveland Clinic

     “The result of such an organization will be that the                                      area (Appendix C is a list of other issues the group identified as possible
     entire staff - the bacteriologist, the pathologist, the                                   areas of exploration). While physicians at Cleveland Clinic are great formal
                                                                                               leaders, there is the challenge of being servant-leaders. Another way of
     biochemist, the physicist, the physiologist, and                                          stating the issue is, “As a physician-led organization, how can Cleveland
     radiologist, no less than the internist and the general                                   Clinic’s ‘officer core’ be leaders at the same time not leaders?”
     surgeon, each, we hope and believe, will maintain the
     spirit of collective work, and each of us will accept                                     This issue can be illustrated in an interaction that two of our team members
     as our reward for work done, his respective part in                                       witnessed at Cleveland Clinic between a caregiver (further details are not
                                                                                               shared to preserve anonymity) and a patient. The patient was told by other
     the contribution of the group, however small, to the                                      doctors elsewhere that her leg would need amputation but the physician at
     comfort, and usefulness, and the prolongation of human                                    Cleveland Clinic was able to save it. Despite this, she complained about his
     life.”8                                                                                   arrogance and poor communication skills.
                                           - Founder Dr. George E. Crile
                                                                                               When we asked the caregiver after this exchange what will be done, the
                                                                                               response was that the physician who provided treatment for that patient is
Cleveland Clinic is a physician-led organization. Along with Mayo Clinic,                      a seasoned and senior physician who is at Cleveland Clinic for a reason - he
Cleveland Clinic takes great pride in this unique form of leadership.                          is a world class expert at what he does. To raise such an issue to this doctor
                                                                                               and say he needs to change his behavior and communication with patients
This is the way it was founded and in many ways this spirit of collective                      is not an easy task. The caregiver’s response was, “It’s a touchy issue.”
work led by the physicians is they way many describe it today.
                                                                                               Providing quality interpersonal interactions between staff and physicians,
There is much to boast in this culture where physicians lead the programs,                     physicians and physicians, families and physicians, and, most importantly,
institutes, and innovation. Many of the physicians have patents in their                       patients and physicians is a formidable challenge for Cleveland Clinic.
name and contribute heavily to the ongoing development of new ideas.

Physicians are the soul, the “officer core” (also referred as one of the
“guardians of the enterprise”9), of Cleveland Clinic and patients and
families travel from near and far to receive treatment from these world class
                                                                                                    Problem statement:
caregivers.

                                                                                                    It is difficult for Cleveland
A challenge for Cleveland Clinic
                                                                                                    Clinic caregivers to change the
While this model of leadership (i.e. physician-led) offers much strength, it
also has its challenges.                                                                            behaviors of physicians with
Upon exploring the domain of caregiver and patient communication that                               patients and their families.
was identified in the last section, an important issue began to emerge in this

8 J. D. Clough, ed., To Act As A Unit: The Story of the Cleveland Clinic: Fourth Edition
(Cleveland, OH: Cleveland Clinic Press, 2004), p. 39.
9 F. D. Loop, “Never Have an Unsatisfied Patient,” Cleveland Clinic Magazine, Winter 2004.

18                                                                            Project Report   Designing for Doctor & Patient Interactions                                19
03. Hypothesis
                                            Patient journey • Why focus on discharge?




20   Project Report   Designing for Doctor & Patient Interactions                       21
Patient journey                                                                                Why focus on discharge?
                                                                                               The last few days of a patient’s stay are very important. They have impact
      “Here at Cleveland Clinic, we’ve always positioned                                       on patients, their families, and the caregivers at the hospital.
      quality in terms of outcomes. But I have come to
      understand that there is more to quality healthcare                                      For patients:
                                                                                               • It is a critical time to understand their physical condition;
      than great outcomes. There is the entire experience
                                                                                               • May be a time of great emotional distress;
      that patients have, from the moment they call for an                                     • They may be incoherent if they are on medication;
      appointment to the moment they arrive at the hospital -                                  • There is a lot of complexity in terms of managing information
      fearful and concerned - to the moment they get in their
      cars and drive away.”8                                                                   For families:
                                                                                               • Is when key decisions are made about the patient’s transition to another
                                             - Dr. Delos M. Cosgrove
                                                                                                 facility, back home, and/or the care of a primary care physician;
                                                                                               • May be a turning point of the family’s lifestyle, especially if the patient
                                                                                                 requires constant care
A patient’s journey consists of the flow of patient actions, thoughts,
emotions, and interactions in an environment of the patient. There are
                                                                                               For caregivers:
various “entry points” for a patient’s journey. This journey could initiate
                                                                                               • It is the last moment at the hospital before patients are sent the
when a patient looks up information about her condition online and
                                                                                                 HCAHPS;
stumbles across the Cleveland Clinic website, as soon as her primary care
                                                                                               • May be an opportune time to deliver service recovery, especially if things
doctor recommends she visit a specific doctor at Cleveland Clinic, or even
                                                                                                 went wrong at moments earlier in the patient journey;
through an accident that brings the patient to the doors of Cleveland Clinic’s
                                                                                               • May be an opportune time to co-create proactive physician-patient
emergency services. The patient’s journey with relations to Cleveland Clinic
                                                                                                 interactions since there are very few moments with physicians currently
could end once the patient leaves the physical environment, arrives home,
transitions to her next care facility, or may not end for many years since she
may continue to receive care due to an ongoing condition.
                                                                                                    Hypothesis:
Patient journey map

     PREARRIVAL     INTRODUCTION        TREATMENT          DISCHARGE          TRANSITION
                                                                                                    Focusing on building quality
                                                                                                    encounters between doctors
It would be too great of a scope to explore doctor-patient communication
                                                                                                    and patients during the
arcoss the entire patient journey experience. Therefore, to make it
managable as a one-year long project, our project team chose one part of
                                                                                                    discharge phase makes a
the patient journey - the discharge experience. We have also called this the
“leave-taking” experience.10
                                                                                                    memorable impression and
                                                                                                    will benefit an important part
10 For more information about “leave-taking,” please see E. Goffman, “Facial Engagements,”
C. D. Mortensen, ed., Communication Theory: Second Edition (New Brunswick, NJ:
                                                                                                    of the patient journey.
Transaction Publishers, 2009).

22                                                                            Project Report   Designing for Doctor & Patient Interactions                                  23
Leadership thoughts on discharge

     “I believe this [discharge phase] is the Achilles’
     heel - the last day or two of hospitalization. This exit
     is important - when people are well enough to be
     annoyed, and then they don’t get the instructions they
     need, and go away mystified ... instead of feeling good
     about knowing how to take care of themselves.
     This is also a big part of re-hospitalizations because
     people leave and they really don’t understand the
     instructions. And I don’t think it’s bad patients - it’s
     a lot to do with communication. Doctors are talking
     way above most people’s ability to understand (13th
     grade level as opposed to 3rd grade level of common
     understanding). We have data on all this.”                                                               04. Design research
       - Dr. Eugene Blackstone, Head of Clinical Investigations at the Sydell              What we did • Research tools & methods • Analysis • Synthesis & themes
             and Arnold Miller Family & Vascular Institute at Cleveland Clinic,
                                             interviewed on March 10, 2011


     “Discharging a patient from a hospital - in my opinion
     - is probably one of the most important objectives that
     has to be undertaken immediately. This whole domain
     of transition of care is exceedingly important ... and
     we have this terrible problem with high re-admission
     rate ... you can be the sickest person in the world and
     come in, have an operation, and have your life saved,
     and have dozens of people hovering over you. Then one
     day, you’re at home and all you have is your family, if
     you even have family. I think that [discharge phase] is
     a huge area of need. We have taken small bites, but
     they’re very small bites.”

