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

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


01. Introduction
Founding principles • Healthcare innovation • Caregiver/patient communication


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.


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).


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


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?”


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).


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.


03. Hypothesis
Patient journey • Why focus on discharge?


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).


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

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.


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


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


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.


“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


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)

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Patient’s perspective of the emotional dimensions during the discharge experience
Recovering Accepting Choosing Planning Learning Leaving Transitioning
Pain points and emotional considerations
Patient is on medication and and
Patient has woken up Many times, patient will be Patients will have tohave any family Patients/family and the
Patient does not make The patient is on medication and has is has been given the
Patient is given instructions Patient Patient is in the care of The service blueprint of the discharge experience on the left has been
is waiting to hear information told that going home will not amemberswiththe area to help choose
decision in family about nursing staff will plan the regarding medications,in the medication
a recap approval to leave and must a family doctor or other
Patient has anxiety about whether a hard time soaking overlaid with an emotional dimension. This emotional dimension is a short
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.
his procedure went well. a facility with him. His insurance also instructions the nurses are telling him. narrative from the patient perspective that captures frustrations, anxieties,
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
He awaits for his doctor to doesn’t give him many choices. He has He also feels anxious trying to gather and sadness that may occur during the discharge phase of the patient
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.
provide any kind of news.
at home. skilled nursing facility (SNF).
to decide where to go with caregivers.
to stay.
all his belongings before leaving. journey.
Optimizing Family may be Asking patient Patient consults with Intern/attending tells Patient & family Patient can Communication
physical directly involved in and family what is caregivers to decide patient she/he is to presented with access MyChart about condition with
If a patient is not going to be able to go home and has to be moved to a
parameters finding a facility meaningful to them where to transition be discharged soon instructional info (EMR) outpatient physician post-acute care setting, long-term care setting, or skilled nursing facility,
this news may be difficult for some patients. It is a lifestyle transition that
Teaching & assessing Explaining/estimating Providing options Discharging Educating Continuing care
Patient is told that he cannot go home Due to his special needs, he needs specific The patient has a hard time remembering the requires a readjustment of one’s habits as well as accepting big changes
Physician may bring in and will have to go to a nursing home.
Discussing d/c with patients Based on patient’s insurance Resident/intern and sometimes Until their the nurse provides
caregivers to help move him. Usually avail- instructions the nursesOutpatient medical team
told him. Luckily, for that may or may not have been expected. If a patient has accepted that
residents/interns into the He is in a lot of emotional distress
and giving wishy-washy, and condition, caregivers will the attending willto remain at the hospital. He notes along with
ability, he has let the d/c summary may take over at this point.
now, the caregivers at the facility are taking things will not be the same, he/she must still consider what is most
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
since he’s always said to himself, “I’d ends up staying an extra day since those who care of that. But he’s going home soon and meaningful to him/her and make an important choice (e.g. a patient may
condition in front of interns. patient may be discharged. locations to where patients ready to leave. More accurate may provide instruction(s)
rather die than go to a nursing home.” can help him already ended workmedication instructions, to
at 4 pm. wonders if he’ll be able to manage on his own. decide to live with her daughter and choose to not go to a healthcare
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. facility for the pleasure of being able to spend time with her grandchildren).
Therefore, the “Accepting” moment of the patient journey during discharge
Chief/attending Filtering and Once patient/family
line of visibility teaches how to doing background has selected a place,
is a critical time.
assess patient paperwork caregiver can take
care of logistics
Another critical moment during the discharge phase is the “Learning”
Assessing: biomedical Researching Finalizing d/c orders
(“Educating,” from the caregiver perspective) period. Although this is a
Physician is trying to optimize Intern discussing d/c with case Intern (or physician) is vital moment to transfer instructions on how best to care for oneself and
biomedical condition. May management or d/c planner. finalizing d/c orders. This is transfer medication instructions, patients may be physically and emotionally
not have continuity of care needed for nurses to do their
(same doctor as before). Researching and contacting job of instructing the patient.
drained; therefore, they may be unable to fully comprehend what the
“Technicians” and not possible rehab or nursing Rehab/nursing facilities need caregivers are telling them. Some may just be eager to get out of the
Summarizing d/c orders Moving along Arranging follow-up hospital so the information does not process well. In addition, while it is
“holistic healers” may see facilities for patient to go to. to have this to prepare in
their work done at this point. Intern starts d/c summary advance. Attending or intern at this point Possible home-care nurses or ideal that caregivers can take their time to provide these instructions, they
(personalized narrative does not really know what home teams may visit homes. are also busy, most likely multitasking and caring for multiple patients, and
Backstage “Will patient be Dance between Back and forth for what happened during D/c orders used has happened with patient. may not provide a comprehensive discharge plan.
Caregiver able to function biomed & functional with rehab/ patient’s stay). to prep at rehab/ They have most likely moved Visiting Nurse Association
Actions at home?” assessment nursing facilities nursing facility
on to other patients or may (VNA), independent
If this “Learning” moment does not have sufficient negotiations between
Assessing: functional Communicating Sent to attending for Coordinating be in the middle of providing Transmitting patient info organization may visit.
approval. treatment/surgery. caregivers and patients as well as quality interactions, patients may
Nurses usually in charge of Case managers Case managers will coordinate Caregivers should transmit incorrectly take prescribed medications or not adhere to the care plan
this. For worst cases, need a communicating with potential with rehab or nursing facility information about patient to created by the hospital discharge team.14 This results in early readmission
social worker or d/c planner. rehab or nursing facilities and if patient requires a transition outpatient medical team.
determining feasibility and to another venue. This is
or the worsening of patients’ conditions and has severe consequences for
Physical therapist may help possibility of having patient important for compilcated If this never happened, there them as well as Cleveland Clinic.
with ADL and IADL. go there (Case managers patients (i.e. 400lb patient is a heavy reliance on EPIC
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)
14 J. Stone and G. J. Hoffman, “Medicare Hospital Readmissions: Issues, Policy Options, and
PPACA,” Published by the Congressional Research Service, September 21, 2010.
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Research synthesis: generation of themes
There are four major themes that emerged from the research:

