Case Study: Leadership in Motion

Building a Platform Measuring Patient Experience within Hospitals

My first foray into Healthcare, I learned a lot about the systems and practices that drive patient experience. I wrote about the experience gap as it relates to consumer adoption to healthcare systems, tools, and devices and laid an organic framework for healthcare providers to empower their doctors, clinicians, nurses and administrators and the care they provide to their patients.

You can read about that here:

Note: This project isn’t necessarily fully disclosable. So, if the case study seems pretty fragmented — that’s intentional. I’d be happy to speak about this project in-depth, in person, but until then, I hope this will do.


Setting the Stage

Since 2015, with the development of both the Patient Experience Division led by Lyn Ketelson and the Mobile Innovation Lab led by Jaclyn Clark (‘MCOE’ which I joined March of 2016), HCA as a whole is experiencing a radical shift in their deployment of healthcare services through its newly formed commitment to foster innovation internally leveraging modern technology through a consumer lens.

Working at HCA was an interesting blend between an agency, a third-party vendor, startup and corporate team. The slightly chaotic, wispy exchange between each mode influenced how my role shifted from leader to researcher to footsoldier to politician and back again. Not to mention, the small team size stretched my capabilities as a designer and as a comrade to a common cause: building tools to enable medical practitioners to facilitate and administer high-quality healthcare.

For the MCOE, we believed that the role of design and internal development is to build a cohesive and flexible framework for healthcare systems and environments to provide intuitive care for patients and efficiency to our medical staff. And while the physical and digital realms of healthcare are received and treated undoubtedly better and faster respectively, the experience of interacting with these processes hasn’t improved much at all.

The Challenge

In recent years, HCA specifically has had issues with patient experience reporting which led to consistently subpar scoring through HCAHPS (Consumer Assessment of Healthcare Providers and System).

Our new teams (MCOE + Patient Experience) were to be the first internally driven effort to right the ship. During our initial brief, our first project was to address the experience gap between a patient’s desire for better treatment and the healthcare providers’ desire to administer it. To do this, we shadowed our nurses, doctors, clinicians.

Here’s some of what we reported:

When patients go to the hospital, pharmacy, or emergency room, their goal is to get well because they need to. Upon arrival, we are often dealing with repetitive processes that lower expectations of satisfactory care and the perceived experience of our service overall.

When we go to the hospital, pharmacy, or emergency room, our goal is to get well because we need to. And once we arrive, we are often dealing with repetitive processes that lower our expectations of satisfactory care and our perceived experience of the service overall.

  • You walk up to the counter and the attendant asks for your name and a reason for the appointment. Nevermind the fact that you probably called and scheduled this appointment ahead of time, and that 9 times out of 10 you are visiting the same hospital where you’ve given your information numerous times before.
  • The attendant hands you a form to fill out with your name, address, phone number, medical history, allergies, and the like. You fill it out and she files it back in what appears to be a FOLDER with your name on it.

— Now I’d rant here, and excuse the informal break of a rather formal case study, as there’s just sheer frustration I have with this point in the process.

  • After you wait a moment (and perhaps you’ve paid your co-pay at this point — which is also annoying because there’s no true transparency with medical billing, and assuming you have insurance that is accepted or you opt to self-pay — another post for a different day), a nurse calls you into a room and she runs a series of normal tests to account for the more fluid variables like weight and blood pressure to log in your file.
  • The nurse goes to a computer, tablet or uses a paper version of your file and asks you the same series of questions the attendant asked of you.
  • Afterward, a doctor enters the room and undergoes the process yet again.

In all of that, there were several touchpoints, which, instead of building on prior information, require that you give them the same information thereby taking more time to get to the heart of your visit—leading to a delay in treatment.

It typically looks like this. Mostly done in patient rooms.

Taking into account the experience gap, we asked Lyn Keteleson — Chief Officer of Patient Experience, what her vision was to impact nurses and nurse leaders — she proposed a rounding* tool.

*Rounding, is a survey nurse leaders conduct to measure the experience patients have during their stay — currently, this process is a mixed bag of paper + digital processes.
For further context to why Lyn would propose a rounding tool: she was apart of the STUDER group for 12 and developed practices around rounding methodology, mainly, the “hourly rounding” method. Hourly Rounding is at the basis of the final product we shipped.
Learn more about the STUDER Rounding Method here.

I was tasked with owning this initiative and I spent numerous time with Lyn and her team to design and deliver a great rounding experience. To do so, we asked three core questions:

  • We know where routine and critical care happens, how do we utilize design to enhance the range of expertise our clinicians have in the care of patients with different motivations, desires, and needs?
  • How can we forge deeper connections between patients, their caregivers, and clinicians to the communities at large who share the same health needs and conditions? And can we foster a community that collectively shares their experiences to gather meaningful insights to improve and manage their health?
  • Companies like ours have access to and collect patient data, how do we contextually serve it to patients when they need it and when they want it to help guide them in taking the best actions for treatment, diagnoses and other insights surrounding their health?

Starting Small

To effectively develop a rounding tool that meets the requirements that all rounding practitioners need, our goal was to analyze one sector of rounding (Nurse Leader Rounding) as a focus group and based upon what would be gathered there, we can test our product not only against the group in question but learn if our product was scalable.

One of the greatest forms of insight comes from ‘shadowing’–a discovery technique used to uncover truths about a particular process as you watch a stakeholder do their job. We collected data about the core stakeholders in Nurse Leader Rounding, captured personas* and illustrated the general user journey these personas go through (as well as their discrepancies).