     - Dr. Randall Starling, Head of the Section of Heart Failure and Cardiac
                      Transplant Medicine, Vice Chair for Clinical Operations,
                                               interviewed on April 10, 2011
24                                                                     Project Report   Designing for Doctor & Patient Interactions                                 25
What we did                                                                                     Conference participation

      “The patient is a person and not a statistic.”9
                                       - Founder Dr. William E. Lower


      “Dr. Cosgrove, who holds the Rich Family Chief
      Executive Chair, gave Cleveland Clinic a new mantra:
      Patients First. He appointed the first CXO in U.S.
      healthcare, and created an Office of Patient Experience
      to expedite change ... their approach is decidedly data-
      driven.11
          - Steve Szilagyi, writing about patient experience at Cleveland Clinic                   Service Design Network conference, October 28-29, 2010, Cambridge, MA


It has been argued that scientific medicine is the very essence of the                          Participating at conferences is a great way to get an idea of what the
concept of “Patients First.”12 This approach collects survey data and other                     emerging themes in healthcare innovation are. The 2010 Service Design
types of metrics and have been proven to produce better outcomes such                           Network conference in Cambridge, MA had participants from notable
as in the case of the Cardiovascular Information Registry, a collection of                      “design-thinking” organizations such as IDEO, Principle Continuum,
data across several decades. Cleveland Clinic holds “an enormous range of                       Microsoft Research, Harvard Business Review, Engine Service Design,
health information that can be retrieved at the touch of a finger, and sliced                   Adaptive Path, and frog design.
and diced in a thousand different ways.”12
                                                                                                A valuable part of the conference was a panel on healthcare innovation with
Design research is another way to gather data (e.g. emotions) that                              leaders from Kaiser Permanente and Mayo Clinic’s SPARC program. It would
complements the rich data that are collected every day at Cleveland                             be great for Cleveland Clinic to also participate in these forward-thinking
Clinic.13 Design research gathers data primarily in the field and can consist                   dialogues on service innovation in healthcare.
of observations (ethnographic-type research), co-creation, co-designing/
participatory design, and generative-making activities, among others.

Our team used the following research methods for this project:

•   Participating in conferences related to healthcare innovation
•   Participating in the H.E.A.R.T.™ Service Recovery program
•   Brainstorming with the Office of Patient Experience
•   Observations
•   Interviews
•   Participatory design tools & methods

11 S. Szilagyi, “The Patient Experience,” Cleveland Clinic Magazine, Winter 2011.
12 D. M. Cosgrove, “Metrics Make Sense,” Cleveland Clinic Magazine, Fall 2005.
13 For an overview of design research, see L. Sanders, “An Evolving Map of Design Practice         Cleveland Clinic Patient Experience Forum, November 17, 2010, Cleveland, OH
and Design Research,” Interactions, November 2008. Also see http://maketools.com.

26                                                                             Project Report   Designing for Doctor & Patient Interactions                                      27
H.E.A.R.T.™ program participation                                                            Brainstorming with the OPE




                            H.E.A.R.T.™ Service Recovery program session, April 7, 2011         Brainstorming with the Office of Patient Experience, March 3, 2011


It was a great experience participating in Respond with H.E.A.R.T.™ Service                  Our team had an opportunity to work with two staff members of the Office
Recovery program offered by the Office of Patient Experience and overseen                    of Patient Experience who have many years as nurse practitioners at
by the Department of Nursing World Class Service. Most of the participants                   Cleveland Clinic. They were insightful in pointing out the various challenges
were non-physicians and many of them were engaged with the narratives                        in the discharge experience.
that were shared throughout the two hour session.
                                                                                             This session was helpful in gaining insight into the mechanics of what
One of the course’s highlights is a set of role-playing activities to let the                happens in the backstage among caregivers for a “happy path” (in-patient
participants try out the service recovery model under different scenarios. It                going directly home after a procedure) as well as an “unhappy path” (in-
is a great way to engage the caregivers and provide a prototype of how the                   patient going to a long-term care or skilled nursing home facility) during
service would be implemented in a real setting. This model offers a tool for                 the last moments of a patient’s stay. Going through the parts of the process
how caregivers can react and use caring words when complaints arise.                         revealed much complexity surrounding the discharge experience.




     Script & role-playing as a methodology in the H.E.A.R.T.™ Service Recovery program         Brainstorming with the Office of Patient Experience, March 3, 2011

28                                                                          Project Report   Designing for Doctor & Patient Interactions                                29
Observations                                                                                     One-on-one interviews




                         “I’m also a part-time waitress.” - Emergency services caregiver            “I have to keep asking people - Who are you and what do you do?” - Patient


Observing the raw setting of caregivers and patients and how they act                            One great way to gather data is to directly engage with patients and
and live is a great way to get insights. While shadowing caregivers, it was                      caregivers, preferably in their natural environment (e.g. patient’s room at
evident that there is no idle employee at Cleveland Clinic. Individuals have                     the hospital). Through personal networks, a wide range of physicians and
their own rhythm and loose-script on how to interaction with patients and                        patients were interviewed.
families.
                                                                                                 To get an understanding of the discharge experience, one-on-one interviews
Patients and families have their own set of needs and desires. One of the                        with caregivers, patients, and families from Cleveland Clinic, University
family members of a patient (shown below) who has been at the Clinic for                         Hospitals, MetroHealth system, and private practices were arranged. In
several months already livens up the room with seasonal decorations - a                          addition, our team met with a few leaders within Cleveland Clinic to gain
snowman for Christmas, four leaf clover stickers on the wall, Easter basket                      clarity about the problem statement and hypothesis. These interviews
for the upcoming holiday - to stay preoccupied and comfort her loved one.                        consisted of questions as well as doing activities (see next section).




 “I like to give pieces of candy to the caregivers as a token of thanks.” - Patient’s family        A doctor illustrating the rushed body language that many doctors have during discharge

30                                                                              Project Report   Designing for Doctor & Patient Interactions                                            31
Cleveland Clinic Patient Discharge Experience: Service Blueprint Exercise
           Physical
          Evidence



                             Patient    Patient’s Family           Patient    Patient’s Family           Patient    Patient’s Family           Patient    Patient’s Family                 Patient    Patient’s Family           Patient    Patient’s Family           Patient     Patient’s Family



            Patient
            Actions



           Caregiver’s
          Information

     line of interaction



             Patient’s
          Information




         Caregiver
          Actions

                             Doctor    Nurse               Staff   Doctor    Nurse               Staff   Doctor    Nurse               Staff   Doctor    Nurse               Staff         Doctor    Nurse               Staff   Doctor    Nurse               Staff   Doctor     Nurse               Staff




     line of visibility




       Backstage
        Caregiver
         Actions

                                                                   Doctor    Nurse               Staff                                         Doctor    Nurse               Staff                                               Doctor    Nurse               Staff




     internal interactions




      Supporting
       Processes




                                                                                                                                                                                                                                                                                                              v1.0 klee 2.2011




Interview tools & methods
In addition to questions about the discharge phase, interviewees were
asked to participate in two activities. The first is a service blueprint activity.
Caregivers and patients were asked to depict their/the discharge journey
and encouraged to share personal stories during their 1.5 hour interview.
There are areas that capture the front stage interactions between patients
and caregivers, back stage actions performed by caregivers that are not
visible to patients/families, and supporting processes (i.e. EPIC) that allow
for the exchange and flow of information across the various moments of the
patient journey (see Appendix D for a quick download of how to use and
interpret service blueprints). The second activity is a collection of metaphor
cards that help patients and caregivers share the emotional dimensions of
their discharge experience. Interviewees were asked to pick 3 cards that
represent their discharge experience and share stories of why those were
chosen. Some insights for both activities are shared in the next two pages.

