This was an academic research project for a capstone MBA class called ‘Design in Management: Concepts, Methods of Practice and Products’ at the Weatherhead School of Management, Case Western Reserve University. It addresses the area of patient experience and was a joint collaboration between Weatherhead and the Office of Patient Experience at Cleveland Clinic. Out of the many dimensions and moments of patient experience, our project focused on the issue of doctor-to-patient interaction during the discharge phase.

The team consisted of one designer (PhD candidate), four MBA students, and the work took approximately seven months from start to finish.

To understand the problem we were interested in, the context of the work has to be briefly stated. Like many hospitals across the United States, Cleveland Clinic has been concerned with the HCAHPS, an in-patient survey mandated by the Center for Medicare & Medicaid Services (CMS) that measures key elements of what the government considers to be patient experience. The HCAHPS was recently created to increase transparency around patient experience and aid consumers in their health provider and hospital decision-making process. While there are a lot of details around this survey, the takeaway is that Cleveland Clinic continues to perform below the national average for several of the questionnaire domains. One of these is doctor-to-patient communication.

At a more fundamental level, Cleveland Clinic takes great pride in its physician-led structure and culture. The doctors lead the various programs, institutes, and innovation. Yet, at the level of experience, that is, the realities of patients and families, encounters with these world-class doctors are sometimes marked by frustration and loss of dignity. For example, we heard from patients that doctors sometimes come off as arrogant and lacking communication skills. While physicians at Cleveland Clinic are great formal leaders, they face the challenge of being ‘servant leaders.’ It is difficult for Cleveland Clinic caregivers – nurses, administrators, and even other doctors – to change the behaviors of physicians with patients and their families. To make this problem manageable as a project, our group focused on doctor-to-patient interactions during the discharge period of in-patients.

In many ways, Cleveland Clinic leads the way in service innovation. They were the first healthcare institution to establish a Chief Experience Officer and also an Office of Patient Experience. They also hold an annual Patient Experience Summit to keep the organization excited about the frontiers of service innovation. Some of the speakers at past summits include the Ritz-Carlton, Disney Institute, Lincoln Center for the Performing Arts, Siegfried & Roy, and the Four Seasons.

Yet, their primary mode of investigating the phenomenon of patient experience can be characterized as a ‘metric-driven approach,’ partly due to the pressures of the HCAHPS and partly due to their ‘engineering’ culture that emphasizes what they call ‘scientific medicine.’ They look to their Cardiovascular Information Registry, a collection of data across several decades that has led to a production of better patient outcomes, as a crowning example of this approach. This essentially means that they collect specific type of data (i.e. relevant and in alignment with the pre-established HCAHPS domains) at the expense of other data (e.g. emotions) that may be especially valuable in understanding the holistic phenomenon of patient experience, something quite different than a heart surgery procedure. To support the Office of Patient Experience, our team provided an alternative research approach – positioned as ‘design research’ – to compliment their ongoing work.

Our project began with identifying the elephant in the room. During our initial talks with Cleveland Clinic, it quickly became clear that a bulk of the Office of Patient Experience’s energy was being investing in some of the lower hanging fruits of the HCAHPS questions. For example, dimensions such as noise level during the evenings and cleanliness of the hospital facility were already getting proactive support throughout the organization. This makes sense since such dimensions can be controlled and outcomes measured. However, research clearly continues to indicate that the most important factor in determining positive patient experience is the doctor-to-patient interaction. We wanted to go after the problem that needed the most attention yet was not receiving it.

Our design process consisted of a range of customary service design methodologies, some primary and some secondary research: participating in conferences related to healthcare innovation (e.g. Service Design Network conference, Cleveland Clinic’s Patient Experience forum); participating in the Office of Patient Experience’s service recovery program; facilitating brainstorm sessions with the Office of Patient Experience; observing patients and families throughout the patient journey; interviewing leaders at various healthcare institutions (e.g. Cleveland Clinic, University Hospitals, The MetroHealth System) about the discharge experience; interviewing residents, attendings, nurses, and social workers; interviewing patients and families; and using participatory design tools and methods with patients, families, hospital staff, and physicians.

This led to a thorough analysis of the discharge – or leave-taking – experience that was captured in a service blueprint. The analysis also included emotional dimensions of the discharge that had never been explicitly captured. Following the analysis, four major themes were synthesized to inform the generation of ten scenario-based concepts that can enrich doctor-to-patient interactions during the discharge experience.

Scenarios or narratives were created as the final, concrete form of the product to deliberately contrast with the familiar ‘metrics-driven’ solutions of the sponsor. It was an effort to humanize patient experience and to make the case that the authentic stories of patients and families have a place in the arsenal of relevant healthcare data.

