PFCC.org

What Matters to You?

Understanding the Patient

Perspective

Sarah Clayton, MIS

sclayton@upmc.edu

April 14, 2016

Photo credits: Shutterstock and CDC (Public Domain)

PFCC.org

CONFLICT OF INTEREST

I hereby certify that, to the best of my knowledge,

no aspect of my current personal or professional

situation might reasonably be expected to affect

significantly my views on the subject on which I am presenting.

$12 billion global health

system

62,000 employees

22 hospitals

400 outpatient sites

3,500 physicians

International and

commercial services

Photo credit: PGH_DWTN_DUQINCLINE_20090824_020.tif via UPMC Creative Services

PFCC.org

Welcome to the Magee Bone and Joint Center

Delivering Value with VolumePhoto credit: UPMC

Improving Safety, Quality & Waste Reduction

Total Joint Replacement Care Experience

Readmission RateWithin 30 days TKA = 1.1% THA = 1.6%

TKA – CY15

BJC National Avg

Average LOS 2.7 days 3.2 days

Infection Rates 0.2% 1.2%

Mortality Rates 0.0% 0.1%

Discharge Destination 88% Home

THA – CY15

Average LOS 2.6 days 3.9 days

Infection Rates 0.0% 1.5%

Mortality Rates 0.0% 0.6%

Discharge Destination 89% Home

PFCC.org

Health Outcomes – A Definition

“Outcomes, by and large, remain the

ultimate validation of the effectiveness

and quality of medical care.”

- Avedis Donabedian

Photo credit: Sarah Clayton

PFCC.org

Common Outcomes

• Complications

• HCAHPS

• Personal/Family History

• LOS

• Hospital Readmissions

• Mortality Rate

• HAI Rate

• Blood Usage

• OR Time

• Cost per Case

Photo credit: Microsoft Clipart

PFCC.org

What is a Patient Reported Outcome?

“any report of the status of a patient’s health condition that

comes directly from the patient, without interpretation of the

patient’s response by a clinician or anyone else”

– National Quality Forum

Photo credit: Adobe Stock

PFCC.org

Clinical Outcomes vs. PROs

ClinicalOutcomes

PatientReportedOutcomes

What really matters to patients?

Relationships

Work

Physical

Health

Emotional

Health

Getting

Healthcare

Medicine Monitoring

Health

Cost

PFCC.org

Shared Decision Making

Barry, M., & Edgman-Levitan, S. (2012). Shared Decision Making — The Pinnacle of Patient-Centered Care.

New England Journal of Medicine, 780-781.

TogetherMake a decision

CliniciansShare

Opinions

PatientsConsider Options

PFCC.org

What Matters To You? – Phase 1

• Co-design tool in the Bone and Joint Center

• Pre-surgical interview/Post-operative interview

What matters to you…

… before surgery?

… during your hospital stay?

… in the first 3 months following

surgery?

…after you’ve recovered from your

joint replacement?

Photo credit: JJAVA via Adobe Stock. Question Mark Puzzle. (Image). Retrieved from: https://stock.adobe.com/Library/ff058db6-2a9f-4bfa-8671-a7338dec48e4

PFCC.org

What Matters To You? – Phase 1

…before surgery?Preparation, infection, BP and DM control, no pain, recovery time

…during your hospital stay?Infection, nice and attentive staff, clean room, good food, private room, sleep

…in the first 3 months following surgery?

Returning to work, able to golf, staying healthy

…after you recovered from TJR?Walking, returning to normal activities, reduced pain

Outcomes Quality of Care/Staff Education

Quality of Life Environment of Care Reduction in Pain

PFCC.org

What Matters To You? – Phase 2

I want a good outcomeInfection or problems with my new joint, quick recovery time, no issues with anesthesia

____________

I want my other medical conditions to be controlledWeight control, nutrition, other conditions such as hypertension, diabetes, needing additional joint replacement

____________

I want to feel comfortable with the people taking care of meTrust in MD, responsiveness and attitude of staff, response time of my providers, meals, physical therapy

____________

I want to know about the process and feel prepared

Overall education, exercise, I’ll know what is going to happen

____________

I want to improve my quality of life after surgeryMobility, independence, resume active lifestyle, travel, exercise, return to work, able to walk, participate in my usual hobbies

____________

My room and other areas of the hospital meet my standards

Cleanliness, noise level, private room, sleep interruption

____________

I want my pain to be reduced ____________

PFCC.org

What Matters To You? – Phase 2

Photo credit: grki via Adobe Stock. Business Infographic. (Image). Retrieved from: https://stock.adobe.com/Library/ff058db6-2a9f-4bfa-8671-a7338dec48e4

