IMPROVING THE PATIENT EXPERIENCE a DESIGN research study on patient care emily carr university health design lab
health design lab
HEALTH AUTHORITY steering team
faculty and staff
Linda Dempster - Executive Director, Quality, Patient Safety, Infection Control and Community Engagement, VCH Georgene Miller - Vice President, Quality, Safety & Outcome Improvement, PHSA Cathy Weir - Director, Quality Improvement and Patient Safety, Fraser Health
Jonathan Aitken - Director, Health Design Lab Guillermina Noel - Adjunct Researcher Melissa Normandin - Project Coordinator research assistants Jessica Baratta Kevan D’Agostino Xch’e’ Hernandez Simper Mina Mirzahossein Leah Pirani Stewart Pressney Carly Yurechko quality forum co-creation facilitators
Nathania Candra Amanda Penuta April Piluso Eric Cheung Eunice Wong Fabyan Blomme Georgina Mackenzie-MacPherson Hanxiu Xu Jane Lee Jodie Lavery Kristina Mok Lauren Low Leigh Selden Maria Cooke Megan Kwan Melanie Bland Melissa Rossi Neil Manchon Nina Chen Petra Willemsen Tina Yan Dylan Moffat
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SECTION TITLE secondary research
CONTENTS
INTRODUCTION
appropriate to diverse populations. (p.3)
The purpose of this literature review is to summarize the literature from several perspectives. It has been systematically divided into major themes and provides information regarding: what is patient experience; its current state; the issues and barriers encountered to improve patient experience; measuring and using data to improve it; and the changes needed for implementation in order to achieve an optimal patient experience.
Some dimensions affecting patientcentered care are “sustaining therapeutic relationships with patients, using effective 4 THE PROJECT interpersonal and communication skills, and with patients, their families, 6 teaming Secondary research and colleagues” et al., 2011, Literature(Ratanawongsa Review . 7 p. 473). Similarly, some features identified by Institute (2013) as impacting primary researcH 14 the Beryl the patient experience are: reducing noise, methodologies discharge process, hourly Co-Creation . 15 rounding, pain management, and responsiveness Ethnographic Probe . 16 of staff/ communication; given Interviews . 17 that “it is only in these personal moments, touch-points of communication, through which the patient data analysis 18 experience is delivered” (p. 16). According Affinity Diagramming . 19 to Feinberg, and Washington (2012) MatrixCoye, Approach . 23 an institution aiming at improving patient experience should have as a mission “healing research overview 24 humankind Fraserone . 25patient at a time, by alleviating suffering, VCH . 28 promoting health, and delivering acts. of PHSA 33kindness” (p. 1). Quality Forum . 37
Defining Patient ExperiencE A definition that encompasses the patient experience has been approached in many different ways. The Beryl Institute (2014) defines the patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care” (p.3). In similar circles, the Institute for Medicine (2001) approaches the terminology of this experience as “patient-centered” defining it as: Care that informs and involves patients in medical decision-making and self management; coordinates and integrates medical care; provides physical comfort and emotional support; understands the patients’ concept of illness and their cultural beliefs; and understands and applies principles of disease prevention and behavioral change
Current State Design Opportunities and 42 Canadian healthcare systems have been Future Directions struggling to improve the overall patient 48 experience in the past few decades. Initiatives appendiX have included shifting some responsibility Bibliography . 49 for hospital safety to patients, boosting patient involvement in policy-making, and improving communication lines between large bureaucratic structures and the
The Project General Design Brief
5 the project
Healthcare systems in Canada have been struggling to improve overall patient experience in light of massive changes to care and its delivery. These initiatives have ranged from shifting some responsibility for hospital safety to patients; boosting patient involvement in policy-making; and improving communication lines between large bureaucratic structures and the communities they serve. Common to all of these initiatives is a recognition of the need to move from treating illness and disease, to treating the patient. While this shift could be dismissed as semantics, in fact it recognizes the need for a fundamental shift in the way in which we approach healthcare—one that recognizes the patient as a whole person, not a collection of treatable symptoms. VCH, PHSA, and Fraser Health, like all health authorities in Canada, are struggling with this issue and have already conducted significant research in the area. To add to the knowledge space, they agreed to collaborate with the Health Design Lab at Emily Carr University of Art + Design on a design research project to specifically consider how they might improve the patient experience in hospitals. The primary goal of this first stage of the project is to apply the Lab’s use of human-centred research methodologies to explore the problem space, considering in depth how patients feel about and experience
their treatment in hospitals. A secondary goal is to make innovative recommendations for change for ways to approach the problem and engage with staff in changing attitudes and behaviour. Designed outcomes are not a primary deliverable, but “key messages” are to be articulated with some suggestions for implementation. This initiative aligns with the BC Ministry of Health’s Patient-Centred Care Framework and Health Authority Strategies (2014) to promote patient-centred care attitudes and behaviors as central to organizational culture.
secondary research literature review
7 secondary research
INTRODUCTION The purpose of this literature review is to summarize the literature from several perspectives. It has been systematically divided into major themes and provides information regarding a definition of patient experience, its current state, issues and barriers encountered to improving patient experience, measurement and use of data to improve it, and changes needed in order to achieve an optimal patient experience. Defining Patient ExperiencE A definition that encompasses the patient experience has been approached in many different ways. The Beryl Institute (2014) defines the patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care” (p. 3). Further in depth, the Institute for Medicine (2001) defines patient experience as: Care that informs and involves patients in medical decision-making and self management; coordinates and integrates medical care; provides physical comfort and emotional support; understands the patients’ concept of illness and their cultural beliefs; and understands and applies principles of disease prevention and behavioral change appropriate to diverse populations. (p. 3)
Another way to understand patient centered care is through its focus on “sustaining therapeutic relationships with patients, using effective interpersonal and communication skills, and teaming with patients, their families, and colleagues” (Ratanawongsa et al., 2011, p. 473). Similarly, some features identified by the Beryl Institute (2013) as impacting the patient experience are noise, discharge process, hourly rounding, pain management, and responsiveness of staff/ communication, given that “it is only in these personal moments, touch-points of communication, through which the patient experience is delivered” (p. 16). According to Feinberg, Coye, and Washington (2012), an institution aiming at improving patient experience should have as a mission “healing humankind one patient at a time, by alleviating suffering, promoting health, and delivering acts of kindness” (p. 1). Current State Canadian healthcare systems have been struggling to improve the overall patient experience in the past few decades. Initiatives have included shifting some responsibility for hospital safety to patients, boosting patient involvement in policy-making, and improving communication lines between large bureaucratic structures and the communities they serve. However, despite
« Patient perceptions of staff courtesy emerged as the most important factor influencing their reports of overall quality of care. » Watson, Black & Peterson, 2008
changes to care and delivery, there remains an underlying need to refine the experience of patients. Within British Columbia, concerns have been established regarding “the scope of control of healthcare professionals, such as staff courtesy, teamwork, comprehensiveness of services, the length of wait for doctors and the availability of nurses” (Watson, Black, & Peterson, 2008, p. 14). Within the past two decades there has been substantial growth in Canada to aid in the understanding of developing patient experiences. As of September 2014, the Canadian Institute for Health Information (CIHI) has collaborated with the national and international research community, as well as with many stakeholders across the country, including the Inter-Jurisdictional Patient Satisfaction Group, Accreditation Canada, the Canadian Patient Safety Institute and The Change Foundation, to develop and begin testing the CPES - IC (Canadian Patient Experience Survey— Inpatient Care).