32                                                                                                                                                                                   Project Report                                                                              Designing for Doctor & Patient Interactions     33
“Patients could be there anywhere between an hour to twelve hours after we finish
because they’re waiting for transportation to a nursing home or a family member to pick
them up … or internally they need one last set of blood samples … there’s definitely                 “I’ll tell you what really contributed to patient experience for our family. After having a
a gap between when we’re done seeing them and when they leave the hospital … I                       procedure done and then being discharged, when the person [doctor] who performed
not only do not touch that process, I have no idea what happens in that process ... the              the procedure then calls us that night and asks, ‘How are you doing? Is there anything I
patient disappears.” - Cleveland Clinic intern                                                       can do?’ That makes all the difference in the world.” - Patient/physician




“Nowadays, the doctor’s big role is to have gotten the d/c orders done. And then they’re
off doing other things. So the doctor is probably not even around when this is happening.
If it’s a surgeon, may come in at 6 before her 7 am case, wake you up and say, ‘Hey, you             “Some patients are awake because they know we’re coming ... you ask them silly
feeling okay?’ Patient says, ‘uhhhhh ehhhhhh … I’m fine …’ [just waking up]. Doctor                  questions like, ‘How was your sleep?’ having just woken them up. They ask a lot of
says, ‘Good! Good! Your leg looks great! I’ll see you in a couple weeks at the office. Bye!’         questions but I try avoid giving committed answers because plans can change.”
and they’re out of there.” - Cleveland Clinic physician                                              - Cleveland Clinic intern




                                                                                                     “If the doctor gave me something I’d love it – I would treasure it. It could be anything –
“I was at a session recently called ‘Act with Heart’ where they had a man come in and he             like a pen from the department. Our doctor said, ‘Before you leave, I’m going to give you
 related an experience of his father who had been hospitalized. He sat in front of a group           a labcoat.’ I said, ‘I’d love that!’ And he said, ‘I’m going to ask Cleveland Clinic to do it
   of about 100 cardiologists and surgeons and in a matter-of-factly way looked us in the            for you.’ Even if the doctors gave us something symbolic, I don’t mind taking it. It tells
      eye and said, ‘My father was transferred from Metro [to Cleveland Clinic], he was in           me that I’m special to the doctor. That means he cares about us and put us in his mind
  the coronary care for 5 days, and we never met the attending physician - we don’t even             before coming to see us – he said, ‘Let me do something special, let me ‘melt the eyes’.’
                know his name.’ That’s a miserable failure.” - Cleveland Clinic physician            When you’re comfortable with the doctor, you heal better.” - Patient’s family

34                                                                               Project Report   Designing for Doctor & Patient Interactions                                                   35
Cleveland Clinic Patient Discharge Experience: Service Blueprint
Analysis of the discharge experience                                                                              Recovering                                       Accepting                                     Choosing                                  Planning                                      Learning                                  Leaving                          Transitioning

The Cleveland Clinic patient discharge experience service blueprint to the                               Patient is on medication and                  Many times, patient will be                   Patients will have to make                  Patients/family and the                       Patient is given instructions             Patient is has been given the     Patient is in the care of
                                                                                                         is waiting to hear information                told that going home will not                 a decision with family about                nursing staff will plan the                   regarding medications, a recap            approval to leave and must        a family doctor or other
right captures the collection of frontstage interactions between patients/             Patient
                                                                                       Actions           from physician on next steps.                 be possible; in some cases,                   what to do; at this point,                  logistics of where the patient                of the treatment or procedure,            manage to gather belongings       caregivers at another location.
families and caregivers (doctors, nurses, case managers, discharge                                       Patient’s assessment: how                     the option is to go to a rehab                patients may choose which                   will be heading and may even                  and extensive information for             and concern about billing and     Patient (and family) may be
planners, physicial therapists, social workers), backstage interactions among                            they feel v. how they usually                 facility/long-term care (LTC) or              nursing home or rehab center                arrange transportation details.               reference once patient is gone.           payment.                          adjusting to another lifestyle.
the caregiver staff, and also supporting processes (we’ve mainly captured                                at home.                                      skilled nursing facility (SNF).               to stay.
how information processes are tied to EPIC) for a case when a patient must
                                                                                                                             Optimizing               Family may be         Asking patient                               Patient consults with                        Intern/attending tells                       Patient & family                                          Patient can       Communication
go to another facility and has the assistance of some family members. Some                                                   physical            directly involved in       and family what is                           caregivers to decide                         patient she/he is to                         presented with                                        access MyChart        about condition with
key considerations - including thoughts and actions - at each moment in the                                                  parameters             finding a facility      meaningful to them                           where to transition                          be discharged soon                           instructional info                                             (EMR)        outpatient physician
discharge journey are captured inside each bubble.
                                                                                                           Teaching & assessing                          Explaining/estimating                             Providing options                             Discharging                                    Educating                                                                Continuing care

Some take-aways from this analysis are:                                                                  Physician may bring in                        Discussing d/c with patients                  Based on patient’s insurance                Resident/intern and sometimes                 Usually the nurse provides                                                  Outpatient medical team
                                                                                                         residents/interns into the                    and giving wishy-washy,                       and condition, caregivers will              the attending will let the                    d/c summary notes along with                                                may take over at this point.
                                                                                     Caregiver
                                                                                       Actions           room and discuss patient’s                    varying estimates of when                     have gathered some possible                 patient know that he/she is                   other information, such as                                                  May reinforce medication or
• Discharge process is highly complex with lots of variables (i.e. depends                               condition in front of interns.                patient may be discharged.                    locations to where patients                 ready to leave. More accurate                                                                                             may provide instruction(s)
                                                                                                                                                                                                                                                                                               medication instructions, to
  on the type of condition for which the patient has come to receive care)                               Other caregivers are                                                                        can transition. The other                   estimate of discharge time                    patient at this point.                                                      contrary to what patient
                                                                                                         assessing various data.                                                                     option is going home.                       presented.                                                                                                                heard at Clinic.
• Physicians may not play a big role during a typical discharge experience
                                                                                                                             Chief/attending                                                          Filtering and      Once patient/family
  if there is a physician, she is most likely an intern or resident                 line of visibility                       teaches how to                                                      doing background        has selected a place,
                                                                                                                             assess patient                                                             paperwork        caregiver can take
                                                                                                                                                                                                                         care of logistics
• If an attending or chief physician is present, the interaction with
                                                                                                          Assessing: biomedical                                  Researching                                                                       Finalizing d/c orders
  patients is at the level of assessing a patient’s biomedical condition;
  other considerations of a patient’s condition include functional                                       Physician is trying to optimize               Intern discussing d/c with case                                                           Intern (or physician) is
  assessments (e.g. will a patient be able to perform activities of daily                                biomedical condition. May                     management or d/c planner.                                                                finalizing d/c orders. This is
                                                                                                         not have continuity of care                                                                                                             needed for nurses to do their
  living?) but this is usually done by non-physician caregivers                                          (same doctor as before).                      Researching and contacting                                                                job of instructing the patient.
                                                                                                         “Technicians” and not                         possible rehab or nursing                                                                 Rehab/nursing facilities need
• If a physician is present, the interaction with patients and families is                                                                                                                            Summarizing d/c orders                                                                          Moving along                                                             Arranging follow-up
                                                                                                         “holistic healers” may see                    facilities for patient to go to.                                                          to have this to prepare in
  not the most optimal - in fact, these interactions may be quick, swift,                                their work done at this point.                                                              Intern starts d/c summary                   advance.                                      Attending or intern at this point                                           Possible home-care nurses or
  and poor in quality (e.g. a quick check to see if a patient’s biomedical                                                                                                                           (personalized narrative                                                                   does not really know what                                                   home teams may visit homes.
  condition is okay and the physician is off to see another patient, usually,       Backstage        “Will patient be         Dance between                                 Back and forth           for what happened during                                         D/c orders used          has happened with patient.
                                                                                     Caregiver       able to function         biomed & functional                           with rehab/              patient’s stay).                                                 to prep at rehab/        They have most likely moved                                                 Visiting Nurse Association
  someone with more severe issues)                                                     Actions             at home?”          assessment                                    nursing facilities                                                                        nursing facility
                                                                                                                                                                                                                                                                                               on to other patients or may                                                 (VNA), independent
                                                                                                           Assessing: functional                              Communicating                          Sent to attending for                              Coordinating                           be in the middle of providing              Transmitting patient info        organization may visit.
• Once the patient has been instructed on how to take medication and                                                                                                                                 approval.                                                                                 treatment/surgery.
  how to take care of herself at home or a new facility, many times,                                     Nurses usually in charge of                   Case managers                                                                             Case managers will coordinate                                                           Caregivers should transmit
  leaving the hospital may be entirely up to the patient (i.e. doctors have                              this. For worst cases, need a                 communicating with potential                                                              with rehab or nursing facility                                                          information about patient to
                                                                                                         social worker or d/c planner.                 rehab or nursing facilities and                                                           if patient requires a transition                                                        outpatient medical team.
  moved on to other patients/cases); for patients and families, this means                                                                             determining feasibility and                                                               to another venue. This is
  taking care of parking, perhaps getting to the airport to go back home,                                Physical therapist may help                   possibility of having patient                                                             important for compilcated                                                               If this never happened, there
  and readjusting back to life at home (e.g. paying hospital bills, home                                 with ADL and IADL.                            go there (Case managers                                                                   patients (i.e. 400lb patient                                                            is a heavy reliance on EPIC
  utility bills, catching up on missed emails and work, etc)                                                                                           have to pre-certify patient).                                                             has specific needs).                                                                    (EMR).