Redeeming the time
“Filling the unforgiving minute” - Rudyard Kipling (“If”)

Spending quality time with patients is a challenge for
physicians who are already overburdened with other tasks (i.e.
documentation). This theme captures the desire of caregivers
as well as patients to make the most of time spent together. If
time is limited, there may be a way to make the most of it.

Simplifying information
“Omit the unimportant” - Dieter Rams

Patients receive a lot of information during the discharge phase 05. Product
and have a difficult time differentiating and understanding the
essential information. It is a challenge presenting information in
Actions+words+props • Concepts • Business case
a way that resonates and sticks in the mental model of patients
and families. One way is to keep the information simple.

Restoring dignity
“What a piece of work is a man” - W. Shakespeare (“Hamlet”)

Upon entering a healthcare setting, patients will often “lose”
their dignity. This may be inevitable as doctors must consider
broken body parts/systems as a technician would. However,
once treatment is done (and even during the process), people
are still people and possess the sactity of life. This theme
captures the need to uphold the dignity of people as often as
possible and in case when it’s “lost,” to restore immediately.

Supporting transitions
“You cannot step into the same river twice” - Heraclitus

After treatment, people must go through a physicial or
environmental transition as they prepare to move from the
hospital to another facility or home. This theme of transition
also captures the notion that people’s livestyles and/or being
may be completely altered. In many cases, they may return to
the same location as a different person, or a different location
as a different person.

40 Project Report 41

Ideation using actions, words, and props
Using the four themes from research, three main ways of understanding
interactions between doctors and patients were explored:

Actions:
The “Cleveland Clinic Experience” interactive learning sessions provide a
great way to interaction with patients through the 10/4 Rule: “At 10 feet
away, make eye contact and smile. At 4 feet away, maintain eye contact
and greet warmly.” The filter of actions during our team’s ideation process
wanted to push the encounter closer than 10 or 4 feet.

The question asked was, “What are some actions between doctors and
patients that can happen at 2 feet away? At 1 foot away?”

Words:
Great care has been put into thinking about the right words when
communication occurs between doctors and patients. In fact, the Respond
Ten concepts
with H.E.A.R.T.™ service recovery program provides a wide range of To demonstrate using the four themes focused around designing for doctor and
possible scenarios when caregivers face complaints from patients and patient interactions during the discharge experience
families. Much of the words in the context of Respond with H.E.A.R.T.™
have been formed as a response or reaction to issues that may arise in the
day-to-day delivery of care. Also, Respond with H.E.A.R.T.™ provides verbal
(as well as actions) guidance on what kind of words and in what ways
caregivers should respond to mostly medically related complaints.

