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Muskegon Family Care & Mad*Pow Human-Centered Design Session
June 15, 2016
IntroductionBackgroundGoalsDay1ResearchDay2Co-designworkshopRecommendationsNextSteps
Schedule
OURTEAM
OlgaElizarova,DDS,MPHBehaviorChangeAnalyst JenniferSmerdel,Experience
Strategist
SamanthaDempsey,BehaviorChangeandExperienceDesigner
DanaOrtegonSeniorContentStrategist
StockardSimonSeniorVisualExperienceDesigner
KimDowdSeniorExperienceResearcher
DustinDiTommasoSVPBehaviorChangeDesign
CiaraTaylorExperienceDesigner
Howdidwegethere?
Everyyearatourcompanyweget40hoursofpersonalvolunteertimethatwecanuseaswelike.
Thisyearwewereseekingforanopportunitytoapplyourknowledge,skillsandtimetotheareaofourpassion:healthcare,andmorespecificallytoimprovingpatient-clinicianinteractions.Inotherwords,applyourvolunteertimetodosimilarworkthatwegettodoforourclientsonadailybasis.
WegotluckytobeintroducedtoRamonaWallacethroughourfriend.Ramonawasfacilitatingourcommunication,helpingustoframetheproblem,connectustopeopleatMFC,organizethelogisticsofprettymucheverythingincludinghostingusinherlovelyhouse.Shewasawonderfulpointofcontactandsupporttousthroughoutthewholeproject.
BACKGROUND
Whyarewehere?
HUMAN-CENTEREDDESIGNMethodologiesandApproach
OurApproach
Human-CenteredDesign(“DesignThinking”) is“acreativeapproachtoproblemsolving.It’saprocessthatstartswithpeopleyou’redesigningforandendswithnewsolutionsthataretailormadetosuittheirneeds.”-IDEO
HUMAN-CENTEREDDESIGN
OurApproach
Co-Designisacreativeprocessbywhichdesigners partnerwithproblemownerstofacilitatethecollaborativecreationofsolutionsthatbestmeettheirneeds.
Thisprocessviewsdesignersasprocessfacilitatorsratherthansolecreatorsofsolutions,andpresentsproblemownersassubjectmatterexperts.
HUMAN-CENTEREDDESIGN
Interview&ObserveHUMAN-CENTEREDDESIGN
IdeateHUMAN-CENTEREDDESIGN
PrototypeHUMAN-CENTEREDDESIGN
IterateHUMAN-CENTEREDDESIGN
BACKGROUND
ProblemDefinitionMFCisaPCMHexperiencinghighratesofpatientnoshowsandlowpatientengagement.
Existinginterventions• anautomaticvoiceremindersystem• ahumanoutreach(calls,mail)toremindpatientsoftheirupcomingappointments.
BACKGROUND
UnderstandingtheEnvironment
*Basedontheclinic’sstaffinterviews,theseinterventionsdidn’tshowsignificantimprovementinratesofnoshow.
Highnoshowratesarepartiallyduetopatientsnotfindingtheirclinicalappointmentsvaluable.
Thereforeweneedto:• Understand whatpatientsfindvaluableintheirappointments• Identify barriers thatkeeppatientsfromcomingtotheappointments• Improveexperienceofthepatient-clinicianinteractionssothatboth
cliniciansandpatientswouldfindtheappointmentsmorevaluable
BACKGROUND
OurHypothesis
GOALS
GoalsClinicReducetherateofnoshows/missedappointments,increasepatientsatisfactionandoverallappointmentexperience(qualityimprovementinitiative)
PatientImprovepatient’sperceptionofvalueofaclinicalappointment,improvepatientsatisfactionandoverallappointmentexperience
ClinicianReducetheinefficienciesintheworkflowcausedbynoshows,increasepatientengagement&involvementintheprocessofshareddecision-making
DAYONE@MFCResearchintheClinic
Wespentthefirstdayconductingresearchinthefieldconductingco-designactivitieswithpatients inthewaitingroom,observingstaff membersatwork,andinterviewingpatientsandprovidersabouttheirexperiences,expectations,andvaluesduringanappointment.