Barriers to Improving the Patient Experience An overview of the collected literature indicates various problems across all dimensions of the patient experience. The UBC Centre for Health Services and Research Policy indicates that: Patient perceptions of staff courtesy emerged as the most important factor influencing their reports of overall quality of care. This suggests that efforts to improve quality should focus more broadly so that other factors such as staff courtesy to patients, ensuring that patients receive the full set of services they need, and supporting team-based interaction with patients, are also addressed—in addition to wait times. (Watson, Black & Peterson, 2008, p. 9) Alongside these factors, many other issues are highlighted throughout the literature. These include: ··communication/documentation errors ··medical judgment errors ··lack of competency training ··unsafe treatment of infection/wounds, unhygienic environments ·· stricter confidentiality of patient information
Another problem affecting the patient experience is considering patients simply as “the recipient of physicians’ information giving, therapeutic acumen, instruction, and persuasive skills” (Vanderford, Jenks, & Sharf, 1997, p. 14). This domineering attitude negatively influences the patientdoctor relationship. There are many barriers that have been identified within the problem space, but it seems that “change will not happen without effective leadership improvements” (Coulter, Locock, Ziebland, & Calabrese, 2014, p. 2). Measuring Patient Experience The patient experience has been approached and analyzed in many different ways. Various data modes are consistently explored to develop, test, and synthesize information into accessible results. By coordinating techniques, the following identified methods may illuminate new ways of organizing results to better inform behaviour change. Within this past year, the British Medical Journal analyzed the role of the National Health Services in Britain, and the introduction of their digital Friends and Family patient experience test. Beginning early next year:
All NHS patients attending any type of healthcare facility in England will be invited to report back on their experiences using a variant of the Friends and Family Test (FFT). Real time feedback, often gathered on-site using handheld electronic devices, has been introduced into many hospitals over the past few years, and since 2013 it has been mandatory to offer all patients in acute hospitals and maternity services an opportunity to complete the FFT. (Coulter, Locock, Ziebland, & Calabrese, 2014, p. 1) With patient surveys, it is important to note that “patients can describe high levels of satisfaction at the same time as describing experiences that are suboptimal, and patients’ subjective satisfaction varies systematically with certain characteristics such as the age, sex, and ethnicity of the patient” (Salisbury, 2010, p. 1). In addition, collecting patient feedback is most effective when “based on a systematic literature review of existing questionnaires, interviews with users, and expert group consultation” (Garratt, Danielsen, Forland, & Hunskaar, 2010, p. 1). From an alternate perspective, the Journal of Health Services and Research Policy examines how co-design is being used to better inform behaviour change in healthcare challenges. This investigation of experiencebased co-design (EBCD) involves situations where “patients and staff work together to improve quality; to observe how acceleration affected the process and outcomes of the intervention” (Locock et al., 2014, p. 2). This participatory action research “marks a significant contribution to using narratives and involving patients in quality improvement in healthcare” (Locock et al., 2014, p. 3). Narratives can also be approached from a different route as documented in the
9 secondary research
Additionally, it has been noted, “relatively few Canadian organizations are improving existing efforts or adopting new interventions to improve safety in Canadian healthcare organizations” (Baker & Norton, 2001, p. 6). From the physician point of view, “patient volume and rapid patient turnover typically limit opportunities to learn and deliver truly patient-centered care” (Ratanawongsa et al., 2011, p. 473). Another physician stated “two recent surveys illustrate the persistent deficiencies that pervade our healthcare system when it comes to accompanying, counseling, and supporting [patients]” (Florez, 2007, p. 1490).
International Journal of Qualitative Methods. The literature indicates that a method of diary writing can also be seen as an “opportunity for reflection and inner dialogue. The articulation of thoughts becomes the catalyst for change in beliefs and practice” (Engin, 2011, p. 2). Measuring people’s responses to their healthcare journey seems to be essential for influencing different dimensions of quality and for understanding what works, what needs to be changed, and how to make improvements (Coulter, Locock, Ziebland, & Calabrese, 2014). Using Data to Improve Patient Experience Although data collection plays an important role in systemic change, “healthcare organizations are realizing that experience happens in the moment, in every moment, so the closer they can get to understanding what happens there, versus just via statistically validated surveys that provide post encounter insights, the better” (The Beryl Institute, 2013, p. 20). De Groot, et al, found that “consumers seem to consider patient experience-based information at least as important as hospitalbased information and may even prefer patient experience-based information over hospital based information on delivered care” (2012, p. 7). Real-time experience
and statistical surveys address the patient experience from two different approaches. This combination of research methodologies benefits both current and long-term improvements. However, “it requires direct, personal and in-the-moment efforts to achieve the greatest results” (The Beryl Institute, 2013, p. 20). Finally, it is important to consider that “it is unethical to ask patients to comment on their experiences if these comments are going to be ignored” (Coulter, Locock, Ziebland, Calabrese, 2014, p. 3). Communication Plays a Crucial Role in the Patient Experience The continuum of care is reliant on strong communication skills during each stage of interaction. From an initial overview of the literature, transparency during communication has been consistently noted as a behavioural priority in improving the patient experience. Many hospitals are currently working to enhance the significant implications of poor communication among staff and their interactions with patients. The honor-roll hospital (as ranked by the U.S. News and World Report), UCLA Medical Centre, has introduced a new approach to communication behaviours, developed completely by staff. Referred to
11 secondary research
as CICARE (pronounced See-I-Care), the acronym breaks down the patient experience (Feinberg, 2012): ··(C)onnect with the patient or family member using “Mr.,” “Ms.,” or their preferred name. ··(I)ntroduce yourself and your role. ··(C)ommunicate what you are going to do, how it will affect the patient, and other needed information. ··(A)sk for and anticipate patient and/or family needs, questions, or concerns. ··(R)espond to patient and/or family questions and requests with immediacy. ··(E)xit courteously, explaining what will come next or when you will return (p.1). In Canada, effective communication has also been identified by the Canadian Medical Association as “critical for the provision of high quality patient care. Planning, funding and training for collaborative care teams must include measures to support communication within these teams” (Canadian Medical Association, 2007, p. 11). A framework of communication factors within patient experience is outlined below. These components can be distinguished as “relational” and “functional” aspects of the
experience, as defined by Doyle, Lennox, and Bell (2013): Relational aspects refer to interpersonal aspects of care—the ability of clinicians to empathize, respect the preferences of patients, include them in decision-making and provide information to enable selfcare. It also refers to patients’ expectations that professionals will put their interest above other considerations and be honest and transparent when something goes wrong. Functional aspects relate to basic expectations about how care is delivered, such as attention to physical needs, timeliness of care, clean and safe environments, effective coordination between professionals, and continuity. (Doyle, Lennox, & Bell, 2013, p. 2) Furthermore, it appears that the way doctors provide information is more important to patients and families than the information itself (Pennbrant, Andersson, & Nilsson, 2012). According to the Beryl Institute (2013), “communication clearly remains an open and broad challenge in the patient experience conversation; one clearly needing continued focus” (p. 16).