The question asked during our ideation was, “What are some proactive
words doctors can use to interact with patients? Also, can there be
conversations not related to medicine or healthcare?”

Props:
In line with the idea of performance (i.e. the stage metaphor of the service
blueprint), certain props can be cues or triggers for certain behaviors. Since
doctors and caregivers are very busy with numerous things to consider at
any given moment, certain props could provide an affordance, that is, a
quality of an object, or an environment, that allows an individual to perform
an action.

The question asked during our ideation was, “What are some props -
preferably things that are already present in the room - that could invite
an interaction between doctors and patients?”

42 Project Report 43

Top three kit Discharge journey map

Mrs. Gibson has been told by Dr. Victoria that After quickly reviewing each card, Dr. Victoria Henry has just woken up from surgery and has Henry opens the card up to look at the content
she can go home soon. She has made all asks Mrs. Gibson if she has any questions. no idea where he is and what is to happen inside. As Dr. Cameron said, there is an easy-
the travel arrangements and is waiting for They review the simple points one more next. Dr. Cameron walks in, sits next to him, to-read map with boxes, bold type, and arrows
her daughter to pick her up in a few hours. time to make sure Mrs. Gibson understands and gives Henry a menu-looking card. He then that summarizes the events Henry can expect
Before she leaves, Dr. Victoria stops by for five everything. The cards are then placed in a asks Henry to open it up and tells him that this to occur during the last moments of his stay.
minutes to give Mrs. Gibson her “Top three folder along with the other documents Mrs. little card contains a simple map of what Henry Dr. Cameron points to where they are in the
kit,” which contains 3 contacts for Mrs. Gibson Gibson is given for a proper discharge. can expect during the last few days of his stay map and tells Henry that he will see him again
should anything come up (or if she has any at Cleveland Clinic. at another point in the map. Henry feels pretty
questions), 3 things she must do, and 3 things Once she gets home, Mrs. Gibson is able to put good knowing that he has but a few boxes to
she must not do. all three cards onto her refrigerator as easily go through before he heads home to see his
accessible reminders since the cards have grandchildren.
magnets on the back side.

Insights from research: Insights from research:

• Patients don’t remember a lot of things • Patients view the discharge phase as a very
• It’s better to provide the second best thing patient complicated process
should do if it means patient will comply with it rather • It’s hard for patients to see that various parts of the
than the best thing that is complicated discharge experience are connected in some way
• Patients treasure what the doctors gives them even if • Patients treasure what the doctors gives them even if
it’s something small it’s something small

Recovering Accepting Choosing Planning Learning Leaving Transitioning Recovering Accepting Choosing Planning Learning Leaving Transitioning

Teaching & Explaining & Providing Continuing Teaching & Explaining & Providing Continuing
Discharging Educating Discharging Educating
Assessing Estimating Options Care Assessing Estimating Options Care


Words, words, words Dignity blanket

Physicians already speak To come up with a set of Dr. Julian uses one of the Carole has been prepped Carole has surgery for Afterwards, and during the
to patients about their keywords that physicians conversation starters from for surgery by caregivers at several hours and it ends beginning moments of her
biomedical condition (1st can use to proactively the workshop he attended Cleveland Clinic. Instead of successfully. She is already discharge experience, Dr.
type of words). They also have conversations with by asking his patient, Mrs. lying naked on the operating in her bed when she wakes Beth stops by and presents
can use the H.E.A.R.T.™ patients, The Office of Patient Rooney, “So, Mrs. Rooney, table where people can see up from her sleep. her with the washed blanket
framework to respond to Experience can organize a what is the first thing you her exposed body, a caregiver that was used to cover her.
complaints (2nd type of workshop with caregivers plan on eating when you covers her with a blanket. She feels protected from this
words). What are some and brainstorm possible get home?” Mrs. Rooney small gesture - surprised
proactive, non-medical words conversation starters with shares her fantasy of eating even, that her caregivers
doctors can use to relate to patients. These could be her favorite ice cream and covered her when she was
patients? (3rd type of words) centered around helping the two share a moment of most vulnerable.
patients readjust back to laughter.
their lives.