The design process – consisting of problem framing, a hypothesis, design research, the development of scenario-based service concepts, and a business case – was presented before the Office of Patient Experience, the Chief Experience Officer, as well as the Chief Executive Officer in April of 2011. A project report capturing the whole process was created, presented, and distributed to the leadership at Cleveland Clinic.

Part of the reason for choosing the discharge experience as a focal point is that this moment of transition is not specific to Cleveland Clinic. It is an area of great concern to healthcare institutions all across the world and we have done some work that begins to address issues around patients interacting with a physician (as opposed to a resident or intern), getting the right information in an accessible way, and exposing some of the complexity that happens during the end moments of a patient journey.

At a practical level, this project demonstrates a strategic dimension of service design work. First, the project report includes a business case section that is the hallmark of management practice. The four MBA students in the team pulled together their expertise from their management education to provide a compelling business case that is often lacking in typical design work. Second, in addition to various ideas of service improvement captured in the ten scenario-based concepts, the project makes the argument that it is a particular demonstration of a larger idea – service innovation. Four ways of thinking about healthcare innovation were presented to the leadership along with the challenges of moving from one type of paradigm to another.

Cleveland Clinic has responded with a desire for further collaboration. At this time, one of the team members along with two faculty members at the Weatherhead School of Management are working with the Chief Experience Officer and the Office of Patient Experience to build on this project. This continuing effort is one outworking of the shift in paradigm that has begun at Cleveland Clinic. The ongoing work will be based on the premise and argument that patient experience is a holistic and emergent phenomenon as opposed to something understood as an aggregation of the parts. The steps forward include an explicit strategic dimension and reference this ‘leave-taking experience’ project as a stepping stone to larger questions about healthcare and service innovation.

The set of service recommendations proposed in the ten scenario-based concepts do not have a strict linear program although a diverse range of moments during the discharge process have been given consideration. Since the doctor-to-human touchpoint moments are unpredictable during the discharge phase, there is no prescribed script. However, the metaphor of a performance is embedded throughout the scenario-based concepts.

In following the stage and performance metaphor, the four major themes identified by the design research – ‘redeeming the time,’ ‘simplifying information,’ ‘restoring dignity,’ and ‘supporting transitions’ – were used to guide the ideation of scenario-based concepts around human actions, words that can be exchanged, and potential props during interactions. Action-centered ideas address the question, “What are some actions between doctors and patients that can happen at one foot or two feet away?” Word-centered ideas address the questions, “What are some proactive words doctors can use to interact with patients?” and “Can there be conversations not related to medicine or healthcare?” Prop-centered ideas address the question, “What are some props – preferably things that are already present in the room – that could invite an interaction between doctors and patients?” The connecting thread throughout concepts is the idea that various actions, words, and props would enable the conception, development, and fulfillment of quality service interactions.

Considering that many patients hardly ever see an attending physician or the physician that actually performed their procedure (i.e. surgery), it was important that the newly designed service system contain moments of face-to-face interactions with these physicians. More often than not, the physician that a patient sees is a resident or intern. In effect, there is an irony in asking patients how communication with their doctors was when the doctor was completely absent during the final moments of their hospital stay. Hence, some of the concepts specifically focused on introducing ways for doctors to have quick yet high-quality moments with patients.

The second leverage point during the discharge is the moment when a caregiver provides information to patients. This is a critical moment from a patient standpoint since such information needs to be learned and remembered after he or she has left the hospital (captured as the ‘learning’ or ‘educating’ moments in the project service blueprint). All too often, patients are not at their full mental and emotional capacity and this can result in not remembering medication instructions or incorrectly taking medication. From the standpoint of Cleveland Clinic and every other hospital in the United States, premature patient readmissions due to mishandling of medication information have significant consequences for brand perception, clinical care, operations, and reimbursement. To support this critical moment, some of the concepts focused on simplifying and contextualizing information for patients.

The third leverage point in the service system deals with the nature and challenge of transitioning during discharge. While some patients may be returning back to a predictable and familiar environment, many patients are told that they must be transferred to a skilled nursing or long-term care facility. Imagine the emotional distress of an elderly patient who has always said to himself, “I’d rather die than go to a nursing home” (captured in the blueprint as the ‘accepting’ moment). From the hospital’s perspective, many of the caregivers had little idea of what actually happens to patients right before sending them off (captured in the blueprint as the ‘leaving’ and ‘transitioning’ moments). From how patients’ information is recorded in the electronic medical record to what actually happens at the parking lot as patients leave the hospital environment, there is a lot of uncertainty in the details. To support transitions, a few of the concepts addressed ways that Cleveland Clinic can provide an overview of what patients can expect during their last moments as well as an opportunity to ask any final questions as they are leaving the hospital.