« The way doctors provide information is more important to patients and families than the information itself. » Pennbrant, Andersson, & Nilsson, 2012
Changes to Improve Patient Experience
to achieve an optimal patient experience. These include:
While many efforts are in place to improve patient experiences overall, findings identify that communication, and more specifically empathy, can be improved in medical education. This includes activities that focus on: “improving interpersonal skills, exposure to role models, role playing, shadowing a patient, hospitalization experiences, studying literatures and the arts, improving narrative skills, watching theatrical performances or movies, audio, or video-taping of student’s encounters with patients” (Hojat, Axelrod, Spandorfer, & Mangione, 2013, p. 1).
··Introduction of flexible visiting hours to support necessary family presence and create an environment supportive of patient- and family-centred care
Research has also identified many factors at the organizational level that may influence changes to the patient experience. These include “the quality and commitment of the leadership, clarity of goals, identification of dedicated champions, active engagement of patients and families, staff skills, training and capacity, and availability of resources, in addition to the quality and depth of understanding of the patient’s perspective” (Coulter, Locock, Ziebland, & Calabrese, 2014, pp. 2-3).
··Integration of patient and family perspectives in the development and review of policies, information and education materials Inter-professional team approach to patient care
McTavish and Phillips (2014) list some changes that might be implemented in order
··Increased involvement of patients and families in decision-making and care planning ··Patient and family representation on governance, clinical and operational committees ··Shift from doing for and to patients to doing with patients and families
··Frequent patient rounds to anticipate patient needs, increase safety and reduce call bell use ··Inter-professional documentation ··Enhanced discharge management ··White boards in patient rooms updated every shift to include team member names,
··Early involvement of allied health professionals in the discharge management process ··Use of inter-professional consultations to propose changes to the plan of care. (pp. 52-53) In addition to communication issues, alteration to the hospital environment should also be considered when analyzing potential changes. Berwick (1996) and Nolan (1998) found that “improving the infrastructure and processes for certain aspects of care may result in broader improvements because common characteristics of the system can influence a broad range of outcomes” (as cited in Anhang Price et al., 2014, p. 534).
Concluding Thoughts Patient experience is composed of several intertwining factors including: an organization’s culture; the involvement of patients and families as active participants; the provision of coordinated and integrated medical care; application of strategies to promote health and alleviate suffering; communication that is clear, effective, timely and respectful; the delivering of care with kindness; and support of patient and families across the continuum of care. Other factors affecting the patient experience are the organization’s facilities, particularly in relation to privacy, comfort, quietness and cleanliness; pain management; and the overall quality of care in terms of safety and effectiveness.
13 secondary research
date, patient/family questions or concerns and staff messages to patients and families
PRIMARY research DESIGN METHODOLOGIES
15 primary research
summary To better understand people’s experiences at British Columbia hospitals and to identify the positive and negative aspects of these experiences, the Health Design Lab applied a human-centered design approach that prioritizes people. Using different methods allowed us to listen, talk and interact with people to understand their views, needs, expectations, and frustrations regarding specific situations. Our methodology included a literature review, focus groups, co-creation sessions, ethnographic probes, and interviews. The following sections describe each process method in detail. Literature Review The literature review in the previous section enabled our team to identify key themes related to patient experience such as: communication, empathy, safety, training, and the hospital environment. We concluded that patient experience seems to be composed of several intertwining factors: the organization’s culture; involvement of patients and families as active participants; provision of coordinated and integrated medical care; application of strategies to promote health and alleviate suffering; communication that is clear, effective, timely and respectful; the delivering of care with kindness; and support for patients and
families across the continuum of care. Other factors affecting patient experience are the facilities, particularly in relation to privacy, comfort, quietness, and cleanliness; pain management; and the overall quality of care in terms of safety and effectiveness. The literature review provided a solid background from which to start planning the co-creation sessions, interviews, and ethnographic probes. Focus groups Focus groups are effective for starting the exploration of and prompting discussion of the relevant issues within a problem. They are useful for gathering information about what people think about a topic, why they think that, and observing how people’s ideas are moderated through conversations with others. Listening and conversing lead researchers and participants to reflect on an issue in a particular context. The Health Design Lab conducted a focus group with the BC Cancer Agency. Three participants discussed their patient experiences with us. Co-creation sessions Co-creation is the creative act of making, telling and enacting, wherein designers provide toolkits to participants to prompt them to interpret and answer ambiguous
questions; discuss problems; describe future experiences, concerns or opportunities; make artifacts or “things;” and create prototypes. Co-creating allows us to quickly understand complex social problems, explore possible solutions, detect mistakes in design ideas, and create solutions tailored to people. For this project, the Health Design Lab developed a series of co-creation sessions. The first was with with 15 patient advisors from Fraser Health. For the second session, 20 people from within Vancouver Coastal Health and the Community Engagement Advisory Network (CEAN) participated in a co-creation, all with different backgrounds and expertise. These two sessions led the Health Design Lab to create toolkits and activities for a very large co-creation session that took place during the BC Quality Forum meeting. Led by 20 student facilitators, 80 conference attendees co-created around the themes of patient empowerment, communication, consistency of care, and patient education and systems. The final co-creation session was with BC Children’s Hospital, and involved approximately ten patients and their families.
Ethnographic probe Ethnographic or cultural probes provide a way of gathering information about people and their activities. Research participants are guided through a series of activities that span a specific time period and probe for their perceptions. Participants are given a kit of materials, and are briefed about requirements to record or note specific events, feelings, or interactions over a period of time. The Health Design Lab team designed a patient experience journal to gather information about participants’ perceptions of different interactions with nurses, physicians, and other healthcare personnel in the hospital. These diaries were distributed on the gynecology/urology ward of Vancouver General Hospital. Of the nine journals distributed, we collected three completed ones.
A key feature of interviews is that they provide the opportunity to focus on individuals. Interviews are effective for understanding participants’ perspectives within the context of their personal experiences. In asking questions, the designer gains a deep understanding of the problem studied, such as the participants’ thoughts, feelings, needs, intentions, attitudes, views, and experiences. The designer is an active participant in managing the interview process, ensuring that the required subjects are covered while respecting the participants’
co-creation preparation A group of students prepare for facilitating the cocreation session for the Quality Forum conference.
views. Most frequently, we conducted structured and semi-structured interviews in person, by phone, or by video conferencing. Our team developed a series of interviews to conduct at the Emergency Department of Vancouver General Hospital. Hospital admissions personnel invited potential participants to meet research assistants in treatment areas. The interviews were designed to be brief, since the time allotted for them was while patients were waiting to be treated. In addition, we interviewed staff at the Eagle Ridge Hospital and the BC Children’s hospital.
