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DVR serves as an inexpensive and powerful tool to improve care delivery
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Most of us are familiar with both clinical pathways and process improvement techniques such as Six Sigma, Toyota Production System and Lean — the two traditional approaches to care delivery improvement. Some of you may also be familiar with a third approach, design science — a systematic form of intentional design first introduced by Buckminster Fuller and later popularized by Nobel Prize laureate Herbert Simon. Design science builds on clinical and process improvement with the goal of making things better for the end user — in the case of health care, patients and families.
Through design science, we can co-design ideal care delivery with patients and family members; patients and families provide real-time input while health care staff lead the design effort, creating a partnership in which each participant fulfills an equal role in bringing true patient-centeredness to bear on the health care experience.
Experts in the field of design science note that understanding end user experiences at a deep level, best accomplished through direct observation, is necessary to making an emotional connection and creating a sense of urgency to drive change. The Patient and Family Centered Care Methodology and Practice (PFCC M/P) is an example of using design science to co-design ideal care experiences and, at the same time, improve patient safety and clinical outcomes while decreasing waste and cost. A simple six-step methodology, the PFCC M/P allows us to view all care experiences through the eyes of patients and families, identify the current and ideal states of the care experiences and provide methods for closing the gaps.
DVR in the inpatient setting
A signature tool of the PFCC M/P is shadowing — the repeated, direct, real-time observation of patients and families as they move through each step of a care experience. Shadowing clarifies the true patient and family experience while leading us to feel a sense of empathy and urgency to drive change. We have recently taken the concept of direct, real-time observations of patient and families a step further, with digital video recording (DVR) of patients’ and families’ care experiences in the inpatient setting. Using video data to understand care delivery through the eyes of patients and families is a new concept for health care. It is also surprisingly inexpensive and yields a tremendous amount of valuable information.
Anthony M.
DiGioia III
In a study recently published in Quality Management in Health Care, we installed a DVR system in two inpatient rooms of the orthopedic unit at Magee-Womens Hospital of University of Pittsburgh Medical Center (UPMC). The system included a DVR and two small digital, infrared color cameras in both rooms. The cameras were positioned so that all activity in the rooms was recorded while minimizing the patient’s sense of intrusion, providing the patient the ability to seek privacy if desired. The specific locations of the cameras were chosen to provide the ability to draw the curtain at the bedside if privacy from the motion-activated cameras was desired. The DVR system is capable of motion activation and creating a virtual bubble around the patient’s bed so that isolated bed activity (e.g., patients rolling over in bed) did not activate the recording system. We found that with DVR technology, a patient’s entire stay — typically 2 days to 3 days — can be analyzed in just a few hours because non-pertinent information is not recorded.
Twenty-two patients’ experiences were recorded in the published study: 13 after total knee replacement (TKR), eight after total hip replacement and one after revision TKR. Results included determining the number, frequency and length of time of bedside interactions between patients and staff members and identifying each staff member’s function (i.e., nurse, aide, dietitian, physician, therapist, etc.). We also were able to document involvement of patients’ family and friends in their care, staff work flow, care delivery processes, and the quality and efficiency of processes and interactions.
We have used the results of the DVR study to implement innovative changes, improve patients’ and staff’s care experiences, increase efficiency and improve clinical processes. For example, three or four staff members now visit the patient at the same time (team visits) instead of coming in one after another to minimize disruptions to patients. A utility cart with common supplies and medications is brought into patients’ rooms during team visits to reduce the number of times staff members have to leave and return to the room, and a bedside medication program was initiated so that most medications can be stored in a locked cabinet in patients’ rooms.
Endless possibilities
Our most recent use of the technology is focused on understanding and improving hand washing compliance, a top national and international priority. Our DVR study demonstrated 28 different staff types have contact with these patients and an average of 4,450 total staff contacts per patient during a 2-day to 3-day inpatient stay. Requiring staff to wash their hands upon entering and exiting a patient’s room brings the number of times staff mush wash their hands to 8,900 per patient. Nurses alone, shown to have the most patient contacts, must wash their hands 3,400 times for each patient. Multiplying this scenario beyond our one-patient unit in one hospital gives us an idea of the scope of the issue and the need for solutions to be simple, efficient and effective 100% of the time. However, the study also identified the fact that five staff types accounted for 81% of these patient contacts: nurses (39%), patient care technicians (26%), physical and occupational therapists (6%), patient support assistants (5%) and physical therapy assistants (5%), and other (19%). With this information we can focus our efforts on designing a hand hygiene program that specifically addresses the experiences of these five staff types. Another example of the applicability of DVR in the area of patient safety is the ability to observe patient falls – e.g., observing whether patients’ techniques for getting themselves in and out of bed are incorrect, leading to falls. The proper technique can them be re-taught in physical therapy.
Pamela K.
Greenhouse
DVR technology is an inexpensive, unobtrusive and powerful approach to viewing all care experiences through the eyes of patients and families without disrupting staff or patient routines. It removes observer bias and the impracticality of situations that do not lend themselves to direct, real-time observation. The possibilities for using DVR to gather data are endless and show promise, locally and nationally, for improving patient safety, quality of care, efficiency and the patient experience.
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Pamela K. Greenhouse, MBA, is executive director of PFCC Innovation Center of UPMC, 3380 Boulevard of the Allies, Suite 270, Pittsburgh, PA 15213; email: greenhousepk@upmc.edu.
Disclosures: DiGioia and Greenhouse do not have any relevant financial disclosures.