The Patient Centered Value System: Transforming

Healthcare through Co-Design

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 Pull quotes for The Patient Centered Value System:
Transforming Healthcare through Co-Design, by
Anthony M. DiGioia, M.D. and Eve Shapiro
“The spiraling costs of healthcare and diminishing value for organizations,
patients, and families requires a new, transformative approach to healthcare deliv-
ery. The Patient Centered Value System is the answer to lowering costs, improv-
ing clinical outcomes, and increasing the patient and family care experience. The
PCVS has resulted in tangible improvements on all levels at the Connecticut Joint
Replacement Institute at Saint Francis Hospital.”
—Steve F. Schutzer, M.D.,
Medical Director, Connecticut Joint Replacement Institute, President, Connecticut
Joint Replacement Surgeons, LLC

“The Patient Centered Value System: Transforming Care through Co-Design offers
a highly readable and practical approach for dramatically improving patient out-
comes and experiences. As health care consumers, we would definitely want our
providers to be following the Patient Centered Value System principles, delivering
high-quality, empathetic, and lower-cost patient care.”
—Robert S. Kaplan,
Marvin Bower Professor of Leadership Development, Emeritus at the Harvard
Business School

“This book captures perfectly the challenge that faces quality improvers every-
where: that lasting change can only be achieved through a change in mindset
which places patients and families at the centre of the improvement agenda. The
Patient Centered Value System is one of the few approaches which does just this.
This system works. What it also does is transform the working lives of the staff
applying it, reconnecting them powerfully with their core mission to care. It has
been a privilege to use this approach with teams from around the United Kingdom,
and a joy to see the changes they make when they see care through patients’ eyes.”
—Bev Fitzsimons,
Head of Improvement, Point of Care Foundation, U.K.

“DiGioia and Shapiro have achieved the goal of every author: to make under-
standable that which is complex, and to make implementable complex principles.
When the subject is patient (and family)-centered care, those goals are both formi-
dable and critical to the nation’s health.”
—John R. Ball, M.D., J.D,
Executive Vice President, Emeritus, American College of Physicians

“This book will teach you how to see. Whether you are a hospital CEO, as I have
been, or a care giver at the front lines of care, as I have been, this book will
open your eyes to the journey of a patient and family throughout care. The care
systems of the future will be designed with and for our patients and their families.
This book is the best guide to give you the tools and methods to co-design care
with them.”
—Maureen Bisognano,
President Emerita and Senior Fellow, Institute for Healthcare Improvement
 The Patient Centered
Value System
Transforming Healthcare through
Co-Design

By Anthony M. DiGioia, M.D. and Eve Shapiro

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Library of Congress Cataloging‑ in‑ Publication Data

Names: DiGioia, Anthony M., author. | Shapiro, Eve., author.

Title: The patient centered value system : transforming healthcare through
co-design / Anthony M. DiGioia and Eve Shapiro.
Description: Boca Raton : Taylor & Francis, 2018. | “A CRC title, part of the
Taylor & Francis imprint, a member of the Taylor & Francis Group, the
academic division of T&F Informa plc.” | Includes bibliographical
references and index.
Identifiers: LCCN 2017014903| ISBN 9781138055964 (hardback : alk. paper) |
ISBN 9781315165615 (ebook)
Subjects: LCSH: Patient centered health care. | Managed care plans (Medical
care) | Health services administration.
Classification: LCC R729.5.H43 D54 2018 | DDC 362.1/04258--dc23
LC record available at https://lccn.loc.gov/2017014903

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 For patients, families, and providers everywhere.
For Don Berwick, Maureen Bisognano, Gene Lindsey,
and Bev Fitzsimons for their enthusiasm, encouragement,
and support of patient and family centered care, for
demonstrating how to drive transformational change,
and for continuing to inspire and lead the way.
For the early adopters of the Patient Centered Value
System and its components, who have helped this
dynamic methodology to evolve and transform the care
and experiences of patients, families, and providers.
For the giants on whose shoulders the Patient Centered Value
System is built: John Kotter, Tim Brown, Paul Bate, Glenn
Robert, Herbert Simon, B. Joseph Pine II, Clayton Christensen,
Stephen Denning, Robert S. Kaplan, and Michael Porter.
And, in gratitude, to my wife, Cathy (A.M.D.), and my husband,
Howard (E.S.). We couldn’ t have done this without you.
Contents

