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TEAMTEAMJason HowellCatarina PereiraAlankrita PrasadSteven SelzerZhen Zeng

UPMC Presbyterian Hospital | Cardiac Catheterization Lab

Project Documentation

Designing For ServiceFall 2007Shelley EvensonSchool of DesignCarnegie Mellon University

SolutionIdeation

ResearchExploration

Introduction

2

Nothing here

Thank YouTo Rose and the rest of the wonderful staff of the CHA, thank you for welcoming us into the holding area

and sharing your world with us. We truly appreciate all of your time and support!

To Judy, Gail, and the rest of the Center for Quality Improvement and Innovation, thank you for your

continued dedication to the project. It is truly inspiring to have worked with such a wonderful group.

To Shelley, thank you for your guidance and persistent motivation. We had a blast!

Table of Contents

1Introduction5 Executive Summary6 Process7 Design Hub & Design Lab8 The Team9 Project Brief

Exploration 2 12 Territory Map13 Observation14 Directed Storytelling15 Core Competency16 Patient Typology17 Patient Pathway18 Patient Journey20 Service Blueprint

Table of ContentsTable of Contents

Research 3 24 Focus Areas25 Patient/Family Journals26 Participatory Design27 Quality Map28 Cost Value

Ideation4 32 Welcome Bag33 “Smart” Healthcare Card34 Waiting Room35 Family LoungeSolution5 38 Design Hub

39 Design Hub Overview40 Scenario41 Screenshots45 Pathways46 Design Lab47 Conclusion

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Introduction1Executive Summary

As both providers and recipients of health care, people have been conditioned to accept general health care as a

fundamentally transactional experience. As a core life service, one that we cannot simply live without, it is time

we focused on the delivery of the service, not only to make the process more efficient, but also to provide a more

comfortable and compassionate experience for all those involved.

Health care in general consists of three interconnected steps: understanding biological processes through

research; developing medicines and techniques to address biological issues; and, finally, delivering the actual

service of medical attention. While the health care industry continues to make great strides in many areas of

research and development, only recently have the nuances of the actual health-care experience begun to receive

significant attention.

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Introduction

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Process

Our design team spent three months conducting a case study of these issues in the UPMC Presbyterian Cardiac

Catheterization Lab. In collaboration with the Center for Quality Improvement and Innovation (CQII), we collected

information through observation, shadowing, interviews, and surveys. Further, we immersed ourselves in the

hospital environment, where staff and patients made valuable contributions via the co-design process. This

collaborative effort motivated us to address service design problems in health care delivery by focusing on a

patient-centered experience.

The design concepts we first developed responded to basic issues we had identified in our own research. While

attempting to validate our concepts, however, we encountered a nearby wing of the hospital that already had

similar solutions in place, with data to support its continuing success. This discovery caused us to step back and

consider a larger, more fundamental problem: in order for the experience provided by UPMC to be consistent,

patient-centered, and comfortable, the provision of services needed to be choreographed and informed by a

central, unifying focus.

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Design Hub & Design LabWe believe that the best way to encourage suitable, meaningful changes to patients’ and visitors’ experience

is to facilitate the improvement process itself. To this end, we developed the concept of the Design Hub and its

counterpart, the Design Lab.

The Design Hub is a central online repository of project research, ideas, and solutions accessible to all UPMC

employees. Maintained by a committee of improvement specialists representing UPMC as a whole, the Design

Hub will accelerate future innovations while bringing the various parts of the UPMC system up to speed on

current best practices. Employees will have a venue to report problems, offer suggestions, and give feedback on

newly introduced practices. Specialists will gain invaluable knowledge from the staff, who are closest to the daily

situations in the hospitals, while improving staff buy-in of new ideas.

The Design Lab is a collaborative physical space for all members of the design team, which will be made up of a

group of stakeholders including hospital staff and improvement specialists, to generate ideas inspired by the best

practices showcased on the Design Hub and test concepts in a creative environment.

Empowered by the resources offered by the Design Hub and Design Lab, UPMC will be able to effectively develop a

design language of best practices and ultimately deliver a consistent patient-centered experience.

SolutionIdeation

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The Team

Alankrita PrasadSustainable Architecture

Catarina Pereira

Multimedia Design | Human-Computer Interaction

Jason Howell

Industrial Design

Zhen Zeng

Industrial Design | Human-Computer Interaction

Steve Selzer

Electrical Engineering | Human-Computer Interaction

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Project BriefDesign Challenge

A representative from the Center for Quality Improvement and Innovation introduced our team to the primary

goal of this project: to create a patient-centered experience in the cardiovascular diagnostic center by taking the

patient’s perspective into account at every stage of the patient journey.