PFCC.org

What Matters To You? – Phase 2

n = 49

74%

16%

4% 4%2%

Most Important to Me (1st Rank) Postoperative

Surgical Results Quality of Life

Reduction in Pain Education

Quality of Care/Staff

n = 49

66%16%

8%6%

2% 2%

Most Important to Me (1st Rank) Preoperative

Surgical Results Quality of Life

Reduction in Pain Quality of Care/Staff

Medical Conditions Education

n = 49

PFCC.org

What Matters To You? – Phase 2

n = 49 n = 49

33%

27%

24%

10%4%

2%

Least Important to Me (7th Rank) Preoperative

Environment Medical Conditions

Education Reduction in Pain

Quality of Care/Staff Surgical Results

35%

29%

20%

10%4%

2%

Least Important to Me (7th Rank) Postoperative

Environment Education

Medical Conditions Reduction in Pain

Quality of Care/Staff Quality of Life

PFCC.org

What’s Next?

Photo credit: Microsoft Clipart

PFCC.org

• 97 patients have contacted the

WNM doctor to get more info

• 95% made appointments to be

seen

• 80% attended their

scheduled appointment

• 53% have had enough

success to move onto

surgery

jannyjus via Adobe Stock. Big juicy red ripe strawberries,apple,lime,peach,kiwi and measu. [Photograph]. Retrieved from: https://stock.adobe.com/search?k=32727426&filters%5Bcontent_type%3Aphoto%5D=1&filters%5Bcontent_type%3Avideo%5D=1&filters%5Bcontent_type%3Aillustration%5D=1&filters%5Bcontent_type%3Azip_vector%5D=1&safe_search=0&safe_search=1&color_last=&ca=

Weight No More

PFCC.org

Blues No More

• Collaborating with a mental health team

• Intervention prior to surgery

• Improve patient outcomes

Photo credits: LEFT - https://www.youtube.com/watch?v=mkp8Ksx8mq4 RIGHT: goir via Adobe Stock. Don't give up. [Image]. Retrieved from: https://stock.adobe.com/search?k=79581169&filters%5Bcontent_type%3Aphoto%5D=1&filters%5Bcontent_type%3Avideo%5D=1&filters%5Bcontent_type%3Aillustration%5D=1&filters%5Bcontent_type%3Azip_vector%5D=1&safe_search=0&safe_search=1&color_last=&ca=

PFCC.org

Outcomes “Flow Chart”

NP/Surg Sched Visit

• Patient demo

• What matters to you? (pilot)

• VR-12 or PROMIS-Global

• HOOS/KOOS Jr.

• Original HOOS/KOOS

Function, Daily Living Subscale

• Original KOOS Pain Subscale

Pre-Op

Testing

• MRSA/MS

SA

screening

DOS

• MRSA/MS

SA

compliance

• SCIP

compliance

OR

• Efficiencies

Inpatient

• Transfusions

• LOS

• SCIP

compliance

• Pain level

• Mortality

• D/C destination

• Adverse

events

In-patient

PT• DOS activity

• ROM

• Ambulation

distance

• Pain level

• Assistive support

at D/C

Out-patient

PT• TJR functional

scale (SSP)

1mo F/U• PRO’s

• Readmission rate

• Infection rate

• HCAHPS

• Net Promoter

Score (NPS)

• What matters to

you? (pilot)

90 days to 1 year F/U• VR-12 or PROMIS-Global

• HOOS/KOOS Jr.

• Original HOOS/KOOS

Function, Daily Living

Subscale

• Original KOOS Pain

Subscale

How likely are you to recommend us to family and friends?

* Reichheld, Frederick F. "The One Number You Need to Grow." Harvard Business Review (2003): 1-10. Photo credit: Adobe Stock

% Detractors

PFCC.org

Patients and Families Become

“Evangelists”

vitalli42 via Adobe Stock. Paradise staircase. [Image]. Retrieved from: https://stock.adobe.com/search?k=73051635&filters%5Bcontent_type%3Aphoto%5D=1&filters%5Bcontent_type%3Avideo%5D=1&filters%5Bcontent_type%3Aillustration%5D=1&filters%5Bcontent_type%3Azip_vector%5D=1&safe_search=0&safe_search=1&color_last=&ca=

5. Shared Vision of the Ideal

Ideal Experience

CurrentState

2. Guiding Council

3. Shadow, Current State, Urgency

4. Working Group thru Touchpoints

6. PFCC Project Teams Close the Gap

1. Define Care Experience

0 www.pfcc.org

Patient and Family Centered Care Methodology and Practice (PFCC M/P)

PFCC.org

Step 3:

Evaluate the Current State

Unique to PFCC M/P: SHADOWING

Shadowing is the repeated, real-time

observation of patients and families

• Walk the walk of patients

and families

• Record observations and

insights

• Identify care experience flow

1 2 3 4 5 6

Photo credit: Microsoft Clip Art

PFCC @ UPMC

70+ Care Experience Working Groups

• Home Health Exp

• Mental Health

• Dental

• ER Registration

• Life After Wt Loss

• ENT Experience

• Imaging

• Urgent Care

www.PFCC.org/Annual-Reports

• Communication in

Ambulatory

• OP Surgery

• Urology/Gynecology

• Cancer Treatment

• Emergency Dept

• Ortho

PFCC.org

True Cost Methodology

Robert S. Kaplan and Michael E. Porter “How to Solve the Cost Crisis in Health Care,” HBR 2011Photo credit: Andy Dean via Adobe Stock. Stethoscope Laying on Stacks of Money. [Photograph]. Retrieved from:

https://stock.adobe.com/search?k=21591033&filters%5Bcontent_type%3Aphoto%5D=1&filters%5Bcontent_type%3Avideo%5D=1&filters%5Bcontent_type%3Aillustration%5D=1&filters%5Bcontent_type%3Azip_vector%5D=1

For a full cycle of care:

• Personnel

• Space

• Equipment

• Consumables

All resources for any clinical condition

PFCC.org

Minutes $/Min

What activities are performed?

What Care Giver is performing each activity?

How long does each activity take?

What other resources (space, equipment, and consumables) are used?

$

Shadowing for True Cost

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%5D=1&filters%5Bcontent_type%3Azip_vector%5D=1&safe_search=0&safe_search=1&color_last=&ca=

PFCC.org

Total Care Experience CostTotal Hip Replacement

44%

2%1%

53%

Personnel

Space

Equipment

Consumables

1 Month Pre to 3 Months Post Surgery*

* Determining the True Cost to Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for Bundling and Reference-Based Pricing. (2015) The Journal of Arthroplasty.

PFCC.org

Space1%

Equipment0.4%

OR Consumables

83%

Personnel

16%

Operating Room CostTotal Hip Replacement

86% of OR consumables

related to implant cost

PFCC.org

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Facility #1

Facility #2

Outpatient THR

Hospital vs. Hospital vs. Outpatient

Pre-Op + Office

Pre-Op Testing + Consults

Day of Surgery + OR

PACU HospitalStay

Therapy Follow Up

Visits

PFCC.org

Cost Savings = $13.06/patient

Yearly Savings for one surgeon = $7,640

Yearly savings for program = $14,522

Chest X-ray Elimination

PFCC.org

• Transfusion Rates <1%

• No AutoVac Savings $75,951/yr

• No T/C $242,112/year

• No T/S $240,657/year

Blood Conservation Program

Achieving the Value Trifecta

1. View All Care as an Experience Through the Eyes of Patients and Families

2. Co-Design

3. Let PFCC M/P be your guide to implementation

3 Keys to Success

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Community of Practice

United States: 27 International: 7

Merging Technology with Process Improvement

Community of PracticemyPFCC.org

http://www.pfcc.org/ihisweden/

Thank you!

CDC, Amanda Mills, 2011, PIHL

CDC, Amanda Mills, 2011, PIHL

Photo credits: Shutterstock and CDC (Public Domain)

For full photo citations, please contact the PFCC Innovation Center of UPMC.

What really matters

The key steps to making it really happen

Learning from patient stories

A personal guide for clinicians

Peter Lachman

CONFLICT OF INTEREST

I hereby certify that, to the best of my knowledge,

no aspect of my current personal or professional

situation might reasonably be expected to affect

significantly my views on the subject on which I

am presenting.

BUZZ Sessions

There will be a few BUZZ sessions

When the BUZZ slide comes up you will take turns in 2

minutes to explore the concept introduced

Turn to the person on your left and introduce yourselves

Discuss one take home message from Sarah’s presentation

The key steps

1. Embrace a new mental model

– It is possible to change

2. Listen to stories

– Patients and providers

3. Study your system and “what matters”

– Follow the person

4. Know “what matters to you”

– Understand your priorities

5. Consider a framework that works for you and ask every day

– Was I person centred or not ?

1 The new mental model

One moment and person at a time to achieve

“What matters to you”

“Its not enough to do your best you must know what to do

and then do your best”

W Edwards Deming

Juran framework

Quality planning

Quality control

Quality management

Quality improvement

Deming

System where you

work

Variation in the system

Psychology - the

people

Theory of knowledge

Profound Knowledge

Better experience

Better health

Great staff experience

Lower cost

The Quadruple Aim

Reference IHI

The Quadruple Aim: care, health, cost and meaning in work R Sikka, Je M Morath, L Leape BMJ Qual Saf

Do it to me

Do it for me

Do it with me

Martha Hayward

2 Listen to stories

“Story is the language of the brain – we think in narrative.