List of Figures...................................................................... xi
List of Tables......................................................................xiii
Foreword.............................................................................. xv
Preface................................................................................. xix
Acknowledgments............................................................ xxv
About the Authors.......................................................... xxvii
Introduction.....................................................................xxix

Part I  THE PATIENT CENTERED VALUE

SYSTEM IN ACTION: A STORY
Prologue: The Epiphany...........................................................3
1 How to Introduce the Patient Centered Value
System in Your Organization..................................15
2 Choose Your Champions: Establish the Care
Experience Guiding Council...................................31
References .......................................................................... 44
3 Shadow Patients and Families to Co-Design the
Care Experience......................................................45
4 Develop Your Care Experience Working Group.....69
5 Create a Shared Vision by Writing the Story of
the Ideal Care Experience.......................................93

vii
viii ◾ Contents

6 Close the Gaps between the Current State and

the Ideal................................................................ 111
7 The Patient Centered Value System: Fact, Not
Fiction................................................................... 153

Part II  DETERMINE AND DRIVE DOWN

THE TRUE COST OF CARE DELIVERY
AND ACHIEVE THE TRIPLE AIM
8 Determine the True Cost of Care Using
Shadowing and Time-Driven Activity-Based
Costing.................................................................. 159
Origins of the Patient Centered Value System................. 162
What Is Time-Driven Activity-Based Costing in the
Context of the Patient Centered Value System?...............163
Benefits of Time-Driven Activity-Based Costing..............164
Time-Driven Activity-Based Costing Plus Shadowing:
A User’ s Manual................................................................165
Step 1: Shadow the Care Segment(s)............................166
Time Detail for Personnel, Space, and Activities..... 167
Photo Option for Consumables and Equipment...... 167
Step 2: Develop Time-Driven Activity-Based
Costing Process Maps................................................... 167
Step 3: Calculate Costs in Four Buckets of
Resources— Personnel, Space, Equipment, and
Consumables— to Determine Cost Drivers and Start
Process Improvement Efforts........................................ 170
Personnel................................................................... 173
Consumables............................................................. 174
Space.......................................................................... 175
Equipment................................................................. 176
Calculate the Actual Cost of Each Care Segment
and the Full Cycle of Care........................................177
The Patient Centered Value System: Identify Cost
Drivers to Begin Improvements...................................177
Cost Drivers............................................................... 179
 Contents ◾ ix

Implement the Patient Centered Value System............180

The Need for the Patient Centered Value System in
Today’ s Healthcare Environment..................................182
References......................................................................185

Part III  THE PATIENT CENTERED VALUE

SYSTEM: THEORY AND PRACTICE
9 The Science behind the Patient Centered Value
System: Built on the Shoulders of Giants.............189
“ Borrowing Brilliance” ......................................................196
Shadowing Patients and Families.................................196
Shadowing to Determine Actual (True) Costs.............197
Storytelling and Storydoing..........................................198
High-Performance Care Teams.....................................199
Overcoming Expected Hurdles................................... 200
Conclusion.........................................................................201
References .........................................................................201
10 Patient Centered Value System + Lean or Other
Process Improvement Approaches = Rapid
Improvement.........................................................203
Similarities between the Patient Centered Value
System and Other Process Improvement Approaches.....204
Differences between the Patient Centered Value
System and Lean or Similar Process Improvement
Approaches........................................................................205
Shadowing.....................................................................206
Performance Improvement...........................................207
Integrating the Patient Centered Value System with
Lean and Similar Process Improvement Approaches......209
Conclusion.........................................................................210
References ......................................................................... 211
11 The Patient Centered Value System in Practice....213
Patient Partnerships = Engagement = Better Outcomes..... 214
The Problem.................................................................. 214
x ◾ Contents

The Real-World Solution............................................... 214

Eliminating Waste and Creating Efficiencies While
Improving Clinical Outcomes...........................................226
The Problem..................................................................226
The Real-World Solution...............................................227
Reducing Readmissions....................................................229
The Problem..................................................................229
The Real-World Solution...............................................229
Reducing Staff Turnover....................................................232
The Problem..................................................................232
The Real-World Solution...............................................233
Reducing the Cost of Care................................................234
The Problem..................................................................234
The Real-World Solution...............................................234
Conclusion.........................................................................235
References .........................................................................236
Glossary.......................................................................239
Appendix.....................................................................249
Index...........................................................................253
List of Figures