17 primary research
Face-to-face interviews
DATA ANALYSIS themes & principles
19 synthesis
aims and methods The methods used to analyse our qualitative data depend partly the manner in which data was collected. To analyse the data collected from the cocreation sessions, the ethnographic probes, and the focus groups, we used affinity diagramming as a method; to analyse the interviews we used a matrix method. The following describes each method in detail. affinity diagramming This method helps designers synthesize data. In co-creation sessions, probes, and focus groups, our team captured attitudes, behaviours, issues, concerns, and needs from notes, drawings, and pictures. Each individual “bit” of information was transcribed onto sticky notes, posted on a wall or white board, and were then grouped based on their affinity—in other words, notes that shared similar key ideas were clustered together to form themes. Arriving at themes is time consuming and requires rigorous interpretation. Sticky notes are particularly useful during the refinement period, as they can be moved and regrouped to better represent the meanings of themes. Once the clustering and refinement stages were completed, the data was interpreted to define concepts, create categories, find associations, seek explanations, and develop new ideas based on people’s answers and reactions.
patient Experience factors Early stage affinity mapping following one of the first co-creation sessions helped to establish the ways in which contributing factors intertwine.
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21 SECTION TITLE
affinity diagramming Attitudes, behaviours, and issues arising from qualitative reasearch sessions are grouped into themes.
« Material collected through qualitative methods is invariably unstructured and unwieldy. » Ritchie & Spencer, 2002
Forming a matrix Compiling the matrix from interview results.
To analyze the data from the interviews, out team created a matrix. The first step in creating a matrix is familiarization. Before sorting data, designers need to become familiar with the information. This required our team to listen to or read the interview transcripts several times. During the familiarization stage, key sentences or words were identified. The matrix used was a double entry chart. The question being asked and the category emerging from it were written at the top of the chart. For example, answers to the question “what are the factors affecting the patient experience” were entered into a matrix labeled “factors.” On the left, each cell indicated the participant’s number. Key sentences were placed inside the cells. In this Developing a matrix Analyzing interview responses. Key sentences grouped according to emerging themes.
case, some of the key sentences answering this question were: “answering the same question to different people,” “make sure the patient understood,” “personnel mood,” and “human interaction.” These answers were grouped under the theme communication. Other themes that emerged from this question were: “wait time and access to care,” “safety and privacy,” “moving patients,” “conditions,” and “facilities.” In this way, we began to summarize and synthesize the data to arrive at themes. Frequently, the interview questions asked provided a framework for starting to sort the themes. An advantage of this method is that, since the matrix shows both the question and the participant, it enables quick and easy access to the original material. It also facilitates comparison, and makes the analyses accessible to other team members.
23 synthesis
MATRIX APPROACH
research overview primary research collection
25 research overview
fraser health location: Surrey Research method: co-creation participants: patient advisors number of participants: 18
In January 2015, Emily Carr research assistants conducted a co-creation session with eighteen participants at the Fraser Health Authority. The two-hour session was comprised of three collaborative activities that largely focused on improving the patient experience. As this was one of the first research sessions conducted by the Health Design Lab team, the activities were directly inspired by the literature review. The co-creation began with an ice-breaker activity, allowing the participants time for brief introductions and an analysis of a common patient-doctor scenario. Participants were provided a picture of a doctor by a patient’s bedside, and were asked to generate the doctor’s response to the patient’s inquiry. The overarching intention of this activity was to get participants thinking about the patientdoctor relationship in a different way, which many seemed to enjoy. Many poked fun at both the patient and doctor, and crafted very humorous responses. The second activity was comprised of two image sets. First, participants were provided with duplicate image sets of four common hospital relationships: patients and nurses,
patients and doctors, patients and patients, and patients and administration. With the first set of images, participants were asked to fill in speech bubbles noting how typical conversations would occur between the two parties. For the second part of the activity, participants were again asked to fill in the speech bubbles (on the second set of images) with a dialogue that would have improved the situation. Many of the participant’s responses highlighted that communication was a common concern across all scenarios. Further, the ‘improved’ conversations were commonly described as much more empathetic than that of the ‘typical’ conversations. After completing the activity, participants were asked to share their favourite scenario; many altered their voice when describing the improvements, using a more light-hearted tone. The final activity allowed participants to fully develop a solution to a problem identified within the second activity. Using the format of WWWWHW (who, what, where, when, how and why), participants collaborated in groups to fill out template sheets designed by the Emily Carr researchers. Each group was provided with imagery (corresponding to each of the categories), post-it notes, and pens to brainstorm solutions In addition, the templates provided space for participants to discuss potential implementation plans. Some of the solutions that were proposed included having teams of nurse practitioners, nurse navigators and community members as
patient advocates accessible to patients at any time. Other solutions included making better use of technology as a means of educating patients, and establishing ground rules for the patient-staff relationships (do and don’t lists). Although the session was scheduled for a two-hour period, there was a wonderful response from participants, with many staying longer to continue a discussion on how to improve the patient experience across BC. location: eagle ridge Research method: interviews participants: STAFF number of participants: 8
Face-to-face interviews were conducted at Eagle Ridge Hospital in Port Moody, BC to understand more about the patient experience inside hospitals and how it can be improved from a patient and staff perspective. The Health Design team interviewed a variety of participants from different units, including patients from rehabilitation/recovery and general care, registered nurses, lead practitioners, healthcare assistants and pharmacists. The results of these short interviews helped the team understand the different perspectives and similarities towards patient safety, language barriers, patient responsibility and general care. The interviews started by asking about participant’s roles inside the hospital. This was followed by asking for participants’ opinions on questions such as: ··what are factors affecting patient experience ··what are strategies used to ensure that the patient understands hospital staff ··what strategies do they use to reduce patient anxiety ··what can patients do to help improve safety and quality of care
··how do participants check that they have addressed the patient’s needs and questions ··how do staff make caring visible. The participants were enthusiastic, though some questions seemed to overlap and many had similar answers for some of the questions. Depending on where we were inside the hospital, some participants had less time than others, which affected the amount of detail they we able to give. To analyze our findings, our team used design research methods such as affinity mapping and a matrix to identify recurring themes. From this data, it was evident that staff took a genuine interest in improving the patient experience within their hospital. All staff expressed the importance of understanding their patients’ needs while also fostering a
ice breaker A humorous example of dialogue filled in by a co-creation participant.
Having toured the different care units of Eagle Ridge to conduct each interview, the HDL team was able to gain multiple perspectives about how staff deliver quality patient care and develop strong team morale. A positive culture within each unit was prominent, and making caring visible was very apparent throughout the the HDL team’s journey at Eagle Ridge. improving dialogue Two examples of an activity where participants were asked to provide ideal conversation alternatives to negative experiences they had experienced.