• Doctors with great communication skills use cues • Patients lose their sense of dignity when they can’t
from their environment or previous interactions with go to the bathroom on their own, can’t wear their own
patient to follow up with something happening in clothes, and have to expose their body parts
patient’s life outside the hospital (e.g. family vacation) • Some doctors provide preferential treatment to people
• Patients have concerns about things happening they know when they think patients and families are
outside the hospital, such as home and family not looking




Dialing doctors Vesture gesture

Joe has been distraught During the weekend, Dr. Pete Not wanting to take too much Bob’s doctor walks into his After taking off his white Bob has been concerned
with the changes that will gives Joe an unexpected call of Dr. Pete’s time, Joe asks room and says while taking coat, Dr. Carson takes a chair about where he should go
happen in his life since his just to check up on him. Dr. him one or two questions off his white coat, “Bob, I and pulls up to sit next to next after leaving Cleveland
big surgery. He only gets Pete says, “Hi, Joe. How are and really appreciates Dr. only have about 3 minutes Bob. “Well, let’s talk - man to Clinic’s main campus and
a moment with Dr. Pete - you feeling? I’m sorry I had Pete’s thoughtful phone call. but I wanted to come in man. Is everything okay?” lets his concern known to Dr.
just enough to go over his to run the other day. Thought While he still has a long list here to ask if you have any Carson. Although not able to
biomedical condition but I’d give you a call just to say of outstanding questions, just questions or if you need stay and explain everything,
not enough to ask some of hi and see how you’re doing.” having a 5 minute phone call anything from me.” Dr. Carson acknowledges
the questions regarding his Joe can hear Dr. Pete’s with Dr. Pete has put him at Bob’s concern and says he
lifestyle changes. Dr. Pete family in the background ease and less anxious about will let his team members
apologizes for the short face and realizes that Dr. Pete his condition. know and will do his best to
time and has to run along. is calling him during his help Bob in this matter.
personal time.


• One great way for doctors to spend time with patients • Some patients consider doctors unapproachable
is through a simple follow-up phone call when they because they always seem very busy
have more time and when away from the stress of the • Patients also feel like it’s not appropriate to ask
hospital environment questions even though they may have a list of
• Patients appreciate this simple gesture that is not questions since they don’t want to be rude by asking
often practiced and are surprised if it ever happens for some personal time with doctors




Guaranteed gifts Patients first in last moments

Charles has been lying bed Instead of just giving Charles Not having had his hair Today is Dorothy’s last day at Cleveland Clinic As Dorothy approaches the exit for the clinic,
for days and is eager to a collection of uncertainties, washed since his surgery, and she’s just about to head home. As she she is taken to a designated “Check out
leave the hospital. When Charles’ doctor provides him he requests to get his hair is escorted to the elevator to go downstairs, station” that has a physician who provides
he asks his doctor when he a service that is guaranteed washed. This milestone she is greeted by Dr. Simon who was the main any kind of guidance or last minute questions
will be discharged, he hears - a free pass to use some of helps him take the first step physician who treated her during this in- about medication Dorothy is supposed to take.
a wishy-washy answer - the grooming services at the toward recovery and getting patient experience. Dr. Simon walks with her Dr. Judy, who is at the station at this time,
“Hopefully soon,” and the Wellness Institute. reimmersed back into some to the elevator, presses the elevator button for asks Dorothy if everything went well and if she
next day, “We’re almost of the small, functional tasks her, and shakes her hand to wish her the best. has any questions about the information she
ready to let you go home.” of his day-to-day life. As the elevator door closes, she can still see received from her final contacts upstairs. Dr.
This uncertainty only adds Dr. Simon standing there waving goodbye with Judy then says everything is good to go and
to Charles’ lacking control of a firm smile on his face. wishes Dorothy the best.
his health and life during his
hospital stay.