Figure   3.1   (a) The Patient Care Experience Flow Map

(b) The family Care Experience Flow Map...............................65
Figure 4.1   Sample of a Level I Trauma care Shadowing
report.......................................................................................... 80
Figure 6.1   PFCC Project fast-track card..............................137
Figure 6.2   Trauma gold pass............................................... 145
Figure 8.1   Segments and sub-segments for the full
cycle of care for a patient requiring surgery...........................166
Figure 8.2   Time-Driven Activity-Based Costing process
map for the pre-operative testing segment of care.................169
Figure 8.3   Process mapping the billing segment of care..... 171
Figure 8.4   Process mapping for the central sterilization
of the operating room.............................................................. 172
Figure 8.5   Combining the time used with the cost per
minute to calculate the actual cost to deliver care.................. 173
Figure 8.6   (a) Determining costs for an x-ray
technician, (b) calculating personnel capacity for an x-ray
technician.................................................................................. 174
Figure 8.7   Calculating the cost of consumables in the
operating room......................................................................... 175

xi
xii ◾ List of Figures

Figure 8.8   Calculating the space costs associated with

the radiology suite.................................................................... 176
Figure 8.9   Costs associated with the x-ray machine.......... 176
Figure 8.10   Example of Time-Driven Activity-Based
Costing process map for a new patient office visit................. 178
Figure 8.11   Calculating the cost of an x-ray taken in
the pre-operative testing segment of the Time-Driven
Activity-Based Costing process map........................................ 179
Figure 8.12 Total cost calculation for patient receiving
a chest x-ray..............................................................................181
Figure G.1 The six steps of the Patient and Family
Centered Care Methodology....................................................243
List of Tables

Table 1   Comparing Berwick’ s new moral era in

healthcare to the Patient Centered Value System................ xxxiv
Table 2.1   Roles and responsibilities of PFCC Guiding
Council Members........................................................................38

xiii
Foreword

Everything possible begins with civility.

Robert Waller M.D.

Excellence in healthcare depends on the quality of relation-

ships with patients and families— really listening to what they
want and need— and remembering the values that led health-
care professionals to their calling in the first place. Gone are
the days when the simple view that “ the doctor knows best”
suffices. Now, if we listen carefully and with open minds to
what patients and families tell us, we can find the best com-
pass toward improving our delivery of care and their care
experience. This is healthcare “ co-design,” and it is the wave
of the future.
Developing relationships with patients and families, prac-
ticing civility, and embracing transparency come first, but the
spiraling costs of healthcare also need to be understood and
brought under control for the benefit of patients, families,
communities, providers, and organizations. Do the bills that
patients and families receive from hospitals reflect the true
cost of their care? Neither patients, nor families, nor providers
can answer this question because the true costs of care— as
opposed to charges or reimbursements— remain unknown.
Providers and organizations need to know what it really costs
to deliver care if they are to reduce costs while at the same

xv
xvi ◾ Foreword

time improving quality and experiences and providing real

value.
In The Patient Centered Value System: Transforming
Healthcare through Co-Design , Anthony M. DiGioia M.D. and
Eve Shapiro present an approach both to co-designing care
delivery with patients and families and to calculating the true
costs of care for medical or surgical conditions over the full
cycle of care. Section I of the book is written as the story of
healthcare providers who are inspired to practice co-design
by seeing the care experience through the eyes of patients
and families using the powerful tool of “ Shadowing” and the
Patient and Family Centered Care Methodology. Section II of
the book begins with a focus on Time-Driven Activity-Based
Costing, first developed by Kaplan and Anderson (2007),
which in the Patient Centered Value System uses Shadowing
to calculate all of the costs— including the hidden costs— of
delivering healthcare. Section III of the book explains the
theoretical underpinnings of the Patient Centered Value
System, and how this approach can be combined with pro-
cess improvement approaches, such as Lean Thinking, that an
organization may already be using. It describes organizations
that have used the Patient Centered Value System, along with
the results they have achieved.
I highly recommend this book to healthcare professionals
of all types and at all levels, including chief executive offi-
cers, chief financial officers, and those responsible for quality,
safety, and patient care. The Patient Centered Value System
as the new operating system for healthcare delivery points
the way to personal and professional satisfaction and the
experience of joy in work while helping patients and families
become true partners in care through co-design.