                                                                                                   Intern or resident         H & P (history                                                         Intern sends                        Attending approves           Nurse(s) and other                             Simplified d/c summary                                                    Outpatient care &
                                                                                                         makes daily          & physical) info                                                   pending d/c order                        d/c order and lets          caregivers also input                          along with other notes by                                                 treatment(s) recorded
                                                                                                      progress notes          looked at                                                               to attending                            nurse(s) know           info in EPIC                                   caregivers compiled                                                       in EPIC (ideally)


                                                                                    Supporting
                                                                                                                                                                                                                                                               EPIC
                                                                                    Processes
36                                                                 Project Report           Designing for Doctor & Patient Interactions                                                                                           37
                                                                                                                                                                                                                                                                                                                                                                                                        v1.0 klee 5.2011
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience
Designing for Doctor and Patient Interactions in the Leave-taking Experience

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Designing for Doctor and Patient Interactions in the Leave-taking Experience

  • 1. Designing for Doctor and Patient Interactions in the Leave-taking Experience A Project Report Cleveland Clinic Office of Patient Experience Designing for Doctor & Patient Interactions 1
  • 2. Motivation and context of this project Table of contents This project report captures the work of our team for a capstone class at the Executive summary 5 Weatherhead School of Management - Design in Management: Concepts, Methods of Practice & Products. Introduction: the strategic imperative Founding principles 8 This class was a one-year studio course with various sponsors across Healthcare innovation 9 several teams. Our team collaborated with Cleveland Clinic’s Office of Service innovation & Cleveland Clinic 12 Patient Experience from Fall of 2010 to Spring of 2011. Office of Patient Experience & HCAHPS 14 Caregiver & patient communication 16 This project report was created and provided as a deliverable to the Office of Patient Experience and complements the oral presentation given at Problem Cleveland Clinic on April 26, 2011. Strengths of Cleveland Clinic 18 A challenge for Cleveland Clinic 19 A separate document captures our design process with detailed photos of our brainstorm sessions and ideation. If you are interested in getting a copy Hypothesis of this, please let us know. Patient journey 22 Why focus on discharge? 23 Thank you, Design research Kipum Lee, Ph.D. candidate in Design, Management & Information Systems What we did 26 Timothy Anderson, M.B.A. candidate in Marketing & Strategy Conference participation 27 Emeka Mbanefo, M.B.A. candidate in Marketing H.E.A.R.T.™ Service Recovery Program 28 Nicole Ujadughele, M.B.A./M.P candidate in Healthcare Systems Mgmt .H. Brainstorming with Office of Patient Experince 29 Jalak Vyas, M.B.A. candidate in Finance Observations 30 One-on-one interviews 31 Interview tools & methods 32 Please contact kipumlee@gmail.com for any inquiries about this work. Analysis of the discharge experience 36 Synthesis of reseach: generation of themes 40 Product: an interaction guide Ideation using actions, words, and props 42 Concepts: scenarios 43 Thoughts on implementation 55 Business case Cost & benefits 56 Risk 58 Final thoughts 59 Appendix 60 2 Project Report Designing for Doctor & Patient Interactions 3
  • 3. Special thanks to Executive summary Prof. Dick Buchanan This project report consists of six main parts: introduction, identification of Prof. Fred Collopy a pressing problem in the area of patient experience within Cleveland Clinic, our hypothesis on how to explore the problem, design research, our product, Dr. Kurt Stange and concluding thoughts. Dr. Eugene Blackstone Dr. Randall Starling Although Cleveland Clinic possesses much strength in being a physician- Dr. Scott Endsley led organization, it is facing challenges in providing world-class, doctor- Dr. Bob Hostoffer to-patient communication because it is difficult to change the behaviors of Dr. Charles Mbanefo these leaders. To make the problem manageable as a project, our group has Dr. Samir Thaker focused primarily on physician and patient interactions during the discharge Dr. Dustin Yoon period of in-patients. This is a critical moment in the patient journey that Dr. Jonathan Ahn currently does not provide patients with quality communication moments Dr. Philip Choe with their doctors. Dr. Anna Irwin To address this problem, we propose an interaction guide – composed of Ms. Fran DiDonato actions, words, and props – to help physicians and their team say goodbye Ms. Patricia Jurca to patients and families during leave-taking. This service guide embodies Ms. Anderson ideas synthesized from themes that emerged during our team’s research Mr. Johnson process. The interactions are depicted in the form of short sketches and Ms. Huda Alawadhi demonstrate scenarios that support the conditions for conversation and Ms. Natalie Hong connection between doctors and patients. Mr. Vinod Shah The project report concludes with some thoughts on how these ideas have From the Office of Patient Experience: the potential to have impact for the organization as a whole. A short section Ms. Donna Oliver at the end captures thoughts on how the interaction concepts could be Ms. Toya Gorley implemented as well as their financial implications. Ms. Angela Costello Ms. Laura Mr. Robert Moreno Ms. Carole Vincent Ms. Mary Swierka Ms. Mary Linda Rivera 4 Project Report Designing for Doctor & Patient Interactions 5
  • 4. 01. Introduction Founding principles • Healthcare innovation • Caregiver/patient communication 6 Project Report Designing for Doctor & Patient Interactions 7
  • 5. Founding principles Innovation “Cleveland Clinic was founded in 1921 by four Celebrating its 90th year this year, the organization has deliberately branded renowned physicians with a vision of providing the celebration under the guiding principle of “Patients First.” As the Clinic reflects upon its 90 years of success and growth and considers its vision for outstanding patient care based upon the principles of the future, CEO and President, Dr. Delos (Toby) Cosgrove, evokes one of the cooperation, compassion and innovation.”1 three founding principles - innovation. Cleveland Clinic still upholds its original “The future belongs to those who seize the opportunities mission statement - “To provide better care of created by innovation.” the sick, investigation into their problems, and - Dr. Delos M. Cosgrove further education of those who serve.” The vision is captured by “Striving to be the Innovation is a theme that is at the core of what the Weatherhead School world’s leader in patient experience, clinical of Management is exploring. We have called this theme of innovation and outcomes, research and education.” entrepreneurship, “Managing as Designing.”4 Cleveland Clinic holds these values: Quality, Therefore, our project group took this theme of innovation very seriously for The Founders (clockwise from Innovation, Teamwork, Service, Integrity, upper left): Doctors Frank E. the past year and questioned what is meant by “healthcare” or “medical Bunts, George E. Crile, John Compassion.2 innovation.” After examining the landscape of healthcare, we propose four Philips, and William E. Lower kinds of healthcare innovation: Cleveland Clinic’s group practice model - which means that the doctors • Quality & safety innovation on staff are salaried employees and are not in private practice - is a • Biomedical innovation unique structure and has also been formed by the principles of teamwork • Technological/device innovation (collaboration/cooperation) and innovation.3 • Service innovation In 2007, the various practices of the Clinic were restructured to The visual mapping on the next page shows how various healthcare complement the group practice model. By combining specialties institutions in the United States fall into one of the four areas. surrounding a specific organ or disease system into practice units called “institutes,” Cleveland Clinic believes it is better equipped to provide integrated patient-centered care along with an easy-to-understand structure for patients and families. Furthermore, in 2004, the former CEO, Dr. Floyd D. Loop, unified the idea of providing great care under the umbrella of “World Class Service,” and this has more recently been captured by the guiding principle of “Patients First.” Crile Forceps designed by and named after founder Dr. George E. Crile 1 Cleveland Clinic Facts & Figures handout, Revised 5.2010. 4 See R. J. Boland, and F. Collopy, ed., Managing as Designing (Palo Alto, CA: 2 Cleveland Clinic Experience booklet. Stanford University Press, 2004). 3 http://my.clevelandclinic.org/about/overview/mission_history.aspx. 8 Project Report Designing for Doctor & Patient Interactions 9
