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Patient Experience Case Study - Dartmouth-Hitchcock
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Patient Journey Mapping: Understanding the Relational Patient Experience in Ambulatory Primary Care

What was the challenge, opportunity or issue faced?

In healthcare systems nationally we have become quite adept at data gathering, analysis and process improvement, often evaluating and attempting to improve our internal workflow processes without fully understanding the voice of our patients from their perspective. Given the complexity of a typical healthcare visit, care is often siloed with each department very attuned to the inter-workings of their own department but less aware of the operations of contingent services (for example a typical primary care visit might include interactions with registration, primary care office, lab, radiology, referral services and billing). As such, it is not uncommon for one department to be unaware of the downstream impact that one department’s decision might have on a patient’s experience within another department. By pulling multiple departments together and developing a full journey process map, the care team is able to fully realize the interrelated dependencies that impact the care experience the patients receive.

At Dartmouth-Hitchcock, we needed to develop a process and strong visual representation for our employees to fully understand the totality of the experience that our patients go through in Primary Care in order to implement improvements focused on their specific needs. While the process steps are what is done to the patient (during the phases of discovery, pre-visit, visit, and post-visit), the focus of this journey map work was to explore the how it is done—the "relational” patient experience. This lets us document the emotions, feelings and reactions our patients have as they experience the office visit process and reveals how effectively we are supporting or eroding the relationships we build with our patients.

The process of creating the patient journey map had three main objectives:

  1. Show the entirety of the experience, since for most participants, this was the first time they actively thought through all of the different ways in which we relate to our patients.
  2. Create an experience/exercise that connects our providers and staff to the actual emotions (relational needs) of our patients’ visit experience.
  3. Create accountability by tying this work to performance objectives for every employee and provider in the ambulatory practices creating greater focus on patient needs.

What did you do to address it?

The patient journey map process began by developing a high level work flow of the typical primary care patient visit process. This was intended to provide a bird’s eye view of the major "stops” along the typical patient experience such as registering, waiting to be seen,  being treated in the exam room, checking-out, etc. We then evaluated our current state of patient satisfaction through our ambulatory survey process. We used data depicting "overall rating of provider,” "overall rating of visit” and "care and concern of all staff to the patients’ special needs and concerns” as starting points to understand the current state from a quantitative perspective, but these metrics are insufficient to understand the patient journey and will rarely tell the full patient story given the use of ratings versus open ended verbatim type questions.

To identify the behaviors that delight and dissatisfy our patients in their primary care journey, we held two, 2-hour sessions with over 120 leaders in our organization and asked them to come up with statements that would create either a positive or negative feeling for the patient within each process step that a patient takes. We instructed our leaders to think about obtaining care within our health care system and to use their own or their family’s experiences as reflection points. This yielded an enormous amount of data. The next step was to sort each statement into categories of description (using an affinity sorting method frequently used in qualitative research) to form groups or themes of feelings. These groups emerged quickly during the sorting process and became the object of the next step in the process, validating the data with our patients.

Next, 30 one-on-one interviews were conducted with our patients to ensure that we had both the breadth and depth of the relational patient experience. Our patients were asked to add to the categories and to validate that we had the right information from a relational perspective within each of the process steps of the visit. The patients had very little to add to the general category or themes, suggesting that we had accurately captured the experience.

A final step was to determine the intensity of the experience. Two patient/volunteer focus groups were conducted. This gave us a clear indication of the degree of importance that various categories had on their overall patient satisfaction. During these sessions we also prompted the patients to describe the specific details of what happened to them so that we could have a more comprehensive understanding of how their experience related to their perception of delight or anxiety (a perceived pain point). The resulting stories were rich with detail and insights that greatly accelerated the value and power of using this type of journey mapping process for obtaining the "voice of our patients.”

The journey map developed was a visual representation of the experience that a patient may have with primary care in our health system. While the process steps are what is done to the patient (discovery, pre-visit, visit, post-visit), the focus of this journey map was on how it was done; or the relationships built or not built with the patients. The points of dissatisfaction and points of delight are highlighted by the words depicted along the journey within the map, as well as real words and testimonials of their experience.

What were the outcomes?

The journey map highlighted the primary care experience in our system from the perspective of the patient and its usefulness in identifying improvement opportunities in service excellence. Following the report out to the 120 leaders who were instrumental in the early phase of data gathering, opportunities, tactics, and associated measures were identified in order to develop departmental projects and performance goals. These goals are tracked in our performance system and also become part of each individual’s performance appraisal. Additionally, we invited individuals to come up with one personal metric to commit to, separate from their departmental goals. This was a "personal behavioral commitment” that they would embrace somewhere within this journey themselves.

In the end, the journey map has been instrumental for analyzing the true voice of the patient, aligning individual and departmental goal-setting to create accountability to celebrate successes, develop opportunities for improvement, and ultimately improve the patient experience. Additionally, using a patient journey map exemplifies a powerful way to create an emotional connection for the staff and providers—reminding them of the emotional components of a health care experience and the true purpose of "caring.”

> Download the Patient Journey Map

About Dartmouth-Hitchcock

Dartmouth-Hitchcock is a nonprofit academic health system that serves a patient population of 1.9 million in New England. Anchored by Dartmouth-Hitchcock Medical Center in Lebanon, NH, the system includes the Norris Cotton Cancer Center, one of only 41 National Cancer Institute-designated Comprehensive Cancer Centers; the Children's Hospital at Dartmouth-Hitchcock, the state's only comprehensive, full-service children's hospital as noted by the Children's Hospital Association; 30 outpatient clinic locations including clinics in Manchester, Concord, Nashua, and Keene, NH and Bennington, VT; and affiliate hospitals in New London and Keene, NH, and Windsor, VT. D-H provides access to more than 1,000 primary care and specialty providers in almost every area of medicine.

The information presented in the Journey Map was collected, vetted and produced for visual presentation during the time period of February to May 2015. For more information, please contact Jason Vallee, PhD, Director of Service Excellence; Jodi Stewart, Service Excellence Communications Manager; or Vicki Patric, Director of Quality & Patient Safety, Ambulatory Care.

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