• Discharge is usually confirmed on the day of and it’s • In many cultures, it’s rude to say goodbye and then
really a moving target - therefore, during most of the close the door - people are expected to walk out to
discharge, caregivers can’t make guarantees where the guest’s car is and wave goodbye as the
• Patients treasure what doctors give them even if guest leaves
it’s something small • There is no real interaction between doctors and
• Small activities of daily living matter to patients patients as patients are leaving the hospital




Jargon Jar & Cleveland Clinic coins Decorated doctors

Mrs. Porter’s doctor, Dr. Instead of letting Dr. Mary Dr. Mary smiles, realizing Jim is greeted by Dr. Susan Dr. Susan tells Jim that The next doctor Jim sees is
Mary, is spending some continue, Mrs. Porter takes that she has been using after his surgery. He notices these badges are based Dr. Nate. Jim points to Dr.
time with her and explaining one of the Cleveland Clinic “doctor-speak,” and says to some badges and stripes on a ranking system based Nate’s shoulder and asks
Mrs. Porter’s condition. The coins she was given at the Mrs. Porter, “Let me try this on her shoulder and asks on feedback from patients. why he doesn’t have the
problem is that Mrs. Porter beginning of her discharge again.” Mrs. Porter is much what they are and why some Her patients have given her same badges Dr. Susan has.
has no idea what Dr. Mary is experience and puts it in more engaged this second doctors have them and why high ratings for things like Dr. Nate says he’s fairly new
talking about. the jar. This let’s Dr. Mary time and is able to ask some don’t. communication skills and and working hard to earn his
know that she is talking important questions related empathy. She says she’s first rank - the first level of
too “medical” and needs to to her care. She also ponders trying hard to earn her next “compassion.” He then asks
speak in a language that Mrs. about what she can buy at badge - the third level of Jim how he feels and takes
Porter can understand. the gift store with all the “empathy” - which is one some time talking with Jim
coins she’s put in the jar. rank higher than what she before his assessment.
has currently.

Insight from research: Insights from research:

• Patients don’t know when to let the physician know • Physicians are competitive at Cleveland Clinic
that they don’t understand what he/she is saying. • When mandates from the top of the organization are
If medical jargon is used by physicians, patients may enforced, physicians comply reluctantly
feel embarrassed to ask physicians to dumb down the • Dr. Cosgrove’s story at Harvard Business School when
language audience member asked him if Cleveland Clinic
teaches its doctors empathy




Thoughts on implementation
To implement some of the concepts, the recommendation is to do a soft roll-
out with approximately fifty physicians. This trial group would include 25
of the top 50 highly ranked HCAHPS performing physicians (i.e. performers
ranked around 26-50) as well as 25 other well-performing physicians in the
next tier (i.e. performers ranked around 51-75).

Physicians with high-scoring HCAHPS are recommended because they
are already motivated and may have a willingness to try something new
to further the awareness of patient experience initiatives. Physicians with
low HCAHPS scores may not have the desire or enough motivation to try
some of these ideas - they may even be turned off by some of the concepts
since they propose some notions of doctor-patient interactions that are
unconventional in the current landscape of physician behaviors.

By including a portion of the high-performing physicians, a control
group could be established since these physicians are already doing
well. Comparing them with the next tier of well-performing physicians
should provide success metrics regarding the implementation of the
recommendations.

Once there are signs that these concepts have merit and can also be
evaluated, the next step would be to scale the concepts for implementation
across a greater part of the organization. This could be done through
workshops but the greatest test of whether or not these ideas have impact is
to see if the fifty physicians in the soft roll-out have a word-of-mouth type of
impact within their units and institutions. Ideally, these chosen physicians
are leaders in their area of care and would have tremendous influence by
being an example to their staff and other physicians.


Business case: costs
There will be several costs to implement the recommendations; however, HCAHPS & the in-patient market:
many of them are marginal. Some of the costs will be incurred from The second benefit is the capture of the Medicare and Medicaid market.
managing additional consumable inventory such as the dignity blankets. The current hospital market size is $757 billion, of which approximately
Others will be incurred from internal consulting and training costs as well as 72.5% is in-patient services, amounting to $549 billion.17 Additionally,
the cost of printing materials. government healthcare programs account for approximately 48% of hospital
spending with a total medical (in-patient, out-patient, pharmaceutical, and
The fifty-person pilot study would incur approximately $1,100 in printing other) value of $809 billion in 2010. The estimated Compound Annual
costs of high quality training materials. Additionally, Cleveland Clinic Growth Rate (CAGR) is 5.37% to $1,051 billion in 2015.18
would come to realize various time and resource expenses during the pilot
program. Internal consulting and design costs for the design of training The issues pointed out in this project are all the more important in this
materials could be in the range of $150 to $300 per hour. context since the HCAHPS specifically asks questions about doctor-to-
patient communication and the discharge experience. According to numbers
from Cleveland Clinic, if the HCAHPS do not improve by 2013 and remain
Business case: benefits similar to scores from 2010, there is a potential lost of $13 million per year
from government reimbursement. The ideas in this report could mitigate
The return on the investment for this recommendation can be seen in at this potential shortfall as well as capture more of the expanding healthcare
least three significant ways: market.