  • 6. Kinds of healthcare innovation Humanistic care specific parts of the body are usually Quality & safety innovation Service innovation considered to find an innovative solution. The top part captures care that can be described as being “holistic/humanistic”: University of Pittsburgh Medical Center Kaiser Permanente (Garfield Center) this type of care has the potential to also (Center for Quality Improvement & Innovation) Mayo Clinic (SPARC) describe care that focuses on the “well- being” of people. The dots represent where each institution gravitates toward in terms of how the organization’s innovation initiative may be perceived by others. Reagan UCLA Arizona State University (Center for Health Quality & Innovation) (Herberger Institute) If an institution is in one part of the four Massachusetts General Hospital quadrants, it should not be interpreted Johns Hopkins Hospital (Stoeckle Center for Primary Care Innovation) (Center for Innovation in Quality Patient Care) that it is limited to having only that kind of innovation. For example, Johns Hopkins Discovery Invention Hospital has a strong research arm as well as a Center for Bioengineering Innovation Cleveland Clinic and Design that is a joint effort at the University Hospitals - Ohio university level between the medical and (Research & Innovation Center) engineering schools (Technological/device Barnes - Jewish/Washington University innovation). Duke University - Medical & Business School Mount Sinai Hospital (Center for Entrepreneurship & Innovation) However, since only the Center for University of Washington Innovation in Quality Patient Care is New York - Presbyterian Medical Center a part of both the medical school and hospital, the primary or dominant type of University of Michigan Health System Hospital of the University of Pennsylvania (Medical Innovation Center) innovation at Johns Hopkins Hospital has been designated in the Quality & safety Biomedical Technological/ innovation quadrant. research innovation device innovation Mechanistic care Out of the four kinds, service innovation is the nascent, “innovation frontier.” The model for this kind of innovation is the hospitality industry where the notion of The mapping above depicts some of the major healthcare institutions or designing for services has been around for healthcare-related organizations in the United States. more than 80 years.5 The left side of the mapping indicates healthcare institutions that have strong research capabilities and consider “discovery” (finding and fixing problems) as the primary goal. The right side of the mapping is a place for healthcare institutions that consider “invention” (novelty) as the primary 5 See J. W. Marriott, Jr., and Kathi Ann Brown, The Spirit to Serve: Marriott’s Way (New York, goal. The bottom of the mapping emphasizes “mechanistic care” where NY: HarperCollins, 1997). 10 Project Report Designing for Doctor & Patient Interactions 11
  • 7. Service innovation & Cleveland Clinic Humanistic care (including the Global Cardiovascular Quality & safety innovation Service innovation Innovation Center) continues the legacy of technological innovation at the Clinic. Beginning with a pressurized rubber suit University of Pittsburgh Medical Center Kaiser Permanente (Garfield Center) for surgical patients (1903) and the first (Center for Quality Improvement & Innovation) Mayo Clinic (SPARC) successful blood transfusion method (1906), Cleveland Clinic continues to engage in innovating devices/technologies and creating spin-off ventures. Hence, Quality and Patient Office of Patient Cleveland Clinic’s positioning on the map Reagan UCLA Arizona State University Safety Institute Quality & Innovation) (Center for Health (Herberger Institute) Experience is supported by its strong emphasis on technological innovations. Massachusetts General Hospital Johns Hopkins Hospital (Stoeckle Center for Primary Care Innovation) (Center for Innovation in Quality Patient Care) The Office of Patient Experience (see next section) is the group that has been formed Discovery Invention to explore “service innovation.” There is great desire for the organization to start Cleveland Clinic moving into this emergent space. University Hospitals - Ohio (Research & Innovation Center) At Cleveland Clinic, experts from Lerner Jewish/Washington University Barnes - Research Cleveland Clinic organizations such as the Ritz-Carlton, Institute Duke University - Medical & Business School GCIC Innovations & Disney Institute, Lincoln Center for the Mount Sinai Hospital (Center for Entrepreneurship & Innovation) Performing Arts, Siegfried & Roy (i.e. University of Washington Empathy & Innovation Summit), and also New York - Presbyterian Medical Center Four Seasons have been invited to begin conversations around service innovation. University of Michigan Health System Hospital of the University of Pennsylvania (Medical Innovation Center) The idea of performance (i.e. Disney refers Biomedical Technological/ to their employees as cast members) research innovation device innovation may begin to shift and challenge parts of Mechanistic care Cleveland Clinic, which at this time can be characterized as an “engineering culture.” Cleveland Clinic has all four kinds of healthcare innovation represented in its organization. “Patients today ar savvy healthcare customers. They judge healthcare providers not only on clinical The Quality and Patient Institute explores innovative ways to enhance outcomes, but also on the courtesy of their personnel, quality metrics and safer environments and processes for patients and the convenience of their facilities and their ability to families. The Lerner Research Institute specializes in translational and clinical research. Its mission is to understand the underlying diseases and deliver excellent service.”6 to develop new treatments and cures. The Cleveland Clinic Innovations - Dr. Delos M. Cosgrove 12 Project Report Designing for Doctor & Patient Interactions 13
  • 8. Office of Patient Experience & HCAHPS Parts and wholes of the HCAHPS “I was invited to Harvard Business School to discuss Totality of hospital experience a case study on Cleveland Clinic. After a very positive and stimulating first session, a student at the second Parts of patient experience session raised her hand and said, ‘Dr. Cosgrove, my Communication Services father needed mitral valve surgery. We knew about Cleveland Clinic and the excellent results you had. But 1 Information 14 we decided not to go because we heard you had no 2 4 7 17 11 empathy there. We went to another hospital instead.’ 3 13 19 20 16 The student then asked me: ‘Dr. Cosgrove, do you teach 5 empathy at Cleveland Clinic?’ The question left me 6 speechless.”6 8 9 21 Environment - Dr. Delos M. Cosgrove 22 Safe Zone (positive scores) In 2007, Dr. Cosgrove created the new position of Chief Experience Officer and soon afterwards, the Office of Patient Experience. e.g. successful surgery The Office of Patient Experience has played a pivotal role in raising the one way is to organize the questions into parts and wholes. In the above level of awareness of patient experience at Cleveland Clinic, starting various visualization, the green outer rings capture all the HCAHPS questions except initiatives such as the H.U.S.H. Quiet at Night program to address the issue 21 and 22 and they have been grouped into categories of communication, of nocturnal noise levels, and importantly, facilitating conversations around information, services, and environment. the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (please refer to Appendix A for details about the HCAHPS Communications captures questions that deal with empathy and behaviors and why they are important). between caregivers and patients (e.g. “Did doctors treat you with courtesy and respect?”). Information envelops straightforward questions that deal To assist the Office of Patient Experience, our group investigated the nature with “knowledge” and are not necessarily tied to emotions and empathy of the HCAHPS survey and discovered an interesting paradox between (e.g. “Did hospital staff tell you what the medicine was for?”). Information the above-the-national-average scores that measure overall satisfaction is inside the domain of communication since it is a form of communication. (questions 21 & 22) and the less-than-national-average (or well below Services deal with staff responsiveness and pain management. Environment the targeted 90th percentile) scores that measure parts of the patient provides a place for questions that ask about cleanliness and noise levels of experience. the stay area. While there are many ways to interpret and organize the HCAHPS survey The blue area is the totality of the patient experience. (see Appendix B for more details and a breakdown of the survey questions), One of the important questions when looking at this visualization is, “Can 6 D. M. Cosgrove, “A Better Patient Experience,” Cleveland Clinic Magazine, Summer 2007, service innovation begin to bridge the gap between the parts and the whole p. 3. and also raise the quality of the parts to match the whole?” 14 Project Report Designing for Doctor & Patient Interactions 15