DAY1:RESEARCH
Part1:Appointments&Scheduling
Methods
Observations&Interviews• Schedulers• Clinicians• Patientmanagers• DentalAdministrators
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeA:Population’shealthandbarrierstohealth• Multiplechronicissues• Manybarrierstogoodhealth• Don’tprioritizehealth,thinkaboutprevention,ortakepersonal
responsibilityfortheirhealth• Lowhealthliteracy(nutrition)• Chaotichomeenvironments
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeB:Scheduling• Coordinatingmandatorynewdentalpatientorientation
• Patientsfrustration• QuestionsarisearoundHIPAApapers
• Patientsrarelyusepatientportaltoscheduleappointments• Day-ofSchedulerandrobremindercalls
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeC:Noshows/cancellations
Patientstellstafftheymissappointmentsbecause…• Transportationissues(40-50%ofallcancellations)• Illness• Fear&anxiety• Weather• Conflictswithworkschedules• Familyobligations• Mistrust• Mindset• Forgetfulness
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeC:Noshows/cancellations(cont.)
• Doublebooking&overbooking• Unclearfollow–upproceduremissedappointments• Cancelationfollowedbyimmediaterescheduling
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeD:Appointments
• Multi-personclinicvisits
• Clinicstaffbelievedthefollowingcomponentsmakeavisitvaluable:– Patientexperience– Personalconnection– Measurableprogress– Communication&Connection– Judgment-freezone– Checkout
DAY1:RESEARCH
Part1:Appointments&Scheduling
ThemeE:Casemanagers&followup
• Unclear&frustratingcasemanagerreferrals• Patientswithcasemanagerstendtobemoreadherentandhavemore
healthimprovements(betterlabwork,lessERutilization,etc.)
• Strugglesforcasemanagers:– Charting/billing– Coldhand-offsfromproviders– Knowingwhentofollow-upwithpatientswhoaredoingwell.– Patientscomplainingthattheycan’tgetenoughpainmedication
DAY1:RESEARCH
Part2:WaitingRoomActivities
MethodsMini-activities
– “GraffitiWall”question– Fill-in-theblankform“Whatwouldmakeyourappointment
awesome?”– “MyIdealClinic”checklist
DAY1:RESEARCH
Part2:WaitingRoomActivities
Theme1:“GraffitiWall”question“Whatmakesanappointmentawesome?”• Patientsdidnotrespond towaitingroomgraffitiwalls
– Involvereceptionist(s)– Increasetimeavailabletointeractwithgraffitiwall
DAY1:RESEARCH
Part2:WaitingRoomActivities
Theme1:“GraffitiWall”question“Whatmakesanappointmentawesome?”• Cliniciansdidrespond.Themainthemewasmutualunderstandingand
clarity addvalueandstrengthentheprovider/patientrelationship.• Approachingpatientswithapositiveandupbeatattitudefreeof
judgmentorassumptions• Allowingpatientstotelltheirstoriesandaskquestions• Addressingpatientsbynameandshowingthemthatyoureallycare• Givingpatientsclear,accurateinformation• Makingsurepatientsunderstandwhattodowhentheyleavetheoffice• Incentivesasrewardsformeetinghealthgoals(thesearen’tcurrentlyusedmuch)
DAY1:RESEARCH
Part2:WaitingRoomActivities
Theme2&3:Fill-in-theblankform&ChecklistActivities• Longwaittimesandperceptionofwastingtime(85%)• Convenientappointmenttimes• Kindness,honestyandgoodadvice• Gymintheclinic(71%)• Abilitytochoosetheirdoctorforeachvisit(71%)• Exerciseclasses,cookingclasses,safetyclasses,andhealthyworkshops.• Patientportal(57%)• Availabilityofchildcareduringtheirappointments(~43%)• Zeropatientsidentifiedthattheywouldwantonlinevisits
DAY1:RESEARCH
Part3:Post-AppointmentPatientInterviews
MethodsInterviewswithpatients
• An8-questionmoderator’sguidewasusedtofacilitatesemi-structuredinterviews
DAY1:RESEARCH
Part3:Post-AppointmentPatientInterviews
Findings• Feelinglikeacliniciancaredaboutthemasapersonanddiscussedtheir
issues• Generallylikedtheircurrentclinicians• Awareoftheirunhealthybehaviorsandlookedtotheircliniciantohelp
themavoidthem(advice)andkeepthemontrack.