27 research overview
positive team environment to deliver a great patient experience. Strategies that participants frequently reported include: asking and repeating back questions to patients so that they fully understand prescribed directions or advice, supporting language barriers through translators or multilingual staff, showing patients respect, having empathy for patients’ needs, leading by example, and being present while caring for patients.
vancouver coastal health location: VCH Research method: co-creation participants: CEAN Patient Advisors number of participants: 20
The second co-creation session involved participation from the Community Engagement Advisory Network (CEAN). These members, who support patient and public involvement in health service planning, were excited to contribute their personal experiences and opinions about health strategies and services. The co-creation activity was similar to the Fraser workshop, and was comprised of three parts: an icebreaker, a group brainstorming session, and a solution-building activity. The purpose of these activities was not to probe for predetermined outcomes, but to harness and direct collective creativity toward suggestions for positive change to the healthcare system in B.C. CEAN members were assembled into small groups of 4-5 individuals along with an HDL facilitator. Once acquainted with one another through a verbal icebreaker, each member felt more comfortable revealing their perspectives on patient experience. The activities were identical to the activities previously described for Fraser Health (see page 25). The first activity was not as effective as planned, as participants took their conversations in a more light-hearted direction than had been the case with the Fraser co-creation workshop. We believe that the icebreaker activity was the cause of this, as it had a humorous intention in order to help participants open up to one another; the humour of the icebreaker may have set the tone for the first activity. This is not to say that the information gathered was
invalid. In the end we were able to define key problems within the hospital space. The recurring themes that required improvement were communication between staff members and staff/patients, patient empowerment, consistency of care, and general resources for patients. Specific problems included a lack of transparency in delivering information to patients, substandard bedside manner, and a lack of teamwork between hospital staff members. Open discussion was also promoted throughout each activity, and allowed participants to speak freely about issues arising in hospital spaces. Using this information, facilitators asked participants to decide on a specific issue with which they would like to move forward in the next activity. This final activity provided a space for CEAN members to work collaboratively to develop a solution for their chosen problem. The activity consisted of a template with five sections, labeled: who, what, where, how, and why, to help CEAN members organize the influencing factors for solving their chosen problem. Picture cut-outs were also provided to place within each category. The pictures included different environments within the hospital space, varying staff occupations, and multiple tools that might help solve problems. This activity proved to be effective, as images generated conversations and helped participants focus on factors that influence a solution. Many of the proposed outcomes were simple, but would require a shift in protocols or organization within the hospital to allow for implementation. An example of this was a suggestion to replace career posting booths in the hospital with designated resource sections for patients to turn to.
29 research overview
In analyzing each group’s solutions, the HDL team devised a list of criteria that should be considered in designing for patients. These criteria were pulled from recurring themes that arose from each group. The proposed solutions must encourage patient learning, encourage transparency of care, make existing resources more readily available, facilitate patient-to-patient connections, keep patients informed and involved, and reduce negative stigmas around health conditions through further education of the community.
Co-Creation An example of the third co-creation exercise used to encourage participants to start imagining solutions.
location: vancouver general hospital Research method: interviews participants: patients number of participants: 3
organizing Ideas Mapping content from co-creation sessions reveal how factors relate and overlap in patients’ experiences.
On January 22, 2015, our research team had the opportunity to conduct interviews in the emergency wing of Vancouver General Hospital. The interviews were conducted between the time a patient checked in at reception and the time they were able to be seen on the emergency floor. During this time, we had the opportunity to speak with three people, but despite the low traffic, major
One of the participants shared her struggles with the lack of accessibility in the ER for someone with a hearing impairment. Her main issue with the current system was the lack of feedback provided to patients in the waiting rooms. She specifically indicated a need for a notification system to inform patients when it was their turn to see healthcare workers; she suggested adding a number call system. The interviewee also identified a need for more privacy on the ward; she felt that privacy was a major issue contributing to patient experience. Last, she stated that the healthcare system asks her opinions, but she sees few changes adopted after the fact. Another participant indicated that two pivotal factors affecting patient experience in the ER are wait times and safety with regards to other patients, specifically those who are acting in a disturbing way or experiencing symptoms in an unexpected or aggressive manner. This participant indicated that increased staffing at peak hours coupled with reduced wait times would improve patient experience. Another factor negatively affecting this patient’s experience was having to repeat medical information to multiple hospital staff, which indicated a need for improved information sharing methods. Last, the participant expressed that she had felt anxiety in instances involving police officers escorting other patients, compromising her feeling of safety and thus her patient experience. Our final participant also indicated a redundancy in the information that was being collected. The participant noted a need to repeat herself, answering the same questions to multiple nurses and doctors. She indicated that this process causes frustration for patients. To improve the quality of care, the participant indicated the need for more time to explain herself, to make sure her
voice is heard. To improve communication, the participant suggested allotting more time to listen to the patient and respond directly to what they are saying. When asked about changes that should be made to the hospital system, she indicated that more efficiency in communication was needed. location: vancouver general hospital Research method: ethnographic probe participants: patients and Family number of participants: 3
The research team developed a patient journal to track a patient’s experience over time in a Vancouver General Hospital inpatient ward. The journals offered valuable insights on both our data collection methods and the design of our materials. The journal itself was an experience booklet designed to allow patients to explain both the context of an interaction—i.e. who it was with, what time it happened, how it made them feel and how it could be improved. In the first step, patients chose from a list of hospital locations and staff to identify who or what they were referencing in their responses. Secondly, they described the experience, indicating the time and giving a description. Next, the patient suggested ways to make the interaction better and what one thing they would change in the interaction. They were then asked who or what would best implement their suggestion based on a selection of icons. Below they were given space to explain their suggestion. The journal was left with patients for 24 hours starting at 12:00 pm on January 22, 2015. The responses we collected were all from the same family, and offered perspectives from one patient and two family members. Overall, the responses were quite positive. They commented on the nurses’ attitudes and their clear communication of procedures as adding to their overall experience. Moreover,
31 research overview
issues concerning accessibility in the ER were identified.
one family member noted that the time and effort put into training family members on changing the patient’s dressing was done in a clear, concise way that left her feeling confident. Additionally, the journals indicated that a hopeful, pleasant nurse at admitting contributed positively to their experience from its beginning. Following the collecting of journals, the data was transcribed and analysed using affinity mapping techniques and a word frequency counter. The results were, for the most part, quite positive. The most frequently used words were positive, good, competent, ease, kind, and great. It was noted a few times that
patient journals An example of how patients recorded and rated their interactions within the hospital.
a healthcare worker with a positive attitude and personality made the experience easier and more enjoyable. Many participants noted that their nurses were competent, friendly, and helpful. Moreover, patients and their families indicated that clear explanation of procedures was a key contributor to a positive patient experience. There were only two negative feelings expressed in the journals. One was that a patient was unsure if their room had been cleaned. The other was a more broad criticism of hierarchy in healthcare, specifically noting wage differences in relation to the amount of work done by different staff members.
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PROVINCIAL HEALTH SERVICES AUTHORITY location: bc cancer society Research method: focus groups participants: patients number of participants: 3
Conducting research with the BC Cancer society revealed barriers to patient-centred care from both patient and healthcare worker perspectives. Having access to both sides of the issue created a more holistic understanding of the problem space. The same activity was used for both groups, and referenced a timeline that began before patient admittance and ended after patient discharge. The timeline served as a guide to generate conversation about successes and struggles during each stage of patient care. The session with the patients revealed two major themes. First, patients want more guidance and support throughout their care. Patients expressed fear of not knowing what to expect throughout their treatment process and wanted to see examples of people who had been through similar experiences and who had survived. They would like to see more support groups and people who can help guide them through difficult decisions. The second major theme that emerged was a desire to have their concerns listened to, and ultimately to feel like they are involved in their own care and decision making. Patients reported instances where they had shared research they had done with a doctor,
and felt the responses from their doctors were condescending. Other topics patients reported were inappropriate methods of communicating their diagnosis and a lack of comfort in treatment rooms. A second session, with BC Cancer healthcare workers gave insight into some of the causes behind patient reported issues and brought up new topics altogether. The healthcare workers discussed numerous support groups available to patients, which indicates an issue with patient awareness and hospital publicity for the groups. The topic of patients doing their own research was also discussed, which from a healthcare professional’s position can be frustrating due to the potential unreliability of some patient resources. Last, healthcare workers identified their patient information system as a barrier to their performance, as patient information is not stored in one database. This results in patients feeling disregarded, as they have to repeat the same information to multiple healthcare workers. Having patient participants and healthcare workers go through the same activity allowed for a thorough assessment of issues affecting patient care. Patients desire empowerment and support, both of which can be achieved or improved by making existing resources obvious and available to every patient. There is also a need for a cross-institutional database which all healthcare workers could access, reducing the need for repetition of information from patients.