  • 9. Caregiver & patient communication Totality of hospital experience Parts of patient experience Communication Services 1 Information 14 2 4 7 17 11 3 13 19 20 16 5 6 Environment 8 9 21 22 02. Problem Safe Zone (positive scores) Strengths of Cleveland Clinic • Challenges for Cleveland Clinic e.g. successful surgery When looking at the HCAHPS this way, it is glaring that a bulk of the questions deal with issues of communication between caregivers (doctors, nurses, staff) and patients (and families). As mentioned in the previous section, communication captures emotional and behavioral types of communication as well as straightforward information that is exchanged between caregivers and patients.7 Setting the scope of our interest to communication between caregivers and patients was an important first step in the process and would eventually form into our problem statement. 7 For more information about communication theory that informed our work, please see C. D. Mortensen, ed., Communication Theory: Second Edition (New Brunswick, NJ: Transaction Publishers, 2009). 16 Project Report Designing for Doctor & Patient Interactions 17
  • 10. Strengths of Cleveland Clinic “The result of such an organization will be that the area (Appendix C is a list of other issues the group identified as possible entire staff - the bacteriologist, the pathologist, the areas of exploration). While physicians at Cleveland Clinic are great formal leaders, there is the challenge of being servant-leaders. Another way of biochemist, the physicist, the physiologist, and stating the issue is, “As a physician-led organization, how can Cleveland radiologist, no less than the internist and the general Clinic’s ‘officer core’ be leaders at the same time not leaders?” surgeon, each, we hope and believe, will maintain the spirit of collective work, and each of us will accept This issue can be illustrated in an interaction that two of our team members as our reward for work done, his respective part in witnessed at Cleveland Clinic between a caregiver (further details are not shared to preserve anonymity) and a patient. The patient was told by other the contribution of the group, however small, to the doctors elsewhere that her leg would need amputation but the physician at comfort, and usefulness, and the prolongation of human Cleveland Clinic was able to save it. Despite this, she complained about his life.”8 arrogance and poor communication skills. - Founder Dr. George E. Crile When we asked the caregiver after this exchange what will be done, the response was that the physician who provided treatment for that patient is Cleveland Clinic is a physician-led organization. Along with Mayo Clinic, a seasoned and senior physician who is at Cleveland Clinic for a reason - he Cleveland Clinic takes great pride in this unique form of leadership. is a world class expert at what he does. To raise such an issue to this doctor and say he needs to change his behavior and communication with patients This is the way it was founded and in many ways this spirit of collective is not an easy task. The caregiver’s response was, “It’s a touchy issue.” work led by the physicians is they way many describe it today. Providing quality interpersonal interactions between staff and physicians, There is much to boast in this culture where physicians lead the programs, physicians and physicians, families and physicians, and, most importantly, institutes, and innovation. Many of the physicians have patents in their patients and physicians is a formidable challenge for Cleveland Clinic. name and contribute heavily to the ongoing development of new ideas. Physicians are the soul, the “officer core” (also referred as one of the “guardians of the enterprise”9), of Cleveland Clinic and patients and families travel from near and far to receive treatment from these world class Problem statement: caregivers. It is difficult for Cleveland A challenge for Cleveland Clinic Clinic caregivers to change the While this model of leadership (i.e. physician-led) offers much strength, it also has its challenges. behaviors of physicians with Upon exploring the domain of caregiver and patient communication that patients and their families. was identified in the last section, an important issue began to emerge in this 8 J. D. Clough, ed., To Act As A Unit: The Story of the Cleveland Clinic: Fourth Edition (Cleveland, OH: Cleveland Clinic Press, 2004), p. 39. 9 F. D. Loop, “Never Have an Unsatisfied Patient,” Cleveland Clinic Magazine, Winter 2004. 18 Project Report Designing for Doctor & Patient Interactions 19
  • 11. 03. Hypothesis Patient journey • Why focus on discharge? 20 Project Report Designing for Doctor & Patient Interactions 21
  • 12. Patient journey Why focus on discharge? The last few days of a patient’s stay are very important. They have impact “Here at Cleveland Clinic, we’ve always positioned on patients, their families, and the caregivers at the hospital. quality in terms of outcomes. But I have come to understand that there is more to quality healthcare For patients: • It is a critical time to understand their physical condition; than great outcomes. There is the entire experience • May be a time of great emotional distress; that patients have, from the moment they call for an • They may be incoherent if they are on medication; appointment to the moment they arrive at the hospital - • There is a lot of complexity in terms of managing information fearful and concerned - to the moment they get in their cars and drive away.”8 For families: • Is when key decisions are made about the patient’s transition to another - Dr. Delos M. Cosgrove facility, back home, and/or the care of a primary care physician; • May be a turning point of the family’s lifestyle, especially if the patient requires constant care A patient’s journey consists of the flow of patient actions, thoughts, emotions, and interactions in an environment of the patient. There are For caregivers: various “entry points” for a patient’s journey. This journey could initiate • It is the last moment at the hospital before patients are sent the when a patient looks up information about her condition online and HCAHPS; stumbles across the Cleveland Clinic website, as soon as her primary care • May be an opportune time to deliver service recovery, especially if things doctor recommends she visit a specific doctor at Cleveland Clinic, or even went wrong at moments earlier in the patient journey; through an accident that brings the patient to the doors of Cleveland Clinic’s • May be an opportune time to co-create proactive physician-patient emergency services. The patient’s journey with relations to Cleveland Clinic interactions since there are very few moments with physicians currently could end once the patient leaves the physical environment, arrives home, transitions to her next care facility, or may not end for many years since she may continue to receive care due to an ongoing condition. Hypothesis: Patient journey map PREARRIVAL INTRODUCTION TREATMENT DISCHARGE TRANSITION Focusing on building quality encounters between doctors It would be too great of a scope to explore doctor-patient communication and patients during the arcoss the entire patient journey experience. Therefore, to make it managable as a one-year long project, our project team chose one part of discharge phase makes a the patient journey - the discharge experience. We have also called this the “leave-taking” experience.10 memorable impression and will benefit an important part 10 For more information about “leave-taking,” please see E. Goffman, “Facial Engagements,” C. D. Mortensen, ed., Communication Theory: Second Edition (New Brunswick, NJ: of the patient journey. Transaction Publishers, 2009). 22 Project Report Designing for Doctor & Patient Interactions 23
  • 13. Leadership thoughts on discharge “I believe this [discharge phase] is the Achilles’ heel - the last day or two of hospitalization. This exit is important - when people are well enough to be annoyed, and then they don’t get the instructions they need, and go away mystified ... instead of feeling good about knowing how to take care of themselves. This is also a big part of re-hospitalizations because people leave and they really don’t understand the instructions. And I don’t think it’s bad patients - it’s a lot to do with communication. Doctors are talking way above most people’s ability to understand (13th grade level as opposed to 3rd grade level of common understanding). We have data on all this.” 04. Design research - Dr. Eugene Blackstone, Head of Clinical Investigations at the Sydell What we did • Research tools & methods • Analysis • Synthesis & themes and Arnold Miller Family & Vascular Institute at Cleveland Clinic, interviewed on March 10, 2011 “Discharging a patient from a hospital - in my opinion - is probably one of the most important objectives that has to be undertaken immediately. This whole domain of transition of care is exceedingly important ... and we have this terrible problem with high re-admission rate ... you can be the sickest person in the world and come in, have an operation, and have your life saved, and have dozens of people hovering over you. Then one day, you’re at home and all you have is your family, if you even have family. I think that [discharge phase] is a huge area of need. We have taken small bites, but they’re very small bites.” - Dr. Randall Starling, Head of the Section of Heart Failure and Cardiac Transplant Medicine, Vice Chair for Clinical Operations, interviewed on April 10, 2011 24 Project Report Designing for Doctor & Patient Interactions 25