DAY1:RESEARCH
Part3:Post-AppointmentPatientInterviews
Findings(contd.)Worstpartsofanappointmentaccordingtothepatients:
– Worrying– Takingtimeoffwork– Waiting
• Betweenwhenthenurseleavesandthedoctorshowsup.Onepatient,whohadtwoyoungchildrenwithhersaid,“Ispent18-20minutesjuststaringatthewall”.
• Longwaitstoscheduleanappointment.
DAY1:RESEARCH
Limitations• Smallsamplesize
– Nopatientinterviewsinthedentaldepartment– Eachmoderatorinteractedwithlessthan10people
• Selectionbias– Giftcardincentivesforparticipation– Patientsforthepost-appointmentinterviewscameonlyfrom2clinicianswhovolunteeredtoparticipate– Nointeractionwithnoshowspatients
• Samplingbias– WeonlyinterviewedpatientswhocameintothecliniconaFridayafternoon.Allresultsshouldbe
validatedwithagroupofpatientswhohaveappointmentsatdifferenttimesandondifferentdaysoftheweek.
• Inabilityto reachouttopeoplewhodon’tshowupfortheirappointmentsonthesameday,becausetheydisappearfromthesystem
• Lackoftime– Forexample,wewereunabletospeaktogroupatMFCresponsibleforpatienttransportation– MoretimewouldalsohaveyieldedmoreresponsesontheGraffitiWall,frombothpatientsandclinicians– Wealsoonlyspoketopatientsfor2-5minutesoutofrespectfortheirtime.Moretimespentwitheach
patientcouldresultindeeperfindings.• Lackofequipment
– Noopportunitytolistenintotheschedulingcalls• Norecordings
– Allfindingsrelyonthemoderator’snotes.
DAY1:RESEARCH
DAYTWO@MFCCo-DesignWorkshop
Wespenttheseconddayconductingaco-designworkshopwithclinicians,patients,andstafftogainaholisticunderstandingoftheproblemareaandidentifypotentialsolutions.
Duringthisworkshop,facilitatorsguidedparticipantsthroughoutvarious activities helpingthemdocumenttheirexperiences, understanddifferentperspectives,andultimately createprototypes thatwouldimprovethevalueofaclinicalappointment forbothpatientsandclinicians.
DAY2:CO-DESIGNWORKSHOP
Activity:SuperPowers
• Patience• Listening2• UnconditionalLove• HugeSmile• PassionforMFC&itsMission• MedicalExperiencewithFQHC/PCMH• Patientmanagement&education• Beingpositiveandupbeat• Peoplearound• Creativity• Empathy• FactFinding
DAY2:CO-DESIGNWORKSHOP
TheSuperpowersoftheMFCTeam!
Activity:CirclesofMe
DAY2:CO-DESIGNWORKSHOP
MostValuableThingsandRelationships:• Immediatefamily• Personalhealth• Faith
IntermediateValueThingsandRelationships:• Closefriends• Traveling&Reading• Community
LessValuableThingsandRelationships:• Movies• Food&Eatingout• Shopping
Activity:DefiningHealth
• Letyouknowifyouarehealthy• Givegoodadviceonmaintaininggoodhealth• Provideeducation,communicationandbetrustworthy• Beaguideandapartnerinnavigatingthe“sea”ofthethingsthatyoucan’tcontrolandcoachaboutthingsthatyoucanimprove:healthyeating,skills,meaning,growing,connection,nature
• Provideinformationtoyou(what/whyandhowtoreachyourgoals)andlisten
• Helprestorefaithinyourownhealth• Understandyou• Provideprofessionalexpertise,encouragement&friendship• Beahealer• Doeverythingsheorhecantohelpme• Care,helpandbenice
DAY2:CO-DESIGNWORKSHOP
WhatistheRoleofaDoctor?