location: bc children’s hospital Research method: interviews participants: staff number of participants: XX
In March 2015, the HDL team conducted a group interview with staff members at BC Children’s Hospital, with participants from various departments. Staff were very welcoming, and excited to share their perspective of the hospital environment. The discussion began with a conversation regarding the hospital infrastructure, focusing on the major construction currently surrounding the exterior entrances. The staff conveyed that this was a common frustration among patients visiting the hospital, and contributed to many navigation issues once entering the space. From here, the discussion shifted to the current lack of space across all sectors of the hospital. Topics focused on the room settings, the size of the elevators, the walkway paths, and the food amenities within the building. These issues seemed to be of considerable importance to staff, as they affect the safety of both families and staff members. Many individual stories were shared that recounted the maximization of room capacity, and how this influenced the level of care provided. Staff next recounted feedback from patients. They said that many patients who had onevisit experiences with the hospital reported positive feedback, which the healthcare workers referred to as a “honeymoon phase.” Feedback from recurring patients was not as positive, as they began to “understand the
system,” referring to issues described above. Despite issues with physical space, there was positive reflection on patient interactions. Staff discussed the initial phase of patient interactions as a way to start the patient’s experience positively. They achieved this by interacting with the child in a relaxed way, offering to answer any questions, and explaining what to expect throughout the process. Because a child must have parental consent throughout their treatment processes, the BC Children’s Hospital is very successful at keeping families involved and engaged in their children’s healthcare plan. Many parents must learn how to care for their children after they are discharged, so their care plans have to be decided on and learned together. This keeps the patient and family involved in decision making. Another positive topic was staff use of anxiety-reducing methods. With parents, this mostly focused on answering questions, while for children and youth it was more about distraction. An example of this was “Buzzy,” a vibrating ice-pack given to distract patients when they were in discomfort. Overall, the staff seemed passionate and engaged in their work. Multiple staff members reported being with BC Children’s Hospital for more than a decade, and expressed specific interest in working there with children.
To close off the series of co-creation sessions led by the Health Design team, research assistants were tasked with developing and running a co-creation activity for children at Ronald McDonald House at the BC Children’s Hospital. The session was a unique experience, as co-creators thus far had been adults. This time, however, we played and created with children between the ages of 6 and 10 years old. Given the sensitive environment of the Ronald McDonald House, the HDL team wanted to ensure that the facilitated activities were light-hearted and fun. While the topics of interest still included how to improve patient experience within the hospital, creativity was required to obtain
this type of information from children without triggering any emotional distress. To this end, the HDL team created a fun, alien activity where the children were told that “the alien has lost their super powers, and has come to the hospital to feel better again and to restore their magic abilities.” A series of illustrative panels, featuring the alien in addition to multiple scenes inside the hospital were provided, allowing the children to colour the blank spaces and draw objects within the existing environments. As an icebreaker, the children were asked to simply name the alien and identify what his/her superpowers were. Colouring and naming was a huge hit, and stirred a lot of zany conversation between the patients and researchers. Children’s co-creation The co-creation session at Ronald McDonald House was designed to be fun and non-threatening for children.
35 research overview
location: ronald mcdonald house Research method: co-creation participants: patients and families number of participants: 10
Once finished, the researchers turned to the panels showing different hospital settings, asking the children what they might include or change in each room to make the alien feel as comfortable as possible. To facilitate this, the children were to asked to imagine that they were the boss of the hospital, and that it was their duty to make sure the alien felt happy and safe. We learned as much by listening to the the children participants during the BCCH co-creation session as we did from their drawings. Many of them identified themselves as fearless individuals. While the children themselves were not scared of the hospital, they were able to consider elements that could be improved for the alien to feel most comfortable during his stay. Their drawings focused on making the hospital as “happy and friendly” as possible. To do so, they suggested that they have a kid-friendly chair in a waiting room environment for the alien to look forward to his appointments.
For equipment, the children suggested that they create a “cool” or atmospheric environment for a MRI machine, similar to other hospitals that are able to visually convince children that they are entering a pirate ship or a space ship, etc. The children also mentioned that when undergoing treatment or testing they prefer being informed about the duration of the procedure. In doing so, they said they would be able to prepare themselves mentally if they knew whether it would be “quick”or whether it would “be over soon.” In probing for changes within the patient rooms, the children did not propose many wacky or particularly innovative solutions. They simply requested basic necessities to ensure a welcoming stay. This included an individual such as a parent or a loved one to support them throughout their personal journey, a blanket to keep them warm, and “nutritional food” to ensure they are getting back to their regular selves. a childs Ideal waiting room This participant thought stars would make a waiting room more comfortable.
location: hyatt regency vancouver Research method: co-creation participants: attendees number of participants: XX
The research activities used in the Quality Forum co-creation session were informed by previous research activities conducted with patients. This research uncovered five overarching themes concerning patient experience: consistency of care, patient empowerment, systems, communication and patient education. Each table of eight participants was given a scenario that was based on one of these themes. Participants were asked to identify a variety of contributing factors to the scenario, ultimately leading them to brainstorm solutions. All solutions and ideas
were recorded on large pads of paper using collage, writing, and sketching, and were then analyzed to extract and combine similar ideas. Solutions ranged from changes to existing systems to other other proposals that were more innovative. Some solutions focused directly on behaviour change. An issue highlighted by this research was inconsistency of how, when, and what information is delivered to each patient. Sometimes decisions were made to withhold information with the intention of avoiding overwhelming or scaring a patient, but this could also result in patients feeling lost and alone. A solution to this is a shift in behaviour to include the emotional aspects of healthcare. This might include healthcare workers being trained to offer resources in a Quality Forum Co-Creation Eighty people participated in this co-creation workshop. Twenty student facilitators were in charge of introducing and guiding the activities.
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QUALITY FORUM
39 SECTION TITLE
Quality Forum results After the co-creation, the team posted all the collected information to facilitate further concept development.
« Inspired by IBM’s Watson artificial intelligence system, the app serves as a knowledge navigator, » Students, HDL
waiting room but were fearful of losing their spot in queue.
Other solutions focused on implementing new technologies. For example, a screen placed in a waiting room on which all patients’ wait times and priority are listed, or a handheld buzzer could be given to patients which would notify them when it is time to go in for an appointment. These solutions addressed a scenario in which a patient felt anxious because they wanted to leave the
Student researchers spent 24 hours reviewing the results of the co-creation event. From these beginnings, they extrapolated and developed the ideas into more final solutions. These ideas were presented back to the group on the second day to show the value of cocreation and how it informed design. The most innovative solution was focused on providing patients with a tool to help them navigate the healthcare system, which was inspired by the theme of patients wanting to know how to be good patients. This solution was a phone and internet application that helps patients navigate their healthcare. The app has a conversational interface, with an appearance and sound that could be tailored to fit each individual’s preferences. Inspired by IBM’s Watson artificial intelligence system, the app serves as a knowledge navigator, showing results for anything a patient needs help with, ranging from post surgery care, to clinic hours, to finding support groups in a specific area.
reme dee This conceptual app was developed by the research team and was based on ideas from the Quality Forum workshop.