Donald M. Berwick, M.D.

President Emeritus and Senior Fellow,
Institute for Healthcare Improvement.
 Foreword ◾ xvii

Reference
Kaplan, RS, Anderson, SR. 2007. Time-Driven Activity-Based Costing:
A Simpler and More Powerful Path to Higher Profits. Boston,
MA: Harvard Business School Publishing.
Preface

The existing deficiencies in health care cannot be corrected

simply by supplying more personnel, more facilities and more
money. These problems can only be solved by organizing the
personnel, facilities and financing into a conceptual framework
and operating system that will provide optimally for the health
needs of the population.

Robert Ebert ,
Dean, Harvard Medical School, 1965

In the more than 50 years between that statement and this

moment, we have been on a frustrating journey, searching for
an operating system and finance mechanism that could “ pro-
vide optimally for the health needs of the nation.” In 2007, the
Institute for Healthcare Improvement crystallized Ebert’ s vision
as the “ Triple Aim” :

◾◾ Improving the patient experience of care (including qual-

ity and satisfaction)
◾◾ Improving the health of populations
◾◾ Reducing the per capita cost of healthcare

More recently, that terse description has been given

greater meaning by being restated as, “ Care better than
we’ ve seen, health better than we’ ve ever known, cost we

xix
xx ◾ Preface

can afford … for every person, every time” (Institute for

Healthcare Improvement 2015– 2016).
Since recasting Ebert’ s description of the “ deficiencies in
healthcare” into a pursuable objective that we can all accept
and understand, we have diligently searched for easily spread-
able methodologies in pursuit of the Triple Aim. Many of us
have tried hard to adopt and spread Lean as this operating
system and some have succeeded, but there has always been
significant resistance as clinicians struggle to see how method-
ologies developed in manufacturing can be applied to the care
of people.
Healthcare professionals have often been unable to connect
the industrial methodologies of process improvement to their
work without a sense that they are losing the essence of why
they became clinicians in the first place. The “ adaptive work”
of continuous improvement, which seems to require them to
give up what they value most, has often felt like a poor fit.
Many a Lean transformation has stalled because of the per-
ceived tension between clinical values and continuous process
improvement toward the Triple Aim.
Since 2006, Anthony M. DiGioia, M.D. and colleagues at
Magee-Womens Hospital, University of Pittsburgh Medical
Center (UPMC), have been working to bring clinicians and
medical institutions a continuous performance improvement
methodology that has its roots in the values of good clinical
practice. This book presents the outcome of this work, called
the Patient Centered Value System. The Patient Centered Value
System is a comprehensive approach to healthcare delivery
that comprises three essential tools— Shadowing, the Patient
and Family Centered Care Methodology, and Time-Driven
Activity-Based Costing— while complementing and fully
embracing current process improvement efforts such as Lean
and the Toyota Production System as described later. The
Patient Centered Value System integrates the scientific meth-
ods, clinical values, and objectives of continuous improve-
ment. Reading about the Patient Centered Value System
 Preface ◾ xxi

