L18 Learning Objectives -...

2014%IHI%Na*onal%Forum:%GoShadow%

1%

L18 This presenter has

nothing to disclose

Go Shadow: See Patients’ Wants and Needs And Lower Costs Anthony'M.'DiGioia'III,'M.D.''

www.pfcc.org/IHI8Shadowing'

December'7,'2014'1pm/4:30pm'

Learning Objectives ! Learn the six steps of Shadowing as a simple

tool to improve care experiences and outcomes while reducing waste and cost

! Learn how Shadowing is used to define what patients want and need

! Invest the power of staff engagement in the redesign of care

! Learn how Shadowing provides the urgency to drive transformational change

! GoShadow

! No industry has survived without focusing on the needs and wants of their end users

! Just ask our patients and families

! Patient “Activation”

Why Change? The Opportunity

PAYMENT MODEL

CHANGES AHEAD

• New delivery systems coupled with new payment systems

• The biggest hurdle is the lack of the “How to…”

You run this hospital…where

would you start and what would you do? 4:20mins


2%

OK…what would you do?

Shadowing… ! Eye opener and generates urgency ! Care team builder ! Silo buster ! Real time co-design ! Simple ! Changes your perspective ! Trains leaders of tomorrow ! Measure true costs ! Is process improvement

Reality TV for Healthcare

Camera #1

Camera #2

DiGioia, A. M., Greenhouse, P. K., & DiGioia, C. S. (2012). Digital video recording in the inpatient setting: A tool for improving care experiences and efficiency while decreasing waste and cost. Quality Management in Health Care, 21 (4), 269 – 277.

Staff Contacts/Time Analysis (22 patients)

01020304050607080

(1)Ane

sthesio

logist

(2)Cardi

ology

(3)Chap

lain

(4)Diet

ary

(5)EKG Tec

h

(6)Florist

(7)HUC

(8)Intern

(9)Lias

on

(10)Mas

seuse

(11)Nurs

e

(12)Nurs

ing Stud

ent

(13)Occ

upatio

nal T

herap

y

(14)Occ

upatio

nal T

herap

y St...

(15)Pati

ent C

are Tec

hnici

an

(16)Pati

ent S

uppo

rts A

ssist

ant

(17)Phy

sician's

Assist

ant

(18)Prim

ary C

are Phy

sician

(19)Pha

rmacy

(20)Phy

sical T

herap

y

(21)Phy

sical T

herap

y Stud

ent

(22)Phy

sical T

herap

y Tec

hician

(23)Rec

overy

Room S

taff

(24)Res

pirator

y

(25)Soc

ial

(26)Surg

eon

(27)Trans

port

(28)Volu

nteer

Staff Type

Num

ber o

f Vis

its

012345678910111213

Tim

e/V

isit

(min

)

Avg Number of Visits Avg Time per Visit

This is Your Hospital Care Team

Contacts/Patient: 86/Day and 260/Hospital Stay ie Opportunities to Impact a Patient and Family Experience

Build Unique Care Teams Care Giver

Any person within a care setting whose work directly or indirectly touches a patient’s or family’s experience (ie: It’s a team effort)

Touchpoints Key moments and places in any care setting

where patient and family care experiences are affected by any Care Giver

5. Shared Vision of the Ideal

The Patient and Family Centered Methodology and Practice (PFCC)

Ideal Experience

Current State

2. Guiding Council

3. Shadow, Current State, Urgency

4. Working Group thru Touchpoints

6. PFCC Project Teams Close the Gap

1. Define Care Experience

www.pfcc.org


3%

Shadowing Shadowing is repeated

observations of patients and

families as they move through each step of

their healthcare journey… not a “secret shopper”

Shadowing is Eye Opening We watch what people do (and do not do) and listen to what they say (and do not say). The easiest thing about the search for insight – in contrast to the search for hard data – is that it’s everywhere and it’s free…

…This enlightened perception reveals the experience, not just the process.

Change by Design, Tim Brown

…to convince others, you must care about what

they think.

– Thomas Jefferson

Know how to distill complexity into a (simple)

message to reach the hearts as well as the minds

of the larger world...

“

”

GoShadow: Connecting with Patients and Families

SHADOWING EMPATHY

INSIGHTS AHA!

URGENT CHANGE STARTS NOW

John P. Kotter

“A higher rate of urgency does not imply

ever-present panic, anxiety, or fear. It means a state in

which complacency is virtually absent.”