Story is the living, breathing cornerstone of evolution.Story

isn’t “a” way we make sense of the world.

It’s THE way.”

Lisa Cron Wired for Story

We all have a first story

The case of building on experience

Baby Alexandra

who taught me to care

3 Understand the system

Where provider and patient meet is

where it really happens

What is the purpose?

What really happens?

And the variation

4 Ask what is my underlying value

Does the process lead to a culture of person

centred care and facilitate

“What really matters to me as a

care giver”

What really matters

Share

What really matters to you?

5 A framework for person centred care http://www.health.org.uk/public/cms/75/76/313/4772/Measuring%20what%20really%20matters.pdf?realName=GuxZKx.pdf

Dignity respect

compassion

Coordinated

Personalised

Enabling

Dignity Compassion Respect

Values/behaviours

Defining our purpose

Story M

The parents who taught me to listen

“What really matters to us”

Story L

From L’s perspective it was the first time for a doctor to

actually speak to her rather than to us parents.

This made her feel a part of the process rather than a

passive observer, which in turn helped her to take

responsibility for herself

“Treat me with dignity and respect”

Coordinated around the person

Designing around the person not the patient

For patient as a person

Holistic approach as well as individual

Story J: I want to lead a normal life

“I attend several consultants clinics and the need

for coordinated care is essential.

Not everyone is privileged to receive coordinated

care and few doctors are willing to take the lead in

administrating it.

Without the holistic approach my care would have

suffered and I would not have achieved what I

have done to date”

Enabling and transfer of power

Promoting self management not dependence

Patient as experts in their own health Sharing of decision making Sharing of information Idea of common ground

Activities to enable transfer of power

Self management support

Shares decision making

Collaborative care

Support planning

Patient coming on the journey

Respect that patient and family may know more than you do

Agenda setting

Narrative and listening

Shared decision making

Shared goal setting

Assessment of self management capability

Developing share measures for outcome

Clinics arranged to promote shared decision making

and self management

Self management

Self Management

IT

Informed activated patient

Informed activated practice

team

Productive integrated

interactions

Supporting self management

Reference Wagner Chronic Care Model

Define issues

Unbiased information

Define roles

Present evidence

Mutual agreement

Shared decision making

Story G

“When my daughter became ill and was diagnosed with

epilepsy, a whole new world opened for me.

While I had some experience in special educational needs

(SEN) and epilepsy (being a SEN teacher), I had never

experienced the kind of seizures G had.

I felt like a total beginner, it was terribly scary. What helped

me most was knowing someone would be replying to my

emails or text messages.

I have a plan to manage the seizures and I therefore don't

feel lost managing on our own.

Shared Decision Making

Share one time you were involved in shared decision

making

How did it feel?

Redesign the focus and personalise

Standardise but personalise

Story B

“We are the parents of a child, who at the age of 3 years

and who is now nearly age 10, suffered severe seizures.

Since the beginning of his treatment till the present we

have greatly benefitted from constant open and direct

access by both email and at times /texts to our consultant.

It has ensured that if we had any worries about his

condition we could inform him and felt safe that any

decisions made were with his complete knowledge relating

individually to our son.”

Sharing experiences

Share a story on “What matters to me”

Kings Fund

Everyone with long-term care needs, whether mental or physical, must be able to access

appropriate emotional, psychological and practical support.

My Name is Fychi and I am 26 years old

I cannot talk, I cannot walk, I cannot eat, I cannot wipe the hair off my face, I

cannot hold anything, I cannot drink, I cannot turn myself in bed, I cannot tell

you what is hurting me I cannot tell you what I would like to do I cannot tell

you what sounds I do not like,

I can smileI can sense who really likes me

I can understand more then would appear but this is not quantifiable I can hearI can see

I can enjoy musicI can enjoy going out and watching children playing

I can enjoy the attention of people who genuinely want to talk TO MEI can hear when people tell me what they are going to do, even though

I may not respond

What I want

I want to be treated as if I can and not as if I can’t so please

Speak to meExplain what you are going to do

Tell me why you are going to do somethingTry to remember that I may be very underweight and

very small but I am 26Treat me like an adult

Do unto me what you would want doing to youDon’t underestimate my ability

I don’t want to be treated as a lost case and when I go into the emergency department

I don’t want to be asked if I should be resuscitated

I am 26 years old with hopefully many more years of life to live, just because I am profoundly disabled don’t treat me like a lost cause.

Fychi March 2016

The key steps

1. Embrace a new mental model

– It is possible to change

2. Listen to stories

– Patients and providers

3. Study your system and “what matters”

– Follow the person

4. Know “what matters to you”

– Understand your priorities

5. Consider a framework that works for you and ask every day

– Was I person centred or not ?

PeterLachman

plachman@isqua.org

Question time