Patient Lifetime Value: Brand equity via service innovation:
A major benefit is having people choose Cleveland Clinic for the long- Lastly, Cleveland Clinic could see benefits in service innovation. Cleveland
term. In the Respond with H.E.A.R.T.™ Service Recovery training program, Clinic has already begun to invest in areas of service innovation yet there is
Cleveland Clinic notes that the Customer Lifetime Value (CLV)15 of each still much to explore in this space. Implementing some of the concepts to
patient is approximately $1 million. When compounded with population improve patient and doctor communication could position Cleveland Clinic
growth - notably the growth in senior populations over 65 years old - this as a global leader in service innovation and raise the brand equity of the
can quickly extrapolate into a significant sum. The number of people organization. With regards to the discharge experience, since physicians
aged 65 and over is expected to grow an average of 3.28% per year from all across healthcare institutions do not participate actively during this
41.1 million in 2011 to 46.8 million in 2015.16 This represents potential time, doing this well would provide a clear service differentiator that is not
customers of Medicare, or more pointedly, approximately $5.7 billion of provided at most places.
possible revenue from providing care to the elderly. The proposed concepts
to improve patient experience could increase patient word-of-mouth Not only would Cleveland Clinic be considered as a place of great clinical
marketing, resulting in attracting more patients to Cleveland Clinic. outcomes, but also as a place that takes the notion of holistic care seriously
with bold investments in patient experience.

15 H.E.A.R.T.™ training program refers to this as the “Cost of dissatisfied patients.” 17 S. Snyder, “IBIS World Report 62211 Hospitals in the U.S.,” retrieved April 10, 2011 from
16 Based on population data from U.S. census website: http://www.census.gov/. IBISWorld database.
18 “IBISWorld Business Environment Report for June 16, 2010: Federal Funding for Medicare
and Medicaid C101,” retrieved April 10, 2011 from IBISWorld database.


Risks
The successful implementation of the concept recommendations will require
management to pay attention to several risks:

First, if the concepts improve communication between doctors and patients
during the discharge experience, Cleveland Clinic will desire similar
executions of the proposed ideas in the earlier phases of the patient journey
(e.g. beginning and middle phases prior to discharge). The organization may
also want these ideas to be rolled out to the regional hospitals as well as to
its global satellite facilities. This will impact established processes, policies,
and also shift the culture.

Another risk is potentially alienating highly skilled medical professionals
who may simply not have the desire to learn and develop these “softer”
people engagement skills. Being sensitive to these individuals and
understanding their concerns will be necessary for a strategic corporate
implementation.
06. Final thoughts
Finally, there is a potential risk of breaking down professional boundaries
between physicians and patients. While these recommendations aim to
help physicians empathize with patients, one could argue that there is also
value in maintaining a degree of distance and professionalism between
physicians and patients. For patients who prefer to view physicians as The space of service innovation in healthcare is ripe with much room for
professionals, creating a new perspective of physicians as a friends with exploration. With stricter government reimbursement rules, an increase in
great interpersonal skills may backfire against a brand that currently is the ability of patients to select their medical provider, projected population
lauded as a place of skilled, technical professionals. growth of the elderly, and a demand for better patient experience in all
facets of healthcare, Cleveland Clinic’s ability to differentiate in the service
innovation space is both necessary and desirable.

The design process and concepts shared in this project report provide
a framework to help physicians - the leaders - deliver better services
during a patient’s leave-taking experience. Beyond this, the thoughts and
recommended actions found in this project report may be a reference, a way
to intiate dialogue around doctor-to-patient communication, and a point of
departure for the caregivers at Cleveland Clinic.

Thank you.