  • 14. What we did Conference participation “The patient is a person and not a statistic.”9 - Founder Dr. William E. Lower “Dr. Cosgrove, who holds the Rich Family Chief Executive Chair, gave Cleveland Clinic a new mantra: Patients First. He appointed the first CXO in U.S. healthcare, and created an Office of Patient Experience to expedite change ... their approach is decidedly data- driven.11 - Steve Szilagyi, writing about patient experience at Cleveland Clinic Service Design Network conference, October 28-29, 2010, Cambridge, MA It has been argued that scientific medicine is the very essence of the Participating at conferences is a great way to get an idea of what the concept of “Patients First.”12 This approach collects survey data and other emerging themes in healthcare innovation are. The 2010 Service Design types of metrics and have been proven to produce better outcomes such Network conference in Cambridge, MA had participants from notable as in the case of the Cardiovascular Information Registry, a collection of “design-thinking” organizations such as IDEO, Principle Continuum, data across several decades. Cleveland Clinic holds “an enormous range of Microsoft Research, Harvard Business Review, Engine Service Design, health information that can be retrieved at the touch of a finger, and sliced Adaptive Path, and frog design. and diced in a thousand different ways.”12 A valuable part of the conference was a panel on healthcare innovation with Design research is another way to gather data (e.g. emotions) that leaders from Kaiser Permanente and Mayo Clinic’s SPARC program. It would complements the rich data that are collected every day at Cleveland be great for Cleveland Clinic to also participate in these forward-thinking Clinic.13 Design research gathers data primarily in the field and can consist dialogues on service innovation in healthcare. of observations (ethnographic-type research), co-creation, co-designing/ participatory design, and generative-making activities, among others. Our team used the following research methods for this project: • Participating in conferences related to healthcare innovation • Participating in the H.E.A.R.T.™ Service Recovery program • Brainstorming with the Office of Patient Experience • Observations • Interviews • Participatory design tools & methods 11 S. Szilagyi, “The Patient Experience,” Cleveland Clinic Magazine, Winter 2011. 12 D. M. Cosgrove, “Metrics Make Sense,” Cleveland Clinic Magazine, Fall 2005. 13 For an overview of design research, see L. Sanders, “An Evolving Map of Design Practice Cleveland Clinic Patient Experience Forum, November 17, 2010, Cleveland, OH and Design Research,” Interactions, November 2008. Also see http://maketools.com. 26 Project Report Designing for Doctor & Patient Interactions 27
  • 15. H.E.A.R.T.™ program participation Brainstorming with the OPE H.E.A.R.T.™ Service Recovery program session, April 7, 2011 Brainstorming with the Office of Patient Experience, March 3, 2011 It was a great experience participating in Respond with H.E.A.R.T.™ Service Our team had an opportunity to work with two staff members of the Office Recovery program offered by the Office of Patient Experience and overseen of Patient Experience who have many years as nurse practitioners at by the Department of Nursing World Class Service. Most of the participants Cleveland Clinic. They were insightful in pointing out the various challenges were non-physicians and many of them were engaged with the narratives in the discharge experience. that were shared throughout the two hour session. This session was helpful in gaining insight into the mechanics of what One of the course’s highlights is a set of role-playing activities to let the happens in the backstage among caregivers for a “happy path” (in-patient participants try out the service recovery model under different scenarios. It going directly home after a procedure) as well as an “unhappy path” (in- is a great way to engage the caregivers and provide a prototype of how the patient going to a long-term care or skilled nursing home facility) during service would be implemented in a real setting. This model offers a tool for the last moments of a patient’s stay. Going through the parts of the process how caregivers can react and use caring words when complaints arise. revealed much complexity surrounding the discharge experience. Script & role-playing as a methodology in the H.E.A.R.T.™ Service Recovery program Brainstorming with the Office of Patient Experience, March 3, 2011 28 Project Report Designing for Doctor & Patient Interactions 29
  • 16. Observations One-on-one interviews “I’m also a part-time waitress.” - Emergency services caregiver “I have to keep asking people - Who are you and what do you do?” - Patient Observing the raw setting of caregivers and patients and how they act One great way to gather data is to directly engage with patients and and live is a great way to get insights. While shadowing caregivers, it was caregivers, preferably in their natural environment (e.g. patient’s room at evident that there is no idle employee at Cleveland Clinic. Individuals have the hospital). Through personal networks, a wide range of physicians and their own rhythm and loose-script on how to interaction with patients and patients were interviewed. families. To get an understanding of the discharge experience, one-on-one interviews Patients and families have their own set of needs and desires. One of the with caregivers, patients, and families from Cleveland Clinic, University family members of a patient (shown below) who has been at the Clinic for Hospitals, MetroHealth system, and private practices were arranged. In several months already livens up the room with seasonal decorations - a addition, our team met with a few leaders within Cleveland Clinic to gain snowman for Christmas, four leaf clover stickers on the wall, Easter basket clarity about the problem statement and hypothesis. These interviews for the upcoming holiday - to stay preoccupied and comfort her loved one. consisted of questions as well as doing activities (see next section). “I like to give pieces of candy to the caregivers as a token of thanks.” - Patient’s family A doctor illustrating the rushed body language that many doctors have during discharge 30 Project Report Designing for Doctor & Patient Interactions 31
  • 17. Cleveland Clinic Patient Discharge Experience: Service Blueprint Exercise Physical Evidence Patient Patient’s Family Patient Patient’s Family Patient Patient’s Family Patient Patient’s Family Patient Patient’s Family Patient Patient’s Family Patient Patient’s Family Patient Actions Caregiver’s Information line of interaction Patient’s Information Caregiver Actions Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff line of visibility Backstage Caregiver Actions Doctor Nurse Staff Doctor Nurse Staff Doctor Nurse Staff internal interactions Supporting Processes v1.0 klee 2.2011 Interview tools & methods In addition to questions about the discharge phase, interviewees were asked to participate in two activities. The first is a service blueprint activity. Caregivers and patients were asked to depict their/the discharge journey and encouraged to share personal stories during their 1.5 hour interview. There are areas that capture the front stage interactions between patients and caregivers, back stage actions performed by caregivers that are not visible to patients/families, and supporting processes (i.e. EPIC) that allow for the exchange and flow of information across the various moments of the patient journey (see Appendix D for a quick download of how to use and interpret service blueprints). The second activity is a collection of metaphor cards that help patients and caregivers share the emotional dimensions of their discharge experience. Interviewees were asked to pick 3 cards that represent their discharge experience and share stories of why those were chosen. Some insights for both activities are shared in the next two pages. 32 Project Report Designing for Doctor & Patient Interactions 33