Create a safe and reliable atmosphere;

Create a comfortable, family-friendly environment;

Promote the ideals of a welcoming and caring staff;

Consistently achieve high-quality outcomes;

In particular, they encouraged us to improve or create services that would promote the following core values:

Our Response

We used this as our starting point for research and ideation, but soon found that the scope of the project would

be much greater than we initially expected. The rest of this document will explore our findings, our process of

ideation, and the resulting service design solutions we believe respond to some of the more significant issues.

Avoid unnecessary delays;

Eliminate the redundancy with providing personal health information;

Facilitate flow throughout the patient journey.

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Exploration2

SolutionIdeation

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Introduction

12 Territory Map

comfort

Hospital Personnel

Please make it better.

Patients

Is my loved one being cared for?

Famliy + Friends

integrity

perception of hospital

brand identity

e�ciency

hospital e�ciency

centralized records

UPMC environment

security privacy

navigation

ambiance

care

personal attention

empathy

accommodations

communication

patient status

family awareness

internal communication

guidance

I want to help patients feel better.

Our territory map illustrates the patient-centered experience, with a focus on comfort as it is derived from the

many facets (i.e. care, integrity, environment, communication, and efficiency) of the UPMC health care system.

Size indicates how much each facet relates to comfort.

Overlap indicates the degree of focus for our project.

We began by developing an affinity diagram of our varying preconceptions of the health care experience. In

order to calibrate the team’s collective eye, we developed a territory map that established “comfort” as the

appropriate lens through which we could focus on the patient experience and the resources by which the

experience is guided.

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Finally, we looked at the people and their roles within the CHA, where a nurse also acted as coordinator and receptionist in addition to the medical responsibilities prescribed by her job description.

We observed various processes in action: patients checking-in, answering questions, and preparing for the procedure; and nurses documenting patient status, verbally handing off responsibilities, and responding to bedside alarms.

After a sufficient self-imposed wait time, we navigated to the Catheterization Holding Area (CHA) where we first encountered patients donning gowns, nurses tending to those in need, and our own visceral response to the familiar hospital environment.

We spent time in the waiting room soaking in the emotional ambiance and evaluating our own experiences in terms of physical comfort and the resources with which we could help pass the time.

Observation

Our journey began by navigating to the Cardiac Catheterization Lab using hospital signage, an exercise that suggested potential problems with wayfinding.

To research the experience, we had to experience the experience.

SolutionIdeation

ResearchExploration

Introduction

14 Directed Storytelling

“Participants tell stories as a way for researchers to

understand and document participants’ experiences.”

Evenson

With a general impression of the patient journey and corresponding levels of comfort, we set out to

develop a better understanding of the processes and personal sentiments that comprise the experience

for both patients and staff. We explored the potential of directed storytelling, a form of narrative inquiry

in which “participants tell stories as a way for researchers to understand and document participants’

experiences” (Evenson).

In order to better understand the experience, we conducted several interviews with both patients and

nurses in which they were asked to describe either the patient journey (if the participant was a patient)

or a typical work day in the CHA (if the participant was a nurse).

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15Core Competency

At the heart of the UPMC Cath Lab are its people. The nurses and technicians

combine their treatment expertise with a willingness to accommodate patients’

needs in a personal, adaptable way. The Cath Lab staff show their commitment to

providing quality care with compassion.

Based on the data we collected from our observational and

research methods, we were able to identify the distinctive

areas of expertise of the Cath Lab and its people. In an effort

to consolidate our collective understanding, we articulated

these unique qualities in a statement of core competency.

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Introduction

16 Patient Typology

Our research provided a wide range of qualitative data on the patient experience. We created

two distinct patient typologies and identified their characteristic qualities in an effort to

consolidate our collective understanding of the patient experience.

First time patients and their families are often overwhelmed by the big city experience and the

negative stigma attached to large hospitals. In addition to the challenges posed by way finding, first

time patients and families frequently ask questions and generally require more information. Often, they

arrive with misconceptions of the procedure and its results, elevating levels of anxiety and prompting

additional attention from staff.

Returning patients and their families are more familiar with the procedure and arrive with

expectations. While their expectations are being met, returning patients and families are generally

content; there is a tendency, however, to get impatient when they experience delays or provide their

personal health information several times throughout the process.

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17Patient Journey

Doctor

Admit into hospital

DischargeCath Lab Journey

The patient journey begins when a patient is either referred to the Cath Lab by his primary care physician or

brought in by ambulance in the event of an emergency. Patients flow through several stages of the journey,

culminating in one of two possible post-procedural pathways: the patient gets admitted to the hospital as an

inpatient, or the patient gets discharged and goes home. Sometime thereafter, patients return to their primary

care physicians for follow-up care.