Activity:Memorablevisit
StrengthsofMFC• Havingspecialists(bridgespatientsneeds)• FriendlyStaff• Compassion/caring• Communication
– Open-endedquestions– Silenceasanopportunityforpatientstoexpressthemselves&sharetheirstory– Activelistening– Followthrough
• “Superpowercape”– Knowingeachotherssuperpowersandusingthem– Helpingotherswheninneed
• Facilitatingshareddecision-making• Humanizationofhealthcareexperience(beyondjustphysical– spiritual,community)• Time
DAY2:CO-DESIGNWORKSHOP
Activity:Memorablevisit
Opportunities• Utilizerole-playinternally
– Implementduringmonthlygatheringswithproviders&staff– Modelcompassionateinteractionsthathaveoccurredtosharewithotherprovidersand
staff• Sharegreatsuccessstoriesasaclinic• “Reset”foreachnewpatient(clinicians)
– Treateverynewpatientwithempathy.Trytothinkhowmuchdidthepatientsgothroughbeforetheycametotheappointment
• Makepatientsfeelcaredforduringeachvisit• Askopen-endedquestions
• Maketheappointmentprocessmoretransparenttothepatientstomakethemfeelcomfortable.
• Helpdealwithstigmaandfearofbeingjudged(addiction,reallypoorhealth)
DAY2:CO-DESIGNWORKSHOP
Limitations• Samplesize
– Wehad14participantsintheworkshop.Inordertovalidatethefindingsidentified
• Selectionbias– Themajorityofparticipantswerestaffoftheclinic,although3
providersand2patientsparticipatedaswell.Wewouldsuggesthavingaslightlylargerratioofpatients- to-clinicianstocreateacomfortableenvironmentforpatientstosharetheirthoughtsandideas.
• Lackoftime– Moretimewouldhaveyieldedmorevaluableideas&solutionsthat
couldaddvaluetotheclinicalappointment.
DAY2:CO-DESIGNWORKSHOP
RECOMMENDATIONS
AftercollaboratingandobservingwithMFCwehavecreatedasetofrecommendationstohelpaddressfindingsidentifiedduringourresearch.
TheserecommendationscombineourpersonalunderstandingoftheMFCprocessesandworkflow,patients’feedback,andmostimportantlythelivingexperienceofcliniciansandstaffmemberswhoworkatMFC.
Thesearemeanttoprovidestrategyandguidancetoaddressingidentifiedopportunities.AsexpertsinMFClifeandprocess,itisuptoyoualltodecidehoworiftoimplementanyoftheserecommendations
RECOMMENDATIONS
StrategicRecommendations
OverallNewPatients
– Makemandatorynewpatientorientationsmoreinteractiveandvaluabletothepatients• Motivationalinterviewingelements• Barrieridentification• Clinicianpresenceattheorientation
– Thinkaboutalternativewaystoconductnewpatientorientations:teleconferences,mailingpaperwork,etc.
RECOMMENDATIONS
OverallScheduling
– Appointmentsoutsideofregularworkhours– Selectionofdoctorforeachvisit– Educateabouttransportationservicesandimproveeaseof
availability– Ensurethatparentandchild’sappointmentsarenotscheduled
simultaneously– Considerwaystoidentifyandprovideaccompanimentfor
patientswhomaybeunfittocometoanappointmentalone.
RECOMMENDATIONS
OverallAppointmentexperience
– Implementgoodpracticesandstrengthsofindividualssystemicallythroughdoingpersonneltraining,writingscripts,etc.
– Don’tinvestinexpandingtelemedicine.Patientswantface-to-faceinteractions.
– Maximize“wasted”waitingtimebygivingpatientssomethingtodowhiletheywait—inthewaitingroomandintheexamroom.
– Reducenegativeperceptionsofwaittimebylettingpatientsknowifthedoctorisrunningbehindorifwaittimesarelongerthanusual.