Shadowing is Storytelling and Co-Design


4%

Shadowing Changes Your Perspective

- Susan P. Ferguson Chief Nursing Officer, Baptist-Collierville

I can’t tell you how impactful Shadowing is; once people Shadow, they talk about care differently—getting to view care through the eyes of patients and families truly provides Care Givers with a different perspective.

Who Can Shadow?… Anyone

• Any Care Givers • New Hires and Light Duty Staff

• Health Profession Students, Volunteers, Summer Interns, Patient Advocates

Impacting Future Healthcare Leaders

Students in… • Medical School • Nursing Students • Public Health • Graduate Students

• Pharmacy • Health

Information Management

2:16 mins

If Any Doubts…Go Shadow • Engages patients and

families as full partners in care delivery redesign

• Opens eyes and creates urgency to drive change

Aim for the Heart and Backfill with the Data


5%

GoShadow Workshop

Lisa Schraeder, MS ~ Senior OD Consultant ~ Patient Experience ~ PFCC Innovation Center of UPMC

To Get us Started…

Handout Questions

Shadowing

Shadowing is the repeated observation of

patients and families as they move through each step of

their health care journey

Impact on One Care Giver

“From the day I shadowed, on, I introduce myself and tell them I am a nurse–every time. I was shocked by how many Care Givers did not and how challenging that was for our families who are meeting people around the clock.” Jodi Licata, RN, MSN, CCRN, CNL

Programmatic Nurse Specialist, PICU Children's Hospital of Pittsburgh of

UPMC

Do you view care differently now?

“In addition to being the eyes and ears for our patients and families, I have gained a completely new perspective for how hard each of my colleagues work--their tireless dedication is awe-inspiring. I have become a better listener, more empathetic, and look for opportunities to connect people, processes, and ideas for improvement.”

Pat Fustich Administrative Assistant

Pediatric Surgery

A Care Giver’s Perspective A Shadowing Story

“Sarah? Get the broom…”


6%

About You Ready…Set…Go Shadow

Start here …

‘Go Shadow’ 101:

The Before, During and After

What to Know Before You Go

!  Not a Secret Shopper

!  Beginning and End

!  Who and # of Shadowers

!  How to approach Cynthia Rasmussen, MD Harvard Vanguard

Medical Associates

Overcoming Hurdles

“We started Shadowing a year ago… Our challenge was cold calling patients over the phone to ask them about Shadowing but once we got over that, we found Shadowing to be extremely powerful and got so much feedback.”


7%

FAQ: Won’t Care Givers change their behavior if they

know they are being Shadowed?

Note: !  Care Givers

!  Touchpoints

!  Time

!  Patient Comments

!  Your Observations

!  Anxiety/Emotive Response

During Shadowing: In the Field

FAQ: Should a Shadower ever intervene on behalf

of the patient or family?

After Shadowing: Sharing Findings

!  Tell the Patient’s Story

!  Report in Order of Experience

!  Share Observations & Recommendations

!  Include Care Experience Flow/ Hassle Map

Touchpoint Care Giver/Time

Parking(Lot(

Reception(Desk

Exam Room

Lab

Patient/Family(park(car(trouble(finding((right( garage(7:15(A

Checked(in(with front(desk(receptionist(7:28(G 7:35(A

Assessment(by(physician(assistant(and((doctor(9:15G9:30

Patient(/Family(sent(to(desk to(get(Rx(for(lab(work((9:37(A

Patient/Family((stop(at(parking(window(to(pay(for(parking;(cashier(10:42(A

lab technician(performs(blood(draw(10:14(A

Patient/Family(exit((garage(after(finding(car((11:02((A

Get(lost(on(way(to(lab;((no(clear(signage;(Shadower(intervenes(and(assists(them(with(wayfinding(9:49(A

Hallway

Parking(PayWindow

Highlighting(Touchpoints(and Care(Givers

Patient(/Family(back(to(desk((to(check(out(from(appointment(10:26(A

Doctor's Office(Suite

Entrance(to(clinic(7:27(A

Waiting Room

60(minute(wait(;(called(back(by(medical(assistant,(8:35(A Sample: Office Visit

Care Experience Flow Map

Sample Bulleted Care Experience Flow Map

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

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

Touchpoints: Care Givers:


8%

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

•  Registrar •  Medical Assistant •  Nurse •  Physician Asst./Dr.

Pre Shadowing Care Experience Flow Map


Post Shadowing Care Experience Flow Map

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

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


PFCC Shadowing Field Journal

! Your turn!

