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Pamela K. Greenhouse Executive Director, PFCC Innovation Center
Shadowing:
Aim for the Heart and Backfill with the Data
Disclosure Statement
I have no affiliation, financial or otherwise, with
any commercial or other industry interest with
regard to the PFCC Methodology and Practice
or this presentation.
Pamela K. Greenhouse, MBA
Executive Director, PFCC Innovation Center
• Understand Shadowing as a tool to view care through
the eyes of patients and families
• Understand how Shadowing creates a sense of
urgency to drive change
• Understand that Shadowing allows us to identify
redundancies and opportunities to reduce waste and
cost
• Understand the 6 steps of Shadowing and Care
Experience Flow Mapping
Learning Objectives
UPMC: Who are We?
• UPMC is a $10 billion integrated global health system headquartered in Pittsburgh, PA
• Named one of the nation’s Top 10 Hospitals on the U.S. News & World Report’s Honor Roll of America’s Best Hospitals
• Pennsylvania’s largest employer with 55,000 employee.
• Operates more than 20 academic, community, and specialty hospitals and 400 outpatient sites, employs more than 3,200 physicians, and an array of rehabilitation, retirement, and long-term care facilities
• A simple, replicable and sustainable six-
step methodology to deliver exceptional
care experiences and improve clinical
outcomes while decreasing waste
and cost.
• Developed for health care, the PFCC M/P is
based on the Design Sciences in which the
goal is always to make things better for the
end user
The Patient and Family Centered Care
Methodology and Practice
Current State
Ideal Experience
1. Define Care Experience
2. Guiding Council
3. Shadow, Current State, Urgency
4. Working Group thru Touchpoints
5. Shared Vision of the Ideal
6. PFCC Project Teams
to Close the Gap
The PFCC Methodology and Practice
Provides the Steps to Success
Care Giver
Any person within a care setting whose work
touches a patient’s or family’s experience
Touchpoints Key moments and places in any care setting
where patient and family care experiences are
directly or indirectly affected by any
care giver.
Let’s define our terms!
Care Delivery
Hospital Hurdles
Scheduler
Valet
Techni-
cian
Nurse/
Doctor
Dietary
PFCC is a grassroots effort to improve care and outcomes
over 60 different Care Experience Working Groups and care
settings of all kinds. In 2012, more than 180 PFCC Project
Teams & Over 440 Completed Projects.
0
200
400
600
800
1000
1200
1400
05
1015202530354045505560
2006 2007 2008 2009 2010 2011 2012
PFCC Working Group Membership
# Total Working Groups
PFCC At UPMC
The PFCC Community
of Practice is Growing
• Baptist Memorial, Collierville - Tennessee
• Nemours, A Children’s Health
System, Delaware & Orlando
• National Health Service, UK
• Korean Health System, Korea
• Atrius/Vanguard/Harvard, Boston
• WellSpan Health, Pennsylvania
• Rochester General Hospital, New York
• UNC Healthcare, North Carolina
• Aneurin Bevin Health, Wales
Three Keys for the PFCC
Methodology and Practice
Key #1: Viewing all care as experiences
through the eyes of patients and families.
Key #2: Engaging patients and families as
full partners in co-designing care with us.
Key #3: Providing simple solutions in a
complex system in order to overcome
hurdles and break down barriers to
providing exceptional care experiences.
The Key We’re Focused on Today
View All Care as an
Experience
and Through the Eyes of
Patients and Families
What is Shadowing?
Shadowing is the direct, real-
time observation of patients
and families as they move
through each step of a Care
Experience, over the full cycle
of care.
It’s Easy
“We watch what people do (and do not do)
and listen to what they say (and do not say).
The easiest thing about the search for insight
– in contrast to the search for hard data – is
that it’s everywhere and it’s free.”
“This enlightened perception reveals the
experience, not just the process. “ Tim Brown
“Change by Design
Shadowing
Shadowing
Empathy
Insights
PFCC Actions and
Implementation Through
Working Groups
Shadowing and
Care Experience Flow Mapping
• Walk the walk of patients and
families…feel what they feel
• Shadow patients and families
through the selected care
experience, record subjective and
objective observations and
insights
• High impact for the $’s and effort
Who Can Shadow?…Anyone!
• Guiding Council and care
givers
• Shadowing for new hires and
light duty staff
• Students, volunteers,
summer interns, patient
advocates
“Being a nurse for 25 years I thought I
had a good understanding of what our
patients and families wanted because I
live it and work it every day. But I found
out that there are some things that are
more important to the patients than I
thought they were. For example, I didn’t
realize how many people were having a
hard time just finding my unit. Or that
parking was such a big issue.”