RECOMMENDATIONS
OverallAppointmentexperience
– Gapbetweenpatientandclinicianexpectations.Askpatientstogivetheirexpectationsfortheappointment— inoralorwrittenform.Makesuretoaddresstheirexpectationsduringthevisit.
– Avoidinformationoverload.
– Thetherapeuticvalidityofbeinglistenedto.
– Childcareduringappointments.
RECOMMENDATIONS
Overall
Postappointmentexperience&followup– Consistentno-showfollow-upprocedure
• Recordthereasonforthemissedappointmentandtrytoreschedulethemrightaway
• Findawaytoallowpatientsnottoscheduleappointmentsthattheydon’tintendtokeep.Ask,“Doyouwanttomakeanotherappointment?”ratherthantellthemthattheyshould.
– Standardizeeducationmaterials&toolsacrossallMFCproviders.– Offerpatientswaystotakeanactiveroleintheirhealth(exercise,
cooking,andsafetyclasses,healthyworkshops)– Findwaystoprioritizehealthinthecommunity.
RECOMMENDATIONS
Overall
• Considerdoingsimilarco-designworkshopswiththeclinicstaffandprovidersasawaytosolveproblemsandimplementgoodpracticesandstrengthsconsistentlythroughouttheentireclinic.
• Thinkaboutdifferentwaysthatstaff’sandprovider’s“superpowers”canbeusedintheirdailyrolesattheclinic
• Thinkaboutdifferentwaysthatcurrentappointments’strengthscanbeenhancedandimplementedwidely
RECOMMENDATIONS
Overall
• Consideraddressingtheopportunitiesduringtheappointmentthatparticipantsidentified– Ensurepatientsdon’tfeellikeaburdentoaprovider– Askpatientsabouttheirexpectationsbeforetheappointmentandtry
toaddresspatientsconcerns• Transparencyaroundprocess• Engageandeducatepeopleabouthealthonacommunitylevel.• Addresspovertyasalargersystemicproblem(violence,depression,
addiction)
RECOMMENDATIONS
PROTOTYPES
Prototype1:DaycareatMFCPROTOTYPES
HypothesisPatients who have children under the age of 13 are more likely to miss their appointments, because they are distracted and stressed when they have children with them in the exam room, and as a result the appointment is less valuable to them.
SolutionDaycare – onsite free “drop in” daycare where patients who have an appointment at the MFC can leave their children while using their clinic services (medical, dental, counseling, wellness workout). After the appointment is finished patients will pick up their children.
Prototype1:DaycareatMFCPROTOTYPES
Benefits
• Provider and patient have less stress or distraction during the appointment
• Reduces no shows by providing additional value to the clinical appointment
• Increases provider’s productivity• Improves patient experience or perception of key aspects of care (quality
improvement)• Helps retention & recruitment of new patients• Marketing effort• Aligns with MFC’s mission and goals of Patient-Centered Medical Home• Sends the message that MFC values family• Improves children’s health/utilization of preventative health services
through providing health education to children while they are at the daycare center
Prototype1:DaycareatMFCPROTOTYPES
Prototype2:Redesignthewaitingexperience
PROTOTYPES
HypothesisWhen patients arrive to their appointment they have to wait to see clinician for 30 min-2 hours. They get upset and frustrated. This affects their appointment experience and willingness to come to next appointment.