! Your on the go resource for Shadowing

! Available online www.pfcc.org

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

Jenny’s Jarring Journey

The Scene of the Accident ED Waiting Area


9%

Exam Room Inpatient Room, Day of Discharge

•  Review the raw notes captured in your journal •  Report, in the order in which the patient and family moved through the Care Experience, the events, timing, Care Givers, and Touchpoints they encounter •  Tell the patient’s story •  Include your Care Experience Flow Map

Writing and Presenting Reports

Creating Your Shadowing Report What to Include

Writing and Presenting Reports

!  Offer suggestions made by patient and family

!  Include your own observations and recommendations

!  Deliver tactfully and include positive observations

!  Remember to note any emotive response as that could become a priority project

!  Pictures are worth a thousand words


10%

1,000 Words

Care Experience:

Date:

Shadower:

Request:

Shadowing Summary Report

Care Experience: ED Care Experience

Date: December 7th, 2014

Shadower: Your Name

Request: To Shadow an ED patient from Arrival thru Discharge

Shadowing Summary Report Patient and Family Bio ! !

!

!

!

!

ED Care Experience Flow Map

•  •  •  •  •  •  • 

•  •  •  •  •  •  •  •  •  • 


Accident Scene/Transport • 

• 

• 

• 

• 

• 

• 


11%

• 

• 

• 

• 

Waiting Area Exam Room "  "  "  "  "  "  " 

•  •  •  •  •  •  • 

Testing • 

• 

• 

• 

• 

• 

• 

Inpatient Room: Day of Discharge

Opportunities/Suggestions •  •  •  •  •  •  •  • 

Impact Projects: Real World Results from Shadowing


12%

Cervical Spine Clearance

Process Change

24/7 Attending

•  Decreased clearance time, 50 then 70%

•  Previous attempts to address issue unsuccessful

•  Decreased length of stay •  Increased patient satisfaction

Hours

Average Time Spent in Collar

Impact of Shadowing: Going Home with Meds in Hand

•  Increased compliance

•  Reducing readmission rates

•  Improving health

Impact of Shadowing: Reducing Readmissions

•  Staff Shadowing b/w inpatient and outpatient settings

•  Self Management tools developed

•  Reduced readmission rate

•  Projected Annual Cost Savings = $400K

Infant Security

Maribeth McLauglin, CNO Magee-Womens Hospital of

UPMC

“Without Shadowing, we

never would have known that

our new protocol was

missing the mark.”

Break Seeing is Believing


13%

Additional Uses for Shadowing

It truly is a multi-purpose tool!

Shadowing…

Will break down silos

Can be used as a means of time study

Shadowing…

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

Shadowing…

Can be used as a measurement tool

Shadowing…

Engages Care Givers in designing improvement

Shadowing…


14%

Highlights inefficiencies and waste

Shadowing…

Is a terrific onboarding tool

Shadowing…

Starts new Care Givers off with valuable perspective

Shadowing… Shadowing Network

Goal: •  A framework to

drive change across your Health System

•  Create “Horizontal Connectors” to adopt, accelerate, and spread the PFCC M/P.

Shadowing… L18 This presenter has

nothing to disclose

Go Shadow: See Patients’ Wants and Needs And Lower Costs Anthony'M.'DiGioia'III,'M.D.''

www.pfcc.org/IHI8Shadowing'''

December'7,'2014'1pm/4:30pm'


15%

How Do You Define Value? Key #1 View All Care Through

the Eyes of Patients and Families and as an

Experience

Value = Experience • Through the eyes of patients

and families includes everything that impacts their journey to wellness.

•  Includes outcomes, communication, transitions in care, safety, costs and for a full cycle of care.

Key #2: Co-Design

Engagement-Partnership-Activation

Service Recovery

Consulting and Advising

Experience Based Co-Design

Current State

Key #3: Implementation

" Methodology " Overcome Hurdles " True Costs

Ideal Experience

Value = Cost

Health Outcomes

(Important to Patients)


16%

What is “cost”? •  Business – Expense? •  Hospitals - Charges? •  Insurers –

Reimbursements? •  MD’s – Overhead? •  Patients – OOP Expenses?

‘Costs’ vs. ‘Charges’ Hospital Charges $89,104

$15,397 Hospital Costs

$26,696 Hospital

Reimbursement

Total Joint

Replacement

Insurance Company

Patient $100

True Costs = TDABC Time Driven Activity Based Costing

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

Identifies true cost to deliver care: • Personnel • Space • Equipment • Consumables

• Bottoms-up approach to costing patient care over the full cycle of care

• Based on actual clinical and administrative processes

• ALL resources

True Costs = TDABC

Patient Centered Value Tool = PFCC + TDABC Patient Shadowing Cost

•  Determines Your Current State and Process Maps (Care Pathways)

•  Accurately and efficiently determines data needed to implement TDABC

•  Continuously Engages End Users in Real Time: Co-Design

•  Implementation Team


17%

Real World Example: TJR Bundling and Reference Pricing

Home

Health Insurance

Pharmacy Home Health

Outpt Therapy

Rehab or Skilled Nursing Facility

Physician

Office

Acute

Hospital

Shadow the Patient

Care Segments (30 days before to 90 days after)

4 PACU

4: PACU

1 PRE-OP/OFFICE

2 PRE-OP TESTING

& CONSULTS

3 DAY OF

SURGERY/OR

5 INPATIENT STAY 6

THERAPY 7

FOLLOW UP VISITS

1a: New Patient Scheduling

1b: Pre Surgical Office Visit

1c: Billing

3a: Day of Surgery Unit

3b: OR

3c: Central Sterile

5a: Day 0

5b: Day 1

5c: Day 2

5d: Day 3

6a: Home Therapy

6b: Outpatient PT

6c: Inpatient Rehab/SNF

7a: 4 Week Follow Up

7b: 3 Month Follow Up

7c: Post-Op Admin Support

2a: Pre-Op Testing

2b: MD Consults

2c: Special Testing

2d: Pre-Op Admin Support

Sample Process Map Pre-Op Testing (2A)

Bone and Joint Center Check In

Renaissance Ortho/BJC Waiting Room

Bone and Joint Center Exam Room

2a : Pre-Op Testing THR

Patient arrives for appointment

Is room available?

No - 20%

Yes – 80%

EKG in last 30 days?

No - 60%

Yes 40%

Urine sample complete?

MWH Diagnostic Imaging Check-In

Patient leaves hospital

2d Pre-Op

Administrative Support

2d Pre-Op


Step 5EKG test done

9

Step 1Patient checks in

2

Step 3Patient verifies medical history

2

Step 2Patient waits in waiting room

1

Patient provides urine sample if

possible

Step 4Patient returns to conference room

3

Bone and Joint Center Conference Room EKG/Blood Draw Room

Step 6Labs drawn

4

Step 7Meds & surgery discussed. MRSA

info given/test done20

Step 8Walk MRSA swabs

to lab 2

Step 9Dictate Notes

10

Step 10Review and approve dictation for notes

10

Step 11Assess & discuss of process for day of

surgery 8


possible

No40%

Step 13Patient registered

into Imagecast5

Step 12X-ray check in

1

Yes – 60%

MWH Diagnostic Imaging Changing Area

Step 14Patient escorted to

changing room5

Step 16 Patient changes back into clothes

4

MWH X-ray Room

Step 15X-ray taken

5

2d Pre-Op


2d Pre-Op


X-ray Tech

Nurse Practitioner Administrative Assistant

Nurse

Patient Care Technician

Patient

Registrar






Is room available?

No - 20%

Yes – 80%


No - 60%

Yes 40%




2d Pre-Op


2d Pre-Op


Step 5EKG test done

9


2


2


1


possible


3


Step 6Labs drawn

4




to lab 2

Step 9Dictate Notes

10


10


surgery 8


possible

No40%


into Imagecast5


1

Yes – 60%



changing room5


4

MWH X-ray Room

Step 15X-ray taken

5

2d Pre-Op


2d Pre-Op


X-ray Tech


Nurse


Patient

Registrar






Is room available?

No - 20%

Yes – 80%


No - 60%

Yes 40%




2d Pre-Op


2d Pre-Op


Step 5EKG test done

9


2


2


1


possible


3


Step 6Labs drawn

4




to lab 2

Step 9Dictate Notes

10


10


surgery 8


possible

No40%


into Imagecast5


1

Yes – 60%



changing room5


4

MWH X-ray Room

Step 15X-ray taken

5

2d Pre-Op


2d Pre-Op


X-ray Tech


Nurse


Patient

Registrar

Bone and Joint Ctr Check In

Renaissance Ortho/BJC

Waiting Room

Bone and Joint Ctr

Conf Room EKG/Blood Draw Room

Bone and Joint Ctr

Exam Room

Diagnostic Imaging Check In

Diagnostic Imaging

Changing Area MWH Xray

Room

Personnel 44%

Consumables 53%

Space 2%

Equipment 1%

THR Costs TKR Costs

Personnel 50%

Consumables 44%

Space 3%

Equipment 3%

- -

Bundle: 1 Month Before to 3 Months PO

3%

12%

16%

2%

59%

7%

1%

3%

16%

19%

2%

52%

7%

1%

0% 20% 40% 60% 80%

TKR THR

1.  Pre-Op/Office

2.  Pre-Op Testing & Consults

3.  Day of Surgery/OR

4.  PACU

5.  Inpatient Stay

6.  Therapy

7.  Follow-Up Visits

Distribution of Costs Across Care Segments

Personnel 16%

Space 1%

OR Costs

Personnel 20%

Consum-ables 78%

THR TKR

Implant Cost in a Bundle THR: 40% TKR: 30%

(Implant 86% of

Consumables)

Consum- ables 83%

(Implant 79% of

Consumables)

Equipment 0.4%

Equipment 0.4%

Space 1%


18%

Consumable Costs Total Hip Replacement

11% Medications

53% of Cost related to Consumables

5% Custom Hip

Pack

1% Surgical Dressing

2% General Nursing

77% Implant

1% Suture

Materials

2% Saw Blades

1% Skin

Antiseptic

For the Full Bundle

Physicians: Orthopaedic Surgeon, Internist, Cardiologist, Radiologist Mid Level Providers: Physician Assistants & Nurse Practitioners Nursing: Various levels of nurses (i.e. Professional Staff Nurse, Senior Professional Staff Nurse) Rehab Team: Various levels of Physical Therapists Anesthesia Team: Anesthesiologist & CRNA Support Staff: Aides, Administrative Staff, Techs, Transporter, Pharmacist

Physicians Mid Level Providers Nursing Rehab Anesthesia

Team Support Staff

Total Knee Replacement: Personnel Time and Cost % of TKR Personnel Cost Time (Hours)

21%

6%

30% 21%

6% 6% 2 4

118 33

2 28

Total Time

Total Knee Replacement

Actual Patient Time

Caregiver Time

Total Care Experience

110 Hours ~4.6 Days

122 Hours ~5.1 Days

123 Hours

30 Days Before Surgery to 90 Days Post Surgery

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

MWH SMH

TJR Care Segment Comparison

Pre-Op + Office

Pre-Op Testing + Consults

Day of Surgery

+ OR

PACU Inpatient Stay

Therapy Follow Up Visits

Pilot Projects @ UPMC

• Fast Track TJR ± Exparel • Rehab at SNF • Care: Inpt Nurse Workflow,

Central Sterile, Pre-op CXR • Hysterectomy ± Robotic

• 12 Month Collaborative • 32 Organizations • Measure Costs with TDABC

• Collect Outcomes/PRO’s • Enable Process Improvement

Joint Replacement Learning Community


19%

Joint Replacement Learning Community

•  Implant Costs – 4x Variation • Types of Anesthesia: General,

Spinal ± Intrathecal Morphine, Nerve Blocks, Intra-articular Injections

• OR Time (TKR): 31 to 155 mins

High Impact Variation

PFCC Shadowing TDABC Helps Providers

Performance and Process Improvement

Personnel and Resource

Utilization

•  Redesign processes •  Reduce waste/idle time •  Optimize cycle of care

•  Who should be doing the work? Where?

•  Reduce unused staff time, equipment, facilities

A Common Platform Patient Care Cost

• Tightly Couple Clinical + Financial Performance

• Cost Reduction Tool • Opportunities for Improvement

• Bundling and Reference Based Pricing Programs

• ACO’s • Chronic Care Medical Homes

Accountable Care

Patient Centered Value Tool

Outcomes Cost

Experiences ^

^ ^

IHI National Forum: Delivering Volume with Value and Operating Room Efficiencies

Tuesday, December 9th 9:30am-10:45am & 11:15am-12:30pm

Session A19 & B19

Friday, February 13th, 2015 Pittsburgh, PA

www.pfcc.org for more information

Wednesday, December 10th 9:30am-10:45am & 11:15am-12:30pm

Session D20 & E20

IHI National Forum: High-Value Practices for Total Joint Replacement

Deliver Value and Reduce Your Healthcare Costs Transparency, Bundling, Reference-Pricing and Direct Contract


20%

Expert Panel

L18 Learning Objectives -...

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