Why Change? Why Change? The Opportunity. Disclosures. Learning Objectives

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1 Disclosures Dr. Tony DiGioia December 6th, Medical Director, Bone and Joint Center and Innovation Center of UPMC Faculty, Institute for Healthcare Improvement Founder GoShadow LLC President, AMD3 Foundation (not-for-profit) Learning Objectives Shadowing is a standardized approach to measure experiences and processes Provides the emotional connection that creates an urgency to drive change A real-time tool that will help your teams transform care Why Change? Why Change? No industry has survived without focusing on the needs and wants of their end users Patient Activation The Opportunity New delivery systems coupled with new payment systems The biggest hurdle is the lack of the How to PAYMENT MODEL CHANGES AHEAD PFCC%Innova*on%Center%of%UPMC% 1%

2 You run this hospital where would you start and what would you do? OK what would you do? Why Shadow? Camera #1 This is Your Hospital Care Team Staff Contacts/Time Analysis (22 patients) Camera #2 Number of Visits (1)Anesthesiologist (2)Cardiology (3)Chaplain (4)Dietary (5)EKG Tech (6)Florist (7)HUC (8)Intern (9)Liason (10)Masseuse (11)Nurse (12)Nursing Student (13)Occupational Therapy (14)Occupational Therapy St... (15)Patient Care Technician (16)Patient Supports Assistant (17)Physician's Assistant (18)Primary Care Physician (19)Pharmacy (20)Physical Therapy (21)Physical Therapy Student (22)Physical Therapy Techician (23)Recovery Room Staff (24)Respiratory (25)Social (26)Surgeon (27)Transport (28)Volunteer Staff Type Avg Number of Visits Avg Time per Visit Time/Visit (min) 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), Contacts/Patient: 86/Day and 260/Hospital Stay ie Opportunities to Impact a Patient and Family Experience PFCC%Innova*on%Center%of%UPMC% 2%

3 Patient Centered Value System ^ Outcomes Experiences ^ ^ Cost 3 Keys For The New Patient Centered Value System 1. View All Care as an Experience Through the Eyes of Patients and Families 2. Co-Design 3. Implementation and Teams The Patient and Family Centered Methodology and Practice (PFCC) Ideal Experience Current State 2. Guiding Council 6. PFCC Project Teams Close the Gap 5. Shared Vision of the Ideal 4. Working Group thru Touchpoints 3. Shadow, Current State, Urgency 1. Define Care Experience The Experience Based Design Science Design Sciences Clinical Designing services, interactions, processes and environments for the complete experience Making it better for the end user Strength: Implementation and the How To Experience-Based Design: From Redesigning the System Around the Patient to Co-Designing Services with the Patient by Bate and Robert, Quality Safety Health Care 2006;15: Process The Patient at the Center Aligns The Catalyst For Change With Our Mission Shadowing Shadowing is repeated observations of patients and families as they move through each step of their healthcare journey not a secret shopper PFCC%Innova*on%Center%of%UPMC% 3%

4 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 View All Care Through the Eyes of End Users Determine Your Current State Co-Design Improvement Opportunities True Costs GoShadow Build Implementation Teams GoShadow for Process (and Performance) Improvement Time studies Transitions in care Communication gaps Inefficiencies Bottlenecks Redundancies Care Experience Flow Map (Hassle Map*) Slywotzky, Adrian J., and Karl Weber. Demand: Creating What People Love before They Know They Want It. New York: Crown Business, Print. Care Experience Flow Map ( And Fewer Hassles) Shadowing: The Urgency to Drive Change* EMPATHY SHADOWING INSIGHTS AHA! URGENT CHANGE STARTS NOW * John Kotter PFCC%Innova*on%Center%of%UPMC% 4%

5 Shadowing Changes Your Perspective 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. - Susan P. Ferguson Chief Nursing Officer, Baptist-Collierville 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 Pharmacy Nursing Students Health Public Health Information Graduate Students Management Merging Technology and Process Improvement GoShadow ios App Collection Tool goshadow.org Cloud-based Collaboration Platform PFCC%Innova*on%Center%of%UPMC% 5%

6 GoShadow Reports Care Experience Flow Map Comprehensive Report captures all qualitative and quantitative aspects Observational Report: Opportunities for improvement that the patients and families propose Opportunity Report: Highlights key observations Time Studies I. Patient and Family Activation and Partnerships Patients and families knowledge, skills and willingness to help Improves clinical outcomes Population health management will deliver higher value and preserve the patient at the David Nash, MD, MBA center, which is really what we are all about. Darves, Bonnie. "Pushing Population Health Management." (2015): American Association for Physician Leaders. Print. III. Joy at Work = Collaborative Solutions We MUST throw a lifeline to Care Givers PFCC + UPMC 70+ Care Experiences United States: 27 International: 7 If Any Doubts Go Shadow Engages patients and families as full partners in care delivery redesign Opens eyes and creates urgency to drive change PFCC%Innova*on%Center%of%UPMC% 6%