Appendix A: Why HCAHPS? Appendix B: HCAHPS questions
Patients are increasingly making health care decisions based on their The survey is composed of 18 questions about patient care, four screening
perception of “quality.” For example, patients may interpret quality as how questions, and five demographic questions. Eight critical aspects of care,
well their doctors and nurses communicated with them, how well their pain referred to as the HCAHPS domains, are covered in the survey questions,
was managed, how easy or difficult it was for them to get an appointment, including:
whether they felt all of their questions were answered, and whether they
had all the information they needed upon discharge. • Overall hospital rating and recommendation
• Communication with doctors
There are several survey instruments and processes that have been
• Communication with nurses
designed to measure patient satisfaction at different touch points. Examples
• Communication about medicine
include surveys sent to patients after care received by home care providers
• Responsiveness of hospital staff
(HH-CAHPS) and after an inpatient visit (HCAHPS). Hospitals routinely
• Cleanliness and quietness of hospital environment
survey other areas of patient care,including emergency department visits
• Pain management
and ambulatory surgery procedures.
• Discharge information
Currently, only inpatient (HCAHPS) and home health care (HH-CAHPS)
HCAHPS Questions:
surveys are mandated by the Centers for Medicare & Medicaid Services
1. How often did nurses treat you with courtesy and respect?
(CMS). The program is intended to increase transparency around patient
2. How often did nurses listen carefully to you?
experience and aid consumers in their health provider and hospital
3. How often did nurses explain things in a way you could understand?
decisions. Every hospital in the United States that treats Medicare patients
4. During hospital stay, after you pressed the call button, how often did
is required to administer and submit survey results.
you get help as soon as you wanted it?
5. How often did doctors treat you with courtesy and respect?
HCAHPS (Hospital Consumer Assessment of Healthcare Providers
6. How often did doctors listen carefully to you?
and Systems) is a standardized survey designed to measure patients’
7. How often did doctors explain things in a way you could understand?
perspectives of hospital care. It was developed by CMS in partnership
8. How often were your room and bathroom kept clean?
with the Agency for Healthcare Research and Quality (AHRQ), two
9. How often was the area around your room quiet at night?
agencies within the Department of Health and Human Services. HCAHPS
11. How often did you get help in getting to the bathroom or in using a
provides a standardized methodology that allows objective and meaningful
bedpan as soon as you wanted?
comparisons among hospitals on topics important to patients.
13. How often was your pain well controlled?
14. How often did the hospital staff do everything they could to help you
Proposed reform legislation would require that a portion of hospitals’
with your pain?
Medicare reimbursement be linked to performance measured by the
16. How often did hospital staff tell you what the medicine was for?
HCAHPS scores. This may occur as early as 2013.19
17. How often did hospital staff describe possible side effects in a way you
could understand?
19. Did hospital staff talk with you about whether you would have the help
you needed when you left the hospital?
20. Did you get information in writing about what symptoms or health
problems to look out for after you left the hospital?
21. Using any number from 0-10, where 0 is the worst hospital possible
and 10 is the best, what number would you use to rate this hospital
19 Information taken from the collateral material from the Office of Patient Experience.
during your stay?
22. Would you recommend this hospital to your friends and family?


Appendix C: Issues explored Appendix D: Service blueprint elements
Service Blueprint Components
Multiple issues identified by project group for possible exploration:

• Cleveland Clinic wants to think of patient experience broadly as an entire
journey versus thinking about patient experience only in terms of aspects
directly affecting HCAHPS domains
• There are Cleveland Clinic staff members who think their work directly
affects patient experience versus those who do not see a connection
• Valuing patient AND family experience versus only focusing on patient
experience
• Patients valuing overall Cleveland Clinic experience versus being
dissatisfied with particular aspects of the patient experience
• “Empathy and Innovation” as desirable themes versus a culture that fears/
respects numbers and makes decisions based on past results
• Maintaining existing programs versus developing new products/services/
programs guided by the new Office of Patient Experience team’s vision
• Integration and standardization of innovative services versus designing for
the specific personality and culture of an individual regional hospital
• Cleveland Clinic’s physician-led organization characterized by formal
leadership v. servant-leadership

©2003. The McGraw-Hill Co

March06 Carnegie Mellon University | School of Design | Interaction | Shelley Evenson

©2003. The McGraw-Hill Companies. All Rights Reserved


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

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