“Experience based design involves being willing to come face-to-face with the emotions our patients are feeling. And that has the potential to be a huge breakthrough. We are good at it, but it is early still and we are not nearly as good as we can be, and we are going to keep getting better at it.”
- Gary S. Kaplan, MD, Chairman and CEO, Virginia Mason
User-centric design or design thinking is widely used in many industries throughout the world today. A relatively new technique in health care − Experience Based Design (EBD) − draws techniques from user-centric design to improve the overall patient experience.
Paul Plsek, an authority on innovation in complex organizations who serves as chair of Innovation at Virginia Mason, played a role in the development of EBD as a consultant to the National Health Service in the United Kingdom. Paul explains EBD this way: Think in terms of three legs to a design stool − Functionality, engineering and aesthetics.
Paul notes that functionality “refers to whether a design is based on the best knowledge, science or technology available.” Engineering means efficiency, reliability and consistency are built in.
“The element of aesthetics,” he states, “refers to the emotions elicited by the design via the look, feel and experience it presents to the customer or service user.”
So what could this possibly have to do with health care? Shouldn’t science trump all in the realm of health care?
“We view Experience Based Design as both a philosophy and set of methods focused on understanding people’s experiences so we can design better services together,” says Jennifer Phillips, director, Innovation, at VM. “We have the patient at top of our (strategic plan) pyramid and applying the EBD methods helps us really understand the patient experience in greater depth. We can then take that data and use it while making improvements.”
In the decade-plus that Virginia Mason has been adapting the Toyota Production System to health care in the form of the Virginia Mason Production System, the goal has been the pursuit of a defect-free patient care experience. EBD has become an essential VMPS tool because it enables us to search more deeply to find negative patient experiences – which are, by definition, defects in the care experience.
Susan Haufe, administrative director, Patient Relations and Service at VM, says, “With VMPS value is defined by the customer. With EBD methods helping us better understand what matters to customers, we can better deliver on value.”
Paul notes there is “a growing body of evidence showing the positive relationship between aspects of patient experience and clinical quality. Simply put, anxiety and unease impedes communications and delays healing.” [Emphasis added]
For patients and their families, as well as for staff members, being in a medical setting often elicits an array of intense emotions – many positive, many others negative.
Touch Points Key
The key in Experience Based Design, says Paul, “is to view the care process the patient experiences through a series of touch points – moments when the patient or family member experiences an emotion – either positive or negative.”
A touch point is a moment that triggers an emotion. It may come when a nurse or doctor enters a patient room, when a test is being administered, or when the patient is being admitted or discharged. Often, touch points are small – a negative reaction, for example, to a nurse seeming to rush through a series of steps to move on to the next room. However small, touch points pack real power because patients remember them and they impact patient emotions.
EBD research techniques include careful observation, interviews structured to create a deep conversation where emotions can be expressed, focus groups and questionnaires that patients and families complete as they progress through the care process. These techniques reveal patients almost always experience an emotional rollercoaster in a medical setting.
For example, a VM team learned from patient families that when they were in the waiting room during a loved one’s surgery, surgeons handled communication to families differently. Some surgeons would come out to the waiting room and reassure the family all was well. Everyone in the waiting room would hear that. Other surgeons had the family brought to a private room where they would speak privately – usually with reassuring news.
Yet families in the waiting room perceived the private meeting as one where bad news was conveyed, and it raised the overall level of anxiety among other families fearing such a summons. With that knowledge, a VM team altered the process so all family members spoke with surgeons in private.
The VM team also learned patients and families become highly anxious when they witness staff members chit-chatting about personal matters unrelated to the work in the hospital or clinic. It raised worries among patients and families about whether the staff members were paying adequate attention to patients. This called for a very simple change: When staff members wish to talk about subjects other than the work at hand, they do it “off stage” away from patients.
Seeing and Hearing from Patient Perspective
Research revealed, for example, that certain words clinicians routinely relied upon caused stress. When a clinician tells a patient he or she has been “downgraded,” or is moving to a “lower level” of care, the connotation is negative and, to many patients, upsetting.
So improved language was identified, such as using the term graduated instead of downgraded and the phrase transitioning to progressive care rather than to a lower level of care.
“Experience Based Design involves being willing to come face-to-face with the emotions our patients are feeling,” says Virginia Mason Chairman and CEO Gary S. Kaplan, MD. “And that has the potential to be a huge breakthrough. We are good at it, but it is early still and we are not nearly as good as we can be, and we are going to keep getting better at it.”
Often, the EBD methods enable staff to see things from a patient point of view that they might never have seen before. “We make a lot of assumptions in health care about what patients and families want,” says Susan. “But often we do so without a great deal of thought. It’s just human nature to project ourselves into a role and it seems so obviously correct and safe and patient-centered. EBD allows us to pause and let customers tell us what matters most, and we find that often our assumptions were correct, but sometimes they are not.”
For example, the assumption in clinics had been that the VMPS flow system in primary care that had proven so highly efficient was prized by patients, as well. And, for the most part, it is. But when EBD research was conducted it was learned that patients were quite negative about having a conversation with a provider in the hallway after the visit was over. Patients felt as though it was not private enough. And, as Jennifer says, “Of course they’re right! In the hallway, staff were discussing pretty private matters in a setting that wasn’t private at all. When we saw this we thought, ‘of course we shouldn’t have these conversations.’”
Through the use of EBD tools, it was also learned patients in the clinic did not like being weighed in a hallway as part of check-in. The risk of someone else seeing their weight created a negative emotional touch point.
While most of the EBD work thus far has focused on patients and families, research into experiences of staff members is enormously important as well.
Says Susan: “Job performance suffers when staff members are having a negative emotional experience at work. The perfect staff experience is what is going to allow us to consistently deliver on the perfect patient experience.”
There is a sense at VM that they have barely scratched the surfaced with EBD work; that huge learning and insight lies ahead. “There’s a lot of excitement around it,” says Jennifer. “It’s really provoking our thinking as we get deeper and deeper into this.”