7 Aim for the Heart and Backfill with the Data Shadowing 101 Lisa Schraeder, MS ~ Senior OD Consultant ~ Patient Experience ~ PFCC Innovation Center of UPMC About You A Shadowing Story Sarah? Get the broom Power of One Shadowing Shadowing is the repeated observation of patients and families as they move through each step of their health care journey PFCC%Innova*on%Center%of%UPMC% 7%

8 Shadowing is a Multi-Purpose Tool Is Co-Designing with Patients and Families Another Benefit: Co-Design Creates Urgency to Drive Change Service Recovery Experience Based Co-Design Consulting and Advising Engagement-Partnership-Activation Will Break Down Silos Engages Care Givers in Designing Improvement PFCC%Innova*on%Center%of%UPMC% 8%

9 A Care Giver s Perspective An Administrator s Perspective 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 Noreen Fredrick, RN, MSN, DNP Executive Director, Mon Yough Community Services I am no longer a fan of surveys. Everyone always told us how nice we were and gave us high scores. Shadowing, however, showed us our real opportunities to improve the patient experience. Is a Terrific Onboarding Tool Enlightens Leaders of Tomorrow Can Be Used for Time Studies Highlights Inefficiencies and Waste PFCC%Innova*on%Center%of%UPMC% 9%

10 Measures True Cost A Surgeon s Story Why Shadowing Matters Hiro Tanaka Consultant Orthopaedic Surgeon Aneurin Bevan University Health Board Wales 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 Overcoming Hurdles During Shadowing: In the Field 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. Cynthia Rasmussen, MD Harvard Vanguard Medical Associates Note:! Care Givers! Touchpoints! Time! Patient Comments! Your Observations! Anxiety/Emotive Response PFCC%Innova*on%Center%of%UPMC% 10%

11 Some Popular FAQ: Won t Care Givers change their behavior if they know they are being Shadowed? FAQ: Should a Shadower ever intervene on behalf of the patient or family? FAQ: How Many Times? After Shadowing: Sharing Findings Tangible and Thought Provoking! Tell the Patient s Story! Report in Order of Experience! Share Observations & Recommendations! Include Care Experience Flow In fact, start with mapping what you think the flow looks like Let s use an outpatient office visit as an example PFCC%Innova*on%Center%of%UPMC% 11%

12 Office Visit Pre Shadowing Care Experience Flow Map Touchpoints: Care Givers: Because Clinic Suite Reception Desk Waiting Room Exam Room Registrar Medical Assistant Nurse Physician Asst./Dr. Office Visit Post Shadowing Care Experience Flow Map Touchpoints: Care Givers: 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 Touchpoint Parking(Lot( Doctor's Office( Suite Reception( Desk Waiting Room Exam Room Hallway Lab Parking(Pay Window Patient/Family(park( car(trouble(finding(( right( garage(7:15(a Entrance(to(clinic( 7:27(A Checked(in(with front(desk( receptionist(7:28(g 7:35(A 60(minute(wait(;(called( back(by(medical(assistant,( 8:35(A Assessment(by( physician(assistant( and((doctor(9:15g9:30 Care Giver/Time Patient(/Family(sent(to( desk to(get(rx(for(lab( work((9:37(a Get(lost(on(way(to(lab;((no(clear( signage;(shadower(intervenes(and( assists(them(with(wayfinding(9:49(a lab technician( performs(blood(draw( 10:14(A Patient(/Family(back(to( desk((to(check(out( from(appointment( 10:26(A Patient/Family((stop( at(parking(window( to(pay(for(parking;( cashier(10:42(a Patient/Family(exit(( garage(after(finding( car((11:02((a Sample: Office Visit Care Experience Flow Map Your Turn! Go Shadow PFCC%Innova*on%Center%of%UPMC% 12%

13 In the Field ER Hallway ER Treatment Room Patient and Family Reunion Imaging Creating Your Shadowing Report What to Include PFCC%Innova*on%Center%of%UPMC% 13%

14 GoShadow Reports Care Experience Flow Map: A map of the patient s journey including all TPs and CGs Comprehensive Report: Captures qualitative and quantitative aspects of the care experience Observational Report: A report that captures as much info you were able to gather while shadowing Opportunity Report Highlights any observations that may be an improvement opportunity Time Studies Tracks the amount of time patient travels from TP to TP and with Care Givers Putting It all Together Your report the patient s story will compel people to action. Writing and Presenting Reports Pictures are Worth! 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 A Thousand Words Your Turn Care Experience: Date: Shadower: Request: PFCC%Innova*on%Center%of%UPMC% 14%