  • 18. “Patients could be there anywhere between an hour to twelve hours after we finish because they’re waiting for transportation to a nursing home or a family member to pick them up … or internally they need one last set of blood samples … there’s definitely “I’ll tell you what really contributed to patient experience for our family. After having a a gap between when we’re done seeing them and when they leave the hospital … I procedure done and then being discharged, when the person [doctor] who performed not only do not touch that process, I have no idea what happens in that process ... the the procedure then calls us that night and asks, ‘How are you doing? Is there anything I patient disappears.” - Cleveland Clinic intern can do?’ That makes all the difference in the world.” - Patient/physician “Nowadays, the doctor’s big role is to have gotten the d/c orders done. And then they’re off doing other things. So the doctor is probably not even around when this is happening. If it’s a surgeon, may come in at 6 before her 7 am case, wake you up and say, ‘Hey, you “Some patients are awake because they know we’re coming ... you ask them silly feeling okay?’ Patient says, ‘uhhhhh ehhhhhh … I’m fine …’ [just waking up]. Doctor questions like, ‘How was your sleep?’ having just woken them up. They ask a lot of says, ‘Good! Good! Your leg looks great! I’ll see you in a couple weeks at the office. Bye!’ questions but I try avoid giving committed answers because plans can change.” and they’re out of there.” - Cleveland Clinic physician - Cleveland Clinic intern “If the doctor gave me something I’d love it – I would treasure it. It could be anything – “I was at a session recently called ‘Act with Heart’ where they had a man come in and he like a pen from the department. Our doctor said, ‘Before you leave, I’m going to give you related an experience of his father who had been hospitalized. He sat in front of a group a labcoat.’ I said, ‘I’d love that!’ And he said, ‘I’m going to ask Cleveland Clinic to do it of about 100 cardiologists and surgeons and in a matter-of-factly way looked us in the for you.’ Even if the doctors gave us something symbolic, I don’t mind taking it. It tells eye and said, ‘My father was transferred from Metro [to Cleveland Clinic], he was in me that I’m special to the doctor. That means he cares about us and put us in his mind the coronary care for 5 days, and we never met the attending physician - we don’t even before coming to see us – he said, ‘Let me do something special, let me ‘melt the eyes’.’ know his name.’ That’s a miserable failure.” - Cleveland Clinic physician When you’re comfortable with the doctor, you heal better.” - Patient’s family 34 Project Report Designing for Doctor & Patient Interactions 35
  • 19. Cleveland Clinic Patient Discharge Experience: Service Blueprint Analysis of the discharge experience Recovering Accepting Choosing Planning Learning Leaving Transitioning The Cleveland Clinic patient discharge experience service blueprint to the Patient is on medication and Many times, patient will be Patients will have to make Patients/family and the Patient is given instructions Patient is has been given the Patient is in the care of is waiting to hear information told that going home will not a decision with family about nursing staff will plan the regarding medications, a recap approval to leave and must a family doctor or other right captures the collection of frontstage interactions between patients/ Patient Actions from physician on next steps. be possible; in some cases, what to do; at this point, logistics of where the patient of the treatment or procedure, manage to gather belongings caregivers at another location. families and caregivers (doctors, nurses, case managers, discharge Patient’s assessment: how the option is to go to a rehab patients may choose which will be heading and may even and extensive information for and concern about billing and Patient (and family) may be planners, physicial therapists, social workers), backstage interactions among they feel v. how they usually facility/long-term care (LTC) or nursing home or rehab center arrange transportation details. reference once patient is gone. payment. adjusting to another lifestyle. the caregiver staff, and also supporting processes (we’ve mainly captured at home. skilled nursing facility (SNF). to stay. how information processes are tied to EPIC) for a case when a patient must Optimizing Family may be Asking patient Patient consults with Intern/attending tells Patient & family Patient can Communication go to another facility and has the assistance of some family members. Some physical directly involved in and family what is caregivers to decide patient she/he is to presented with access MyChart about condition with key considerations - including thoughts and actions - at each moment in the parameters finding a facility meaningful to them where to transition be discharged soon instructional info (EMR) outpatient physician discharge journey are captured inside each bubble. Teaching & assessing Explaining/estimating Providing options Discharging Educating Continuing care Some take-aways from this analysis are: Physician may bring in Discussing d/c with patients Based on patient’s insurance Resident/intern and sometimes Usually the nurse provides Outpatient medical team residents/interns into the and giving wishy-washy, and condition, caregivers will the attending will let the d/c summary notes along with may take over at this point. Caregiver Actions room and discuss patient’s varying estimates of when have gathered some possible patient know that he/she is other information, such as May reinforce medication or • Discharge process is highly complex with lots of variables (i.e. depends condition in front of interns. patient may be discharged. locations to where patients ready to leave. More accurate may provide instruction(s) medication instructions, to on the type of condition for which the patient has come to receive care) Other caregivers are can transition. The other estimate of discharge time patient at this point. contrary to what patient assessing various data. option is going home. presented. heard at Clinic. • Physicians may not play a big role during a typical discharge experience Chief/attending Filtering and Once patient/family if there is a physician, she is most likely an intern or resident line of visibility teaches how to doing background has selected a place, assess patient paperwork caregiver can take care of logistics • If an attending or chief physician is present, the interaction with Assessing: biomedical Researching Finalizing d/c orders patients is at the level of assessing a patient’s biomedical condition; other considerations of a patient’s condition include functional Physician is trying to optimize Intern discussing d/c with case Intern (or physician) is assessments (e.g. will a patient be able to perform activities of daily biomedical condition. May management or d/c planner. finalizing d/c orders. This is not have continuity of care needed for nurses to do their living?) but this is usually done by non-physician caregivers (same doctor as before). Researching and contacting job of instructing the patient. “Technicians” and not possible rehab or nursing Rehab/nursing facilities need • If a physician is present, the interaction with patients and families is Summarizing d/c orders Moving along Arranging follow-up “holistic healers” may see facilities for patient to go to. to have this to prepare in not the most optimal - in fact, these interactions may be quick, swift, their work done at this point. Intern starts d/c summary advance. Attending or intern at this point Possible home-care nurses or and poor in quality (e.g. a quick check to see if a patient’s biomedical (personalized narrative does not really know what home teams may visit homes. condition is okay and the physician is off to see another patient, usually, Backstage “Will patient be Dance between Back and forth for what happened during D/c orders used has happened with patient. Caregiver able to function biomed & functional with rehab/ patient’s stay). to prep at rehab/ They have most likely moved Visiting Nurse Association someone with more severe issues) Actions at home?” assessment nursing facilities nursing facility on to other patients or may (VNA), independent Assessing: functional Communicating Sent to attending for Coordinating be in the middle of providing Transmitting patient info organization may visit. • Once the patient has been instructed on how to take medication and approval. treatment/surgery. how to take care of herself at home or a new facility, many times, Nurses usually in charge of Case managers Case managers will coordinate Caregivers should transmit leaving the hospital may be entirely up to the patient (i.e. doctors have this. For worst cases, need a communicating with potential with rehab or nursing facility information about patient to social worker or d/c planner. rehab or nursing facilities and if patient requires a transition outpatient medical team. moved on to other patients/cases); for patients and families, this means determining feasibility and to another venue. This is taking care of parking, perhaps getting to the airport to go back home, Physical therapist may help possibility of having patient important for compilcated If this never happened, there and readjusting back to life at home (e.g. paying hospital bills, home with ADL and IADL. go there (Case managers patients (i.e. 400lb patient is a heavy reliance on EPIC utility bills, catching up on missed emails and work, etc) have to pre-certify patient). has specific needs). (EMR). Intern or resident H & P (history Intern sends Attending approves Nurse(s) and other Simplified d/c summary Outpatient care & makes daily & physical) info pending d/c order d/c order and lets caregivers also input along with other notes by treatment(s) recorded progress notes looked at to attending nurse(s) know info in EPIC caregivers compiled in EPIC (ideally) Supporting EPIC Processes 36 Project Report Designing for Doctor & Patient Interactions 37 v1.0 klee 5.2011