Assumed
• Counter 1
• Counter 2
• Main Waiting Area
• Patient Room
• Small Waiting Area
True • Parking Garage
• Counter 1
• Counter 2
• Main Waiting Area
• Vitals Room
• Patient Room
• Small Waiting Area
• Discharge Desk
• Pay Station
Examples: Assumed vs. True
Touchpoints:
• Call Center
• Parking Garage
• Dr.’s Office
• Exam Room
• Ultrasound
• Transport
• Inpatient Unit/Room
Care Givers:
• Scheduler
• Valet attendant
• Receptionist
• CRNP
• Technician
• Transporter
• Unit Director
• Nurse
Outpatient Office Visit
Care Experience Flow Map
Six Steps to
Shadowing
Actual Experience
Presumed Flow
1. Define the Care Experience for Shadowing
2. Select the Patient and Family Shadower
3. Gather Information for the Shadowing Project
4. Connect with the Patient and Family
5. Observe the Patient’s and
Family’s Care Experience
6. Report Your Findings
Patient and Family Shadowing
Step 1
Which care experience do you want to
shadow?
Broad vs. narrow care experience?
Define the Care Experience
for Shadowing
Six Steps to Patient and
Family Shadowing
Defining the Care Experience
Emergency Room Care Experience
ER Admitting DeskRegistration/Triage
Registration/TriageER Exam Room
ER Exam RoomCheck Out/Discharge
Segments of Care
Step 1
Defining the Care Experience
Discharge Care Experience
Discharge Notification Preparation for D/C
Nurse Arrival for Discharge Instructions
Transport for Exit Check Out/Discharge
Segments of Care
Step 1
Example of Discharge
Touchpoints and Observations
Initial Discharge Notification
• Was the notification within a
reasonable time of discharge?
Preparation for Discharge
• Was the patient ready for discharge?
Nurse Arrival for Discharge
• Did the nurse arrive in a timely
fashion?
Example of Discharge
Touchpoints and Observations
Instructions
• Were the instructions presented in a way
the patient could understand?
Transportation for Exit
• Did the patient need transportation upon
discharge?
Exiting Facility
• Were there any issues for the family
members with valet or parking?
Examples of Ways to Segment
Shadowing for Other Experiences
Morning Rounds
• Physician and nurse communication to patient
• New nurses coming on duty
• Medication delivery
“Adopt-a-Patient”
• Can be at various time intervals
• Conversations will allow you to gain insight
about the patient experience
Step 2 Select the Patient and Family
Shadower
• Be a good observer and listener
• Have a positive, open and supportive
attitude
• Approach Shadowing with open eyes and
no biases
• Be empathic, compassionate, reliable and
trustworthy
Six Steps to Patient and
Family Shadowing
Gather Information for the
Shadowing Step 3
• Which patients and families should be Shadowed?
• What is the current pathway of the care experience to be Shadowed?
• When is the ideal time for Shadowing to occur,
based on patient volume, activity, type of
procedures involved, or other considerations?
Six Steps to Patient and
Family Shadowing
• When will you notify care givers about
the Shadowing that is about to take
place?
• Shadowers are Not Secret Shoppers
• Tip: It is always helpful for the
Shadower to take a quick tour of the
area to be Shadowed in advance.
•
Patient and Family Shadowing
Preparation Checklist
Prepare for Reporting
• How will you report information back to
the care givers who are requesting the
Shadowing?
Closing
• Provide your contact information to the
patient, family and care givers
• Confirm the date for Shadowing and
patient information
Patient and Family Shadowing
Preparation Checklist
Connect and Coordinate with
the Patient and Family Step 4
Steps to Patient and
Family Shadowing
• Make arrangements in advance with
patients and family members
• Explain that your role as Shadower is
to observe, record and evaluate their
care experience
Request to Shadow the Patient and
Family: Sample Dialogue
Presenting the Concept of Shadowing
• Make phone call at least 24 hours prior to
appointment –Tool 4 for guidance and scripting
purposes
• Arrangements with patients and family
members in advance will reduce their anxiety
• Emphasize your role in improving their
experience
• Defuse any “secret shopper” impressions that
they may have
36
Tool 4. Request to Shadow Patient and Family: Sample Dialogue
PFCC Methodology and Practice
Website
• www.pfcc.org
• Click on Go Shadow
• Click on Shadowing Resources
Step 5 Shadow: Observe and Record the
Patient’s and Family’s Care Experience
Steps to Patient and
Family Shadowing
The overall flow of Patients, Families, and
Care Givers…
• Care Experience Flow Mapping
• Record Touchpoints and care giver roles
• Record who enters and leaves and where they go
• How long they are gone and when they come back
• What they do…and how they say and do it
Tool 5: Shadowing Observational Template
Tool 2: Creating the care Experience Flow Map Tool 6: Sample Observational Reports
41
Tool 2: Creating the care Experience Flow Map
Care Experience Flow Map:
Example A
Outpatient Office Visit
Care Experience Flow Map
Mom’s Melodrama
Placeholder for PFCC Live
Video Skit
Heart Care Experience Flow Map
Dr.’s Office
Transport
Housekeeping
Home
Call Center
Lab
Reaches scheduler
to make an
appointment
Call transferred to
office takes info and
receptionist makes
appointment
Front desk
receptionist
checks patient in
Physician assesses
patient and orders
tests
Escorted to
Ultrasound by
Transporter
Escorted to Inpatient
Unit by Transporter
Returned to Exam
room Physician
updated pt.