15 PFCC%Innova*on%Center%of%UPMC% 15% Patient and Family Bio ED Care Experience Flow Map Touchpoints: Care Givers: In the Field Exam Room Waiting Area Imaging

16 Opportunities/Suggestions Impact Projects: Real World Results from Shadowing Cervical Spine Clearance Impact of Shadowing: Going Home with Meds in Hand Average Time Spent in Collar Hours Process Change 24/7 Attending Increased compliance Decreased clearance time, 50 then 70% Previous attempts to address issue unsuccessful Decreased length of stay Increased patient satisfaction YR 1 YR 2 YR 3 YR 4 YR 5 Reducing readmission rates Improving health Impact of Shadowing: Reducing Readmissions Infant Security Staff Shadowing b/w inpatient and outpatient settings Self Management tools developed Reduced readmission rate Projected Annual Cost Savings = $400K Without Shadowing, we never would have known that our new protocol was missing the mark. Maribeth McLauglin, CNO Magee-Womens Hospital of UPMC PFCC%Innova*on%Center%of%UPMC% 16%

17 Shadowing Network Power of One Goal: A framework to drive change across your Health System Create Horizontal Connectors to adopt, accelerate, and spread the PFCC Methodology and Practice Be the Spark. Ignite Change. Q & A Patient Centered Value System Experiences ^ Dr. Tony DiGioia December 6th, ^ Outcomes ^ COST PFCC%Innova*on%Center%of%UPMC% 17%

18 The Cost Crisis The Final Frontier Outcomes Value = (Important to Patients) Cost Actual Costs Not Chargemaster or Reimbursements Hospital Charges $89,104 Patient $100 Total Joint Replacement Insurance Company $26,696 Hospital Reimburse ment The Final Frontier Outcomes Value = (Important to Patients) Cost Actual Cost to Deliver Care Time Driven Activity Based Costing For a full cycle of care: Personnel Space Equipment Consumables All resources for any clinical condition Robert S. Kaplan and Michael E. Porter How to Solve the Cost Crisis in Health Care, HBR 2011 Steps to Determine the Actual Cost of Care " What activities are performed? " What Care Giver is performing each activity? " What other resources (space, equipment, and consumables) are used? " How long? Minutes $/Min " What is the cost per minute? for each Care Giver and resource? $ PFCC%Innova*on%Center%of%UPMC% 18%

19 Steps to Determine the Actual Cost of Care We Needed a Connector Identify Segment of Care Create Process Maps Determine Time That Each Resource is Used Determine $/min per Resource Calculate Total Costs Minutes $ $/Min We Needed a Connector Real World Example Home TJR: Actual Costs for CMS CCJR, Bundling and Referenced Pricing Physician Office Acute Hospital Health Pharmacy Insurance Home Health Outpt Therapy Rehab or Skilled Nursing Facility Follow the Patient *What is the total # of provider categories? # Personnel Categories # Organizations Pre- Inpatient Post- Hospital Hospital Beyond the Walls of the Hospital = PFCC%Innova*on%Center%of%UPMC% 19%

20 True Costs for the Full Bundle THR TKR Space 2% Consum ables 52% - Equipment 1% Personnel 45% Space 2% Consum ables 45% - Equipment 3% Personnel 50% 1 Month Before to 3 Months PO Process Improvement and Refocusing Resources 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 1% 1% 7% 7% 2% 2% 20% 17% 16% 12% 3% 3% TKR THR 51% 58% 0% 10% 20% 30% 40% 50% 60% 70 OR Costs OR Costs Space 1% Equipment 0.4% Space 1% Equipment 0.4% Space 1% Equipment 0.4% Space 1% Equipment 0.4% Consumables 83% Personnel 16% THR Consumables 78% TKR Personnel 20% Consumables 83% Personnel 16% THR Consumables 78% TKR Personnel 20% (Implant 86% of Consumables) (Implant 79% of Consumables) Space 1% Consumables 83% OR Costs Personnel 16% THR Implant Cost in a Bundle Equipment 0.4% (Implant 86% of Consumables) Space 1% Consumables 78% Equipment 0.4% TKR Personnel 20% (Implant 79% of Consumables) THR: 40% TKR: 30% Consumable Costs (THR) For the Full Bundle 53% of Cost related to Consumables 77% Implant 11% Medications 5% Custom Hip Pack 2% General Nursing 2% Saw Blades 1% Skin Antiseptic 1% Surgical Dressing 1% Suture Materials PFCC%Innova*on%Center%of%UPMC% 20%