41 research overview
variety of formats, as well as strengthening communication techniques.
Design opportunities and Future Directions
43 creative opportunities
The primary goal of this research project was to explore the problem space through human-centred methodologies. We were asked to consider how patients feel about, and experience, their treatment in hospitals. The bulk of this report has focused on documenting the results of that research. But an important secondary goal was to uncover future opportunities for design. While some issues can only be resolved at an administrative or political level, many others can be addressed through an innovative approach to design, grounded in the qualitative evidence from this, and other, research projects. From the themes identified in previous sections, we looked for areas where design thinking might be able to suggest systemic changes or concrete practical solutions. This section identifies such opportunities and it is expected that the collaborative project will move from research to design over the next few years. The following opportunities will form the basis of that next phase. Design Strategies for Partners Using human centric design research methods in explorations into patient experience has proven to be hugely insightful throughout this project. In fact, according to the collected evaluation forms from the 2015 Quality Forum conference, 91% of attendees to our workshop agreed or strongly agreed that our co-creation workshop helped them become inspired to address challenges and opportunities within their workplace. Co-creation was a newly introduced research activity to most individuals at the conference, yet they expressed interest in applying this method of learning to their own environment. To support this, a human centric research toolkit could be designed and distributed widely
to all authorities for local applications. This would allow continued stakeholder involvement in decision-making. This toolkit could offer a variety of co-creative activities that could be customized to many different areas that affect patient experience. Most importantly, framing future explorations into patient experience in human centric design methodologies may result in a generative research process yielding further ideas for innovation. Patient Empowerment Throughout our research we discovered that patients had the desire to be an active member of their care team, but were unsure on how to access and understand the tremendous amount of information
and resources that are available. This is an opportunity to not only educate patients on where to look for appropriate resources, but also to empower patients to be constructive participants in their own care. Opportunities lie in educational programs that teach patients such things as how to make the most out of clinic visits, when to go to emergency, which resources are reliable, what information is useful to their healthcare team, etc. By educating and empowering patients to work in collaboration with their care team there is the potential to alleviate unneeded strain on the healthcare system. Information Architecture of Resources While there is a vast amount of resources available to patients, we consistently found they patients could not find the right resources at the right time. Also, more often than not, we found that patients would look to unreliable or outdated sources for information. A research initiative into the aggregation and organization of approved available resources is necessary for patients to be informed and have a positive experience when searching for information. Moreover, the aggregation of resources needs to be searchable and responsive to users and ideally it should guide users through their healthcare journey. These resources may include: support groups, journal articles, online chat rooms, educational seminars, books and websites. We propose to design an intelligent
system that can sift through the mass of available resources and present relevant sources to patients in a searchable manner. Nudge for Behavior Change At points throughout our research, specifically during interviews in the ER, we noticed that patients were not using the best channels to seek out medical care for their conditions, which places a strain on healthcare services. Launching an initiative to identify when critical decisions are made concerning where to seek out help, and introducing systems that may nudge people towards the channels best suited for their situation would be a useful approach. These subtle nudges for behavior change would serve to educate the population as to the scope and limitations of various healthcare services and facilities. The aim of this initiative is to target users outside of the hospital space with educational materials that guide patients down the most relevant path when seeking out care. Clear Communication One of the identified problem spaces involved communication challenges. These included: patient to patient, staff to patient and staff to staff. Clear and effective communication between all parties plays an important role in the care delivery process. To ensure that patients receive the appropriate information they need to make decisions around their clinical care, there
45 primary research
must be strong communication between staff, patients and family members. Our findings have shown that communication breakdowns occur frequently as the delivery of information relies heavily on health care professionals. This dependency can cause great stress in nurses, as patients and family members can become frustrated and/or dissatisfied if their personal information is not appropriately addressed or provided in a timely manner. There is an opportunity here for integrating information technologies with unified communication systems. By taking advantage of the current resources that are accessible within a hospital and combining it with a digital platform, it could be possible to direct patients to the resources they need at the right time in their care. This includes support groups, establishing virtual communities for patients and providing appropriate documentation to allow for efficient patient briefing. In establishing a digital resource hub, reliance on healthcare staff for basic medical information could be reduced. Collaborative Care We learned that establishing a collaborative relationship between patients and physicians is a key factor in delivering an excellent patient experience. Through an emphasis on collaborative care, physicians would be able to provide their patients with the tools needed to build confidence around managing their own health. For this model to function appropriately, the delivery of information
from a physician must be articulated in an inclusive manner that respects the skills, competencies and knowledge of their patient. Issues with this model include the following. Patients generally lack the ability to research credible information regarding their own health. This is a common concern for healthcare professionals as patients can easily be misled and precious time needs to be spent in re-education. An easy solution is to curate information for patients and present it in an accessible and searchable database, with a clear user interface. This resource could be an opportunity to provide a space for credible information around varying healthcare concerns and diagnoses. In providing a consolidated resource hub for patients to turn to, they would be able to maximize the expertise and input of physicians, allowing staff to provide them with comprehensive and definitive care. Considering Patient Emotions Any diagnosis of illness or disease raises many complex emotions in patients. However, our current system focuses on the illness, not the emotions. This has proven hugely successful in treatment outcomes, but can often leave patients vulnerable and stressed. Acknowledgment of these emotions in treatment plans may have a beneficial effect in overall patient satisfaction. One such example of this was revealed in our research. We found that the delivery
of a diagnosis must be handled in a highly sensitive manner for patients to feel cared for. While this information is often provided empathetically, some patients revealed some difficult encounters. There is an opportunity here to design a system of protocols that would help physicians and other healthcare professionals present this type of information in the most appropriate manner possible. Additionally, there may be opportunities to help sensitize physicians and other professionals to the emotional needs of their patients. Waiting Rooms The time that patients spend in waiting rooms presents opportunities to reduce anxiety and educate patients. When patients are in waiting rooms, especially in the ER, there is a potential for increased anxiety. This anxiety stems from anticipation of upcoming appointments, not knowing wait times, and concerns for personal safety. A system could be implemented which informs patients of likely wait times and their general priority in the queue. A notification system could easily be implemented that texted patients when their turn has come, or a simple buzzer, as provided in some pharmacies. The opportunity to provide patients with educational resources could be addressed during the time spent waiting for appointments. While traditional brochures and posters abound in such spaces, usually
they simply become “visual noise� and are largely ignored. Instead, a digital system could present general information on large screens interactively and personal information via smart phones. Having the right information at the right time can reduce patient anxiety and provide for smoother doctor/patient appointments. Patients also expressed interest in learning more about navigating hospital systems, learning about patient support groups, and details around specific conditions. Universal Design and Accessibility Designing for universal accessibility was not one specific issue but rather an overarching theme that should be evident in all design solutions. Universal design addresses the needs of people of all abilities, genders, races, languages, and cultures. These requirements are important to consider in physical infrastructure, digital software, and communication techniques and materials. One example of such an opportunity was indicated by a patient in an emergency waiting room who was hearing impaired. She was unable to hear when it was her turn, and feared leaving the waiting room to go to the washroom, for fear of missing something. This is a relatively simple example, and easily solved. In order to be truly successful a healthcare system must accommodate the needs of a variety of people, and universal design principles ensure widespread access.