should feel familiar to anyone interested in quality, safety,

efficiency, and the traditions of professionalism. The Patient
Centered Value System feels as though it has evolved organi-
cally from a desire to improve the experience of care by
seeing the entire care experience through the eyes of patients
and families.
Section I of The Patient Centered Value System:
Transforming Healthcare through Co-Design uses the tech-
nique of storytelling to quickly connect with readers fac-
ing new and challenging learning curves of their own. Over
the course of a long career, I have played many of the roles
depicted in the story: the enthusiastic Chief Executive Officer
(CEO), the physician leader, and the reluctant and skeptical
clinician. The roles that I have not played I have observed in
others in numerous efforts to improve care and advance the
mission of our organization against significant internal resis-
tance and harsh externalities. I can testify that the character-
izations in the story are effective presentations of the many
ways that real people react to the challenges of change. The
story demonstrates that adaptive change is both an interactive
process and a challenging learning curve that must be climbed
for both individuals and groups.
The book begins with a story that demonstrates the princi-
ples and objectives of Shadowing in action. As a former leader
who has struggled with introducing the need for change, the
dialog and the actions described in the story feel realistic. It is
easy to recognize the leadership challenges and the need to
build a guiding coalition of diverse stakeholders. What is most
powerful about the story, for me, is how the CEO of Exemplar
Memorial Hospital, Dr. Ben Highland, keeps bringing the
reasons for change back to the best care of the patient, the
hospital’ s mission, and the foundational principles of profes-
sionalism. As he introduces his colleagues to the what, why,
and how of the Patient Centered Value System, the reader
learns right along with them. The detail that Dr. Highland
presents is so complete that readers should be encouraged to
xxii ◾ Preface

introduce the Patient Centered Value System in their own orga-

nizations simply by emulation.
Sections II and III of this book serve as the didactic
resource written in the usual tradition of the medical litera-
ture that Dr. Ben Highland might have used in leading his
colleagues to understand the power of the Patient Centered
Value System. The story portion of the book and the technical
portion cover the same issues in a highly complementary way.
Repetition and review are the keys to learning.
The information in the Introduction is so useful to under-
standing the evolving state of healthcare and the theory and
science of continuous change that it deserves special mention.
If the book just began without some set-up to the story, many
readers might miss some of the messages the story delivers.
The Introduction should not be quickly glossed over. It has
great merit as a stand-alone piece.
My favorite chapter is Chapter 8, “ Time-Driven Activity-
Based Costing in the Patient Centered Value System: A User’ s
Manual,” which demonstrates how to use Shadowing along
with the costing approach developed by Robert S. Kaplan
and Steven R. Anderson (2007) to determine the true cost of
care delivery. Any organization that hopes to lower its costs
to succeed in the era of value-based reimbursement needs
to develop competency in combining Shadowing with Time-
Driven Activity-Based Costing. This ‘ monograph’ within a
book makes the subject easy to understand and demonstrates
nicely how it can be implemented.
Chapter 10, “ Patient Centered Value System + Lean or Other
Process Improvement Approaches = Rapid Improvement,” is
also of particular interest because it explains how to add the
Patient Centered Value System to other process improvement
approaches you may already be using to accelerate the pace
of change. Lean is a management philosophy in continu-
ous evolution. Just as the English language has continuously
become richer and more effective by adopting new words
and expressions from other cultures and languages, Lean too
 Preface ◾ xxiii

has always been in a process of continuous acquisition. Ever

since a rainy Saturday morning when I first met Dr. DiGioia
in downtown Boston to hear about the Patient Centered Value
System, I have stressed how compatible his work is with our
Lean efforts. How does “ going to the gemba” really differ
from Shadowing? The projects that are chosen as the focus for
improvement in the Patient Centered Value System are quite
similar to kaizen, or rapid improvement, events.
What is different about the Patient Centered Value System is
the explicit focus on the patient and family as the core con-
cern. In this book, the elimination of waste and the improve-
ment of the care process are articulated more clearly as an
extension of our professional accountability and values than
often comes through to clinicians as they struggle with their
prejudices against Lean as a form of “ medical Taylorism.” In
Chapter 10, the authors embrace this compatibility between
their methodology and other forms of continuous improve-
ment, including Lean. This is huge!
Perhaps the two greatest barriers to success with any
improvement methodology are “today’s work” and the time and
effort that individuals must devote to learning how to use any
new methodology. Competent and committed leadership that
extends deep into the enterprise can lower those barriers, yet
patients and families who are given the opportunity to co-design
the healthcare experience are the true catalysts for change.
Two additional barriers to change in many organizations
are the costs of consultant help in managing the change
process and revenue lost when frontline staff are required to
learn the methodology. If one considers the broad spectrum of
healthcare organizations across the nation, it is easy to realize
that many just do not have the resources to invest in consult-
ing and their staff doesn’ t have time to read and digest the
message of a long technical treatise describing a new approach
to practice. The authors of The Patient Centered Value System:
Transforming Healthcare through Co-Design definitely con-
sidered these realities as they wrote this book. An interested