SolutionIdeation

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Introduction

18 Patient JourneyScheduling Arrival Registration CHA Pre-Procedure Procedure Post-Procedure

We identified seven stages of the patient journey: Scheduling and Getting Informed, Arrival,

Registration, Encountering the CHA, Pre-Procedure, Procedure, and Post-Procedure.

Scheduling and Getting Informed

Patients are contacted by phone to schedule an appointment, at which point they are provided general

information about the procedure and how to prepare. A formal letter is mailed to patients, though our

research suggests that they often have to come in for the procedure before the letter even arrives. In

addition, a link to an informational video is provided to patients, but again it seems this video often goes

unwatched.

Arrival

Since many patients and families are traveling to Pittsburgh from rural parts of Pennsylvania, the big

city experience can be overwhelming. They often experience problems with finding parking, orienting

themselves in the matrix of buildings, and finally navigating their way to the Cath Lab by following

inconsistent and often vague signage.

Registration

Once patients arrive at the ambiguously-named Medical Procedure Unit (MPU), which is essentially a

waiting room where patients check-in, this stage of the journey involves verifying one’s medical record

and signing a consent form. The physical space is shared with another unit of the hospital, confounding

processes and generally adding to the level of discomfort in this typical hospital waiting room.

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Pre-Procedure

Patients are assigned a room, at which point they may don the patient gown, use the restroom, and

settle in before the pre-procedural questioning and physical preparation. Patients are then required to

verify one’s medical record a second time, while simultaneously getting shaved and medicated for the

procedure. Family members are then allowed to enter the CHA and accompany patients until they are

escorted in for the procedure.

Procedure

During the procedure, family members are given a pager and encouraged to visit the café or return to

the MPU. The pagers are reportedly nonfunctional in the café and the MPU provides little in the way of

relief affordance.

Post-Procedure

In this final stage of the journey, family members are reunited with patients as they return from the

procedure. Patients are monitored for excessive bleeding and provided a meal after several hours of

recovery. At this point the nurses determine whether the patient needs to be admitted into the hospital

or may be discharged.

Encountering the CHA

Wayfinding from the MPU to the Cath Holding Area (CHA) seems easy enough considering it is located

just around the corner, but patients often walk right past the CHA to Radiology. The CHA has no obvious

reception area and the clutter of medical equipment floating around the walkways, the constant beeping

of bedside alarms, and general ambiance can be a bit overwhelming.

SolutionIdeation

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Introduction

20 Service Blueprint

Due in part to the complexity of interactions during the pre-procedure stage, we developed a service blueprint

to understand in even greater detail all of the front- and back-end interactions that take place. We highlighted

several points in orange where patients typically experience heightened levels of anxiety.

line of interaction

line of visibility

line of internal Interaction

Physical Evidence

Patient Actions

Onstage Contact

Backstage Contact

Support Process

check inundress & bathroom

break

verify medical history

verify medical history

prepare physically

wait waitfamilyjoins

patient

admit patient

draw bloodmedicate

shave

enterpatient

info

order lab work

schedulesheet & eRecord

signconsent

form

review risks& consent

form

explain procedure

set patient status to “ready”

notifyattendant

let family in

eRecord whiteboard

nurse’s stationeRecord

schedule sheet

patient roompatient gown

bathroom

computer cart status monitor & equipment

consent form television television

wait

televisionchairscafe

pagernursepractitioner’s

clipboard

review medical history

review medical history

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Research3

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Focus Areas

Communication Inefficiency

Way Finding to CHA

Waiting RoomRegistration Process

Nurse’s Station

Patient Rooms

Nurse-to-Nurse Communication

Linen Service Check-in

Overflow Room Bloodwork Process

AmbianceFood quality Entertainment

Patient Status

Family Accommodations

Due in part to the complexity of interactions during the pre-procedure stage,

we developed a service blueprint to understand in even greater detail all of the

front- and back-end interactions that take place. We highlighted several points

in orange where patients typically experience heightened levels of anxiety.

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Patient/Family Journal content happy comfortable aware hopeful bored lonely exhausted anxious confused frustrated overwhelmed

After procedure

Arrival

Registration

Cath Holding Area

During procedure

In order to validate our focus areas and supplement our research with more qualitative data, we created a

patient journal that gave patients and family members an opportunity to document their journey in terms

of the emotions they felt at any particular stage. Much to our chagrin, the results showed that people were

generally comfortable and content throughout the journey. It did, however, reveal that there were still levels

of anxiety to address, especially for family members during the procedure

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Participatory Design

welcoming interesting uninviting

boring

uncomfortable

relaxing

cozy

With our focus still on comfort, we set out to

address the inadequacies of the MPU waiting

room with specific attention to reducing the levels

of anxiety and discomfort that were revealed in

the patient journals.