*Personas often capture superfluous information such as age, personal preferences and length of tenure (as it relates to a job) as a measuring stick for how well a particular system works within their daily job.
This doesn’t mean that they are always great tools to use—more on that in another post.

Discovery Efforts

  • 8+ weeks of discovery
  • Shadowing in 9 facilities
  • Extensive interviews
  • 8 weeks of wireframing and design
  • Collaboration with Rounding Steering Committee
Persona sampling
Journey map from Shadowing Nurse Leaders

Insights

  • All Nurse Leaders felt that the technology had hindered their workflow.
  • All Nurse Leaders felt that an intuitive and contextual interface would enable them to perform efficiently and they would adopt the technology.
  • The current method of rounding is a mixed bag and the method they were coached on is used by a small percentage of Nurse Leaders.

Key Challenges

  • Developing an intuitive interface that handles the analytics, tasking, and surveying of patients and nurse leaders.
  • Tapping into the HCA suite of integrations for Employee data, Patient information, and a system to track and calculate rounding numbers.

Competitive Analysis

In addition to shadowing, we had done a comprehensive audit of all rounding processes throughout HCA. There were at least nine reported digital applications providing rounding-type services across HCA’s divisions. Within that, the most common of them were:

Outside of those digital workflows, nurse leaders who were new to rounding and were not influenced by STUDOR often used a clipboard with a patient list print out and another paper for questions, a mishmash of paper and digital processes or no formal process at all.

The biggest issue with all of the current methods implemented was predicated based on each workflow being incomplete and didn’t capture an end-to-end workflow. Those areas included:

  • Lack of enterprise reportinghow would leadership track performance?
  • Lack of intelligent patient and employee integrationare the patient lists accurate? What happens when Nurse Leaders are assigned to multiple hospitals? Can we ensure that they have the most accurate and up-to-date information at any time?
  • Un-intuitive interface and user experiencemany of the platforms used did not build native experiences on iPad and iPhone. There were a lot of third-party web-socket integrations that we not dynamic, janky and lacked any sense of general accessibility (tap targets were too small, content was cluttered, lack of clear actionable CTA’s, etc)

As rounding requests increase, we needed to create a solution that addressed all of our needs. We developed Orbit, as an enterprise platform to enable nurses to round effectively and for admins to accurately quantify their hospital’s patient experience.


Never before in the history of HCA have we been on a well-defined path towards quality and consistency of experience.

Rounding for the digital age

In being the first mobile app developed by HCA’s IT&S division, we hoped that we built something that hit all marks and started an overall shift in how the IT&S department would approach future projects.

One of the benefits of being internally-developed by IT&S, we knew inherently with the amount of patient and employee data we could leverage through ADT + Lawson HR, we could create a fully integrated and secure system for nurse leaders to use. ADT or (Admitted, Discharged, Transferred) for real-time patient lists, HCA 3/4 credentials for login, Lawson HR data (for pulling in your direct reports), and an Active Directory to select an employee(s) for recognition or coaching.

Rounds are conducted through STUDER, providing a set of questions (2x2) and coaching to help the nurse effectively gather insights from their patients. There are also templates based on each hospital’s priority of care [i.e; medication, call light usage from incapacitated patients, surgery check-ins, etc].

To make the round process contextual, we created question types in the form of coaching, employee recognition, and observations — interactive “modules” that appear based on the answers from the rounding 2x2’s.

We wanted to address feedback from patients wanting to fully understand what’s going on with their care. Our app featured, bedside shift reports — engaging the patient in the conversation about arrangements from one shift to the next.

There are reports for stoplights and issues, as well as reports that track both recognition and coaching, enabling managers to keep a on the pulse of employees’ performances and the feedback they are providing.

An example of sending a task to a co-worker
Shows all three task types: Issues, Feedback + Stoplights

Calling all units

Our launch was well received and we hit many of the marks we set for ourselves from our initial discovery phase. That being said, Orbit required operational preparation before its implemented in each division and while we created a governance committee slated to do said work, we were ultimately responsible for the deployment + support of the platform.

What was shipped:

Here’s what our Pilot Deployment Schedule looked like:

2017–2018 Deployment:

Roadmap for improvements to the app
The deployment cycle of the app with the rest of HCA’s facilities
  • Travel to all facilities in the first Division
  • Assumption: 16 Facilities in the first Division
  • Travel to one location for Division Pre-Flight Training and Facility 1 of that Division
  • Support for the remaining facilities in a Division will last for 8 weeks
  • Assumption: Division/Facility devices are ordered and received in advance of Go Live preparation
Our pilot sites saw improvements in how patients rate their experience, how nurses handled reporting issues, tasks and coaching — all because we asked the right questions and provided the right technology to make sure patients’ voices were heard.

Looking Ahead

Deploying an app enterprise wide to over 200 hospitals to service 40k+ nurses is no small task. Shifting gears from product development to support can be stressful and halts big changes to improve an app’s structure and performance. Managing a team to wade through 10+ stakeholders of varying divisions can be challenging.

  • Who’s directives are relevant and actively important?
  • Can I challenge our junior designers to run wild with items in our backlog?
  • What’s the data telling us?
  • How do we build a superior version of the product? What else can we introduce?
Apple Watch Concept

From the 2017 deployment schedule and on, we worked to introduce a full platform experience covering web apps for admins to construct new 2x2 questions for contextual data mining, a monitoring system to keep track of patient intake and outflow through Orbit, prototypes for Apple Watch and TV integration.

The process was fun and it became a staple in how I wanted the relationship between designers, developers, pms and leadership to be. Not all of it was perfect, but what is? For the 14 months walking through HCA’s doors, I can be proud in saying that the work we did changed some lives. For that, I’m forever grateful.