47 primary research
Consistency of Care There is an opportunity to improve consistency of care throughout all patient experiences. It was found that two patients may go through the same treatment for the same health concern yet receive very different service. To ensure that every patient receives exemplary treatment tailored to their individual needs, an improved protocol could be implemented which ensures that each patient receives the same quality of treatment throughout all stages of their hospital visit. A specific factor that arose from this area was consistency of resources that were shared with each patient, which could be solved by making resource sharing a part of patient experience protocol.
appendix bibliography
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bibliography Anhang Price, R., Elliott, M. N., Zaslavsky, A. M., Hays, R. D., Lehrman, W. G., Rybowski, L., … Cleary, P. D. (2014). Examining the role of patient experience surveys in measuring healthcare quality. Medical Care Research and Review, 71(5), 522–554. doi:10.1177/1077558714541480 Baker, G. R., & Norton, P. (2001). Patient safety and healthcare error in the canadian healthcare system: a systematic review and analysis of leading practices in canada with reference to key initiatives elsewhere (p. 167). Health Canada. Canadian Medical Association. (2007). Putting patients first: patient-centred collaborative care (Discussion Paper) (pp. 1–16). Coulter, A., Locock, L., Ziebland, S., & Calabrese, J. (2014). Collecting data on patient experience is not enough: They must be used to improve care. BMJ, 348, g2225. doi:10.1136/ bmj.g2225 De Groot, I. B., Otten, W., Dijs-Elsinga, J., Smeets, H. J., Kievit, J., Marang-van de Mheen, P. J., & For the CHOICE-2 Study Group. (2012). Choosing between hospitals: the influence of the experiences of other patients. Medical Decision Making, 32(6), 764–778. doi:10.1177/0272989X12443416 Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open, 3(1), e001570. doi:10.1136/bmjopen-2012-001570 Engin, M. (2011). Research diary: a tool for scaffolding. International Journal of Qualitative Methods, 10(3), 296-306. Feinberg, D., Coye, M., & Washington, E. (2012, April). Healing humankind one patient at a time. University of California, Los Angeles (UCLA). Garratt, A. M., Danielsen, K., & Hunskaar, S. (2010). The patient experiences questionnaire for out-of-hours care (PEQ-OHC): data quality, reliability, and validity. Scandinavian Journal of Primary Healthcare, (28), 95–101. Harlos, K. P., & Axelrod, L. J. (2005). Investigating hospital administrators’ experience of workplace mistreatment. Canadian Journal of Behavioural Science, 37(4), 262.
Hojat, M., Axelrod, D., Spandorfer, J., & Mangione, S. (2013). Enhancing and sustaining empathy in medical students. Medical Teacher, 35(12), 996–1001. doi:10.3109/014215 9X.2013.802300 How hospitals can maximize the patient experience. (n.d.). Retrieved December 18, 2014, from http://www.gallup.com/businessjournal/179843/hospitals-maximize-patient-experience. aspx Improving patient care: group visits 101 - family practice management. (2003). Retrieved December 18, 2014, from http://www.aafp.org/fpm/2003/0500/p66.html Laschinger, H. K., Grau, A. L., Finegan, J., & Wilk, P. (2010). New graduate nurses’ experiences of bullying and burnout in hospital settings: Bullying and burnout in new graduate nurses. Journal of Advanced Nursing, 66(12), 2732–2742. doi:10.1111/j.13652648.2010.05420.x Locock, L., Robert, G., Boaz, A., Vougioukalou, S., Shuldham, C., Fielden, J., … Pearcey, J. (2014). Using a national archive of patient experience narratives to promote local patient-centered quality improvement: an ethnographic process evaluation of “accelerated” experience-based co-design. Journal of Health Services Research & Policy, 19(4), 200–207. doi:10.1177/1355819614531565 Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patientcentered care. Explore: The Journal of Science and Healing, 5(5), 277–289. doi:10.1016/j. explore.2009.06.008 Manary, M., Staelin, R., Kosel, K., Schulman, K. A., & Glickman, S. W. (2014). Organizational characteristics and patient experiences with hospital care: a survey study of hospital chief patient experience officers. American Journal of Medical Quality. doi:10.1177/1062860614539994 Pennbrant, S., Pilhammar Andersson, E., & Nilsson, K. (2013). Elderly patients’ experiences of meeting with the doctor: a sociocultural study in a hospital setting in Sweden. Research on Aging, 35(2), 163–181. doi:10.1177/0164027512436430 Petersen, L. A., Woodard, L. D., Urech, T., Sookanan, S., & Daw, C. (2006). Does pay-forperformance improve the quality of healthcare? Annals of Internal Medicine, 145(4), 265–273.
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Ratanawongsa, N., Federowicz, M. A., Christmas, C., Hanyok, L. A., Record, J. D., Hellmann, D. B., … Rand, C. S. (2012). Effects of a focused patient-centered care curriculum on the experiences of internal medicine residents and their patients. Journal of General Internal Medicine, 27(4), 473–477. doi:10.1007/s11606-011-1881-8 Ritchie, J., & Spencer, L. (2002). Qualitative data analysis for applied policy research. In A. M. Huberman & M. B. Miles (Eds.), The qualitative research companion (305-329). Thousand Oaks: Sage. Gindi, R. M., Cohen, R. A., & Kirzinger, M. P. H. (2012). Emergency room use among adults aged 18–64: early release of estimates from the national health interview survey, January–June 2011. Center for Disease Control. Reti, S. R., Feldman, H. J., Ross, S. E., & Safran, C. (2010). Improving personal health records for patient-centered care. Journal of the American Medical Informatics Association, 17(2), 192–195. doi:10.1136/jamia.2009.000927 Salisbury, C., Wallace, M., & Montgomery, A. A. (2010). Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling. BMJ, 341, c5004. doi:10.1136/ bmj.c5004 Senior, R. (2006). Commentary: Patient’s experience, Mrs Patel with the support of Roxy Senior. BMJ, 332, 644. The Beryl Institute. (2013). The State of Patient Experience in American Hospitals 2013: Positive Trends and Opportunities for the Future. The Manitoba Experience Real-life stories of EMR implementations. (April 12) (pp. 1–13). Vanderford, M. L., Jenks, E. B., & Sharf, B. F. (1997). Exploring patients’ experiences as a primary source of meaning. Health Communication, 9(1), 13–26. doi:10.1207/ s15327027hc0901_2 Watson, D. E., Black, C., & Peterson, S. (2008). In pursuit of quality opportunities to improve patient experiences in British Columbian emergency departments. Vancouver: Centre for Health Services and Policy Research. Retrieved from http://site.ebrary.com/lib/celtitles/docDetail. action?docID=10277338 Wolf, J. A. (2014). Expanding the dialogue on patient experience. Patient Experience Journal, 1(1), 1–3.