Escorted to Exam
Room by
Transporter
Moved to Room by
Clinical Manager;
waits 40 minutes for
room
Greeted by Unit
Clerk
Touchpoints and Care Givers
Ultrasound
Technician
performs test; test
takes 45 minutes
Phlebotomist draws
blood
Parking
Information
Desk
Parked car in wrong
lot per attendant
Dietary
Clinical Manager made
follow-up phone call
Cardiac Unit
Touchpoints: • Call Center
• Parking
• Doctor’s Office
• Transport
• Ultrasound
• Cardiac Unit
• Information Desk
• Housekeeping
• Lab
• Dietary
• Pharmacy
Heart Care Experience Flow Map
Care Givers: • Scheduler
• Parking Attendant
• Physician
• Transporter
• Technician
• Unit Clerk
• Greeter
• Housekeeper
• Phlebotomist
• Dietary Aide
• Pharmacist
Shadowing Results
Segment of Heart Care
Experience:
Begins: With phone call to schedule appointment
Ends: With follow-up phone call post discharge
• Automated phone
greeting
–Not caller friendly
–Misleading
• Receptionist friendly
• Same day appointment
• Texted directions to phone
• Parking long way from clinic
First Contact & Parking
Registration Experience
• Questions repeated
from phone call
• No wheelchair for
patient
• CRNP comes out to
greet patient
Exam Room Experience
• Nurse
–Uses medical
jargon
–Patient/family
anxious
–Orders ultrasound
• 30 minute wait for
transport
Ultrasound Experience
• Daughter told to stay
behind
• Transport leaves
patient in hallway
• Daughter alone in
exam room for 45
minutes w/o updates
• Results ready quickly;
delivered by CRNP
• Patient arrives on floor
–Staff is unprepared
• Waits for room in
hallway
–40 minutes
–Shadower intervenes
• Blood work not taken
• Cafeteria closes early
Inpatient Admission Experience
• Confusion on time of D/C
• 7 hour wait
• Patient and Daughter
present for instructions
• Medications not
explained
• Patient looking for
prescription
• Follow-up call from nurse
Discharge and Follow-up
• Improve automated recording
• Confirm information once
• Wheelchair access in garage
• Clearer signage in garage and to unit
• Improve Care Giver handoffs
• Room service options
• Discharge process
Recommendations
Another Kind of Shadowing
“Reality TV for Care Givers”
Reality TV for Care Givers
Staff Contacts/Time Analysis (22 patients)
0
10
20
30
40
50
60
70
80
(1)A
nesthe
siolog
ist
(2)C
ardiology
(3)C
haplain
(4)D
ieta
ry
(5)E
KG T
ech
(6)F
loris
t
(7)H
UC
(8)In
tern
(9)L
iaso
n
(10)
Mas
seuse
(11)
Nur
se
(12)
Nur
sing
Stude
nt
(13)
Occ
upatio
nal T
hera
py
(14)
Occ
upatio
nal T
hera
py S
t...
(15)
Pat
ient
Car
e Tec
hnician
(16)
Pat
ient
Sup
ports
Ass
ista
nt
(17)
Phy
sician'
s Ass
istant
(18)
Prim
ary
Car
e Phy
sician
(19)
Pha
rmacy
(20)
Phy
sica
l The
rapy
(21)
Phy
sica
l The
rapy
Stu
dent
(22)
Phy
sica
l The
rapy
Tec
hician
(23)
Rec
overy
Roo
m S
taff
(24)
Res
pirato
ry
(25)
Soc
ial
(26)
Sur
geon
(27)
Trans
port
(28)
Volun
teer
Staff Type
Nu
mb
er
of
Vis
its
012345678910111213
Tim
e/V
isit
(m
in)
Avg Number of Visits Avg Time per Visit
Hand washing - Top 5 Care Giver Groups
That Interact with Patients
39%
26%
6%
5%
5%
19% Nurse 39%
Patient Care Technician 26%
PT and OT 6%
Patient Support Assistant 5%
PT Technician 5%
Others 19%
28 Staff Types Top 5 Care Givers
# of contacts = 4034 # of contacts = 3221
(23 Staff Types)
Account for 81% of contacts
57
Shadowing Changes
Your Perspective
--Susan P. Ferguson
Chief Nursing Officer,
Baptist-Collierville
“I can’t tell you how impactful
Shadowing is; once people
Shadow, they talk about
PFCC differently—getting to
view care through the eyes
of patients and families truly
provides Care Givers with a
different perspective.”
59
A Physician Becomes a Patient
"So now, on the other side of the fence, I have also
been able to think about being a patient, and one
whose life is threatened. I have come to regret how
much better a doctor I might have been, had I been at
the receiving end of medical care earlier in my
career. In the past eighteen months I have learnt as
many lessons from sometimes unwittingly insensitive
doctors and nurses as from many others
whose patience, encouragement and
quiet humor have sustained me through
dark times."
-Elizabeth Bryan
Singing the Life
Leaders, Followers and Catalysts