SolutionThe valuable appointment time should begin as soon as a patient walks through the door of the clinic. We need to redesign patient’s waiting time experience to provide general education during the time when they have to wait to see clinician. It would reduce the perception of this time as “wasted”. Two types of education can be delivered:
1) Waiting rooma. Passive – use existing TV screens -> general educationb. Active – gazebo -> general education
2) Exam rooma. Passive - use existing TV screens -> specifi c education / general educationb. Active – 1:1 with medical assistant or clinical resident -> specifi c education/
general education
Prototype2:RedesignthewaitingexperiencePROTOTYPES
Benefits
• Addresses patients biggest complaint: wait time by changing perception of the time as “wasted”
• Increases patient satisfaction• Improves patient experience (the doctor saw you for your appointment in 15
minutes after you arrived)• Low cost solution since the infrastructure for this intervention already exists within
the clinic. MFC has TV monitors in the waiting areas and in the exam rooms.• Reduces no shows by providing additional value to the clinical appointment• Delivering health education and raising awareness about important issues• This structure could be first used to educate patients about the patient portal• Improving patient-clinician shared decision-making• It can be applied as way to increase patient participation in the appointment and
help them ask questions that they are interested in, in regards to their reason for visit
• Helps retention & recruitment of new patients• Measure the perception towards MFC as patient-centered medical home (~clinic
values patients and cares).
PROPOSEDPILOTS
Prototype1:DaycareatMFCPROTOTYPES
In this quasi-experimental study of 200 patients who have children under the age of 13 and have an upcoming appointment with clinician at MFC, 100 control participants will go to an appointment as usual with their children,and 100 participants will be offered a daycare service where parents can drop off their children prior to the appointment and pick them up at the end of their appointment.
Three surveys will take place (1) several weeks prior to the daycare intervention to serve as a baseline and provide the chance to sign up for a daycare at their next appointment; (2) 4-6 weeks later, post intervention to assess initial impact, identify changes in appointment experience, perception of care, perceived value of the daycare service; (3) several weeks-months after the daycare intervention when these patients would have a follow up visit to measure the rate of no shows/missed appointments.
Prototype2:RedesignthewaitingexperiencePROTOTYPES
In this quasi-experimental study of 200 patients who have an upcoming appointment with clinician at MFC 100 control participants will go to an appointment as usual, and 100 participants on the day of their appointments will receive passive and active education in the waiting room and in the exam room.
Three surveys will take place (1) prior to the intervention to serve as a baseline (2) 4-6 weeks post intervention to assess initial impact, identify changes in appointment experience, perception of care, satisfaction with the appointment, perceived length of waiting time, perceived value of provided education; (2) several weeks/months after the intervention when these patients would have a follow up visit to measure the rate of no shows/missed appointments.
Successcriteria/measures
• Statisticallysignificantreductioninnoshows/missedappointmentsamongthetargetedpopulation(baseline:historicalaverage)
• Morethan50%ofpatientswhohavechildrenreportthattheyvaluetheprovideddaycareserviceORmorethan50%ofpatientsreportthatthey valueprovidededucation
• Statisticallysignificant improvementinoverallpatientreportedexperienceorperceptionofcare(baseline:historicalaverage)
• Statisticallysignificant increaseinpostappointmentpatientsatisfaction(baseline:historicalaverage)
• ImprovedperceptionofMFCasapatient-centeredmedicalhome
• Improvedchildren’seducationmeasuredthroughself-report(askingchildren/parents)ORthroughincreasednumber ofpreventivevisitsamongchildrenORimprovementsinselectedhealthmeasures
RECOMMENDATIONSPILOTS
DISCUSSION
NEXTSTEPS
WearethankfulthatwecouldworkwithMuskegonFamilyCare’swonderfulclinicians,staffandpatients.Itwasinsightfultodiveintoyourworkflowandinspiringtoseehowmuchyoucareaboutyourcommunity.
ThiscollaborationwasparticularlyrewardingforusanditsparkedmanyinterestingideasandconversationsbothinsideMad*Powandinthelargerdesigncommunity.Wewouldlovetostayintouchandserveasexpertadvisersandreviewers.Wedefinitelywanttohearhowthethingsaregoing!
NEXTSTEPS
Thankyou,MFC!
Wewanttokeepimprovingthepatient-clinicianinteractionsandbriningvaluetotheappointmentsofpatientswhoreceivecareatFQHClikeMFC.Wewouldbegratefulifyoucouldprovidefeedbackontheworkthatwe’vedoneandanysuggestionsabouthowwecouldmakeitmoreusefultoclinicsandpeoplelikeyouinthefuture.
NEXTSTEPS
Keepintouch!
TheEnd