We designed a tool that would engage patients

and family members in the waiting room and

help convey to us their conceptions of “comfort”.

We subjectively selected images of furnished

and decorated rooms in the range of extremely

comfortable to somewhat uncomfortable.

Patients and family members were asked to sort the images into categories based on 3 positive,

1 neutral, and 3 negative adjectives. As they sorted the images, we asked them to explain their rationale

and noted their reasons on post-it notes (as shown in the rendering).

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Quality Map

lack of cushion

formal / clinical

comfortable chair

better color

plants

window art

magazines

lighting

waterfall

rug

hardwoodfloor

lack ofcolor

fixedfurniture

dimlighting

clutter

We took the qualitative data from our participatory design results and developed a quality map of both positive

and negative aspects and their relative importance to patients and family members. The results were consistent

with our preconceptions but also introduced new ideas that inspired service design concepts during our

brainstorming sessions.

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Cost / Value

High Value

Inexpensive

Expensive

Low Value

daily newspapers & new magazines

welcome bag

coat rack

plantsgames

stainless steel trashbins

aquarium

website for patients

smart healthcare cards

virtual window

built-in couch in CHA

personal cubbies

wifi

unique room names

use “lighter” materials

resin panels for wallsmodular furniture

flat-panel monitors

aquarium

consolidate printers

universally shared record

snacks

community gaming

After several brainstorming sessions, we narrowed down our ideas and evaluated them in terms of their relative cost

and potential value. This was ultimately an exercise in prioritizing ideas in order to validate our concepts and help us

focus our efforts where we felt we would make the greatest positive impact.

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Ideation4

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Info brochure Hospital mapStress relief ball Feedback cards

UPMC

Welcome bag

In an effort to reduce anxiety at arrival and provide a warm welcome to

patients and their families, we developed the welcome bag, a simple

solution with an ideal low-cost / high-value relationship. The bag would

ideally contain informational brochures about the Cath Lab experience

along with any number of useful goodies such as a UPMC stress-ball, pen

and paper, puzzle, pair of cozy socks, or coupons for the café. This would

also be an ideal opportunity to distribute feedback cards, reinforcing the

positive hospital experience while providing a venue for patients and

their families to voice their opinions.

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Smart healthcare cardWe are proposing a UPMC-issued “smart” healthcare card with the ability to store and easily retrieve a patient’s

complete medical record. The card would enable patients to share their updated medical records with primary

care providers and hospitals instantly. In effect, the “smart” healthcare card would streamline medical visits by

facilitating flow, significantly reducing manual data entry and virtually eliminating redundant questions.

Paperwork and documentation have a tremendous impact on the

patient journey. Patients are asked to verify their medical records

several times, and as our data suggests, delays are often attributed to

bottlenecks that occur while updating and verifying records.

UPMC

UPMC

UPMC

primary care physician

SolutionIdeation

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Waiting room

We were excited about the prospect of a new waiting room for the Cath Lab and saw this as an opportunity to rethink this physical

space and propose a new design concept. Pulling from our research and participatory design data, we identified seven (7) concepts

and integrated them into our redesign.

We also propose that the current waiting room continue to facilitate the registration process for both Cath Lab and GI patients, while

the new space, alternatively labeled “Family Lounge”, provide a more casual environment that facilitates relief affordance.

1. Check-in kiosks

In order to streamline the check-in

process, electronic kiosks should be

installed in direct view as a person

enters the waiting room. The kiosks

could require a patient to answer a few

questions (in order to streamline the

process) before automatically notifying

the registrar that a patient has arrived.

2. More colors

Patients and family members clearly

expressed a desire for more color in the

waiting room. In addition to broadening

the color palette on walls, color would

also be introduced in the furnishings.

View from entrance

Turn to the right Turn to the left

2

1

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Family lounge3. Aquarium

All of our participants responded well to

the aquarium during our participatory

design sessions. The soothing sound of

flowing water and natural beauty of this

visual alternative to television make it

an excellent addition to the ambiance of

this space.

4. Local artists’ artwork

A rotating display of local artwork will

connect the hospital with the surround-

ing community while adding to the

eccentric atmosphere of the lounge. Re-

turning patients and staff will appreciate

the change of scenery and may develop

an interest in a particular artist or piece

of work.

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5

8

4

5. Computer Stations

All of our participants responded well to

the aquarium during our participatory

design sessions. The soothing sound of

flowing water and natural beauty of