21 Personnel Capacity Rate ($/min) Total # of Personnel = 46 Categories #1-10 #36-46 Orthopaedic Surgeon 11.6 Administrative Assistant 0.4 Radiologist 8.1 Health Unit Coordinator 0.4 Cardiologist 6.0 Rehab Aide 0.4 Anesthesiologist 5.8 Registrar 0.4 Internist 3.0 PT Office Assistant 0.4 CRNA 1.8 Pharmacy Tech 0.4 Nurse Practitioner Office 1.2 Room Service Attendant 0.4 PA - Office 1.2 Transporter 0.3 PA - Hospital 1.1 Housekeeping - SSA 0.3 Sr. Prof Staff RN 1.1 Sales Rep 0.01 TKR: Personnel Time and Cost 21% 2 Physicians Time (Hours) 6% 4 Mid Level Providers 30% 118 Nursing 21% 33 Rehab % of TKR Personnel Cost 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 6% Anesthesia Team % Support Staff Time Commitment and Wasted Time for Patients (TKR) Actual Patient Time Unproductive Time Hospital to Hospital Comparison $8,000 $7,000 $6,000 $5,000 Facility #1 Facility #2 $4,000 $3, Hours ~4.6 Days 0.2 Hours 30 Days Before Surgery to 90 Days Post Surgery $2,000 $1,000 $0 Pre-Op + Office Pre-Op Testing + Consults Day of Surgery + OR PACU Inpatient Stay Therapy Follow Up Visits Year 1 Joint Replacement Learning Community 12 Month Collaborative 32 Organizations Implant Costs 4x Variation High Impact Variation Types of Anesthesia: General, Spinal ± Intrathecal Morphine, Nerve Blocks, Intra-articular Injections OR Time (TKR): 31 to 155 mins CMS - Comprehensive Care for Joint Replacement (CCJR) Starting Jan 1 st, 2016 Episode: 90 days Hospital Focused $ s Risk/Benefits PFCC%Innova*on%Center%of%UPMC% 21%

22 Breast Imaging True Cost Project Tomography, deemed Experimental (no coverage) Findings: very slight actual cost difference between Mammogram and Tomography Building the business case for coverage Breast Imaging True Cost Project Check In to Check Out $100 Total True Cost $80 $60 $40 $20 $0 Mammogram Tomography Patients and Families are the only way for us to understand and deliver value Value for Patients and Families Results in Value for Care Givers and Organizations Where s the Value? Value is not intrinsically found in any value based payment model but is created and increased by co-designing care delivery Operationalize the Patient Centered Value System Care Experiences Clinical Outcomes, Quality and Safety Patient and Family at the Center True $ Cost Patient Reported Outcomes Triple Aim = Value Trifecta Population Health Experience of Care Per Capita Cost No Margin No Mission PFCC%Innova*on%Center%of%UPMC% 22%

23 Shadowing for Cost Now That You Know How to Shadow You can now shadow in order to determine the actual cost to deliver care! Lisa Schraeder, MS ~ Senior OD Consultant ~ Patient Experience ~ PFCC Innovation Center of UPMC Steps to Determine the Actual Cost of Care " What activities are performed? " What Care Giver is performing each activity? " What other resources (space, equipment, and consumables) are used? " How long? Minutes $/Min " What is the cost per minute? for each Care Giver and resource? $ Easy as a Click of the Camera Already Have: " Care Givers/Personnel " Touchpoints/Space " Time All You Need is:! Consumables! Equipment The Imaging Experience Care Givers: Nurse ER Physician Radiologist Aides (2) The Imaging Experience Equipment MRI Scanner Ventilator Gurney Touchpoints/Space: Radiology Room PFCC%Innova*on%Center%of%UPMC% 23%

24 The Imaging Experience Shadower s Role Consumables Vent Tube Catheter Central Line Capture the Shadowing Experience Add/include photos of: Space Consumables Equipment Share all info with Project Team/Champion ER example True Cost Map And Wouldn t you rather reduce actual cost than Now What? GoShadow! PFCC%Innova*on%Center%of%UPMC% 24%

25 Merging Technology and Process Improvement goshadow.org Videos GoGuides Case Studies Articles Resources PFCC.org PFCC%Community%of%Prac8ce% What%Ma'ers%to%You?% PFCC%Community%of%Prac8ce% mypfcc The%Pulse%of%Pa*ent%and%% Family%Centered%Care% Blog.PFCC.org% PFCC%Community%of%Prac8ce% Resources At the back tables! MyPFCC Step-by-Step GoShadow sign up Step-by-Step PFCC%Innova*on%Center%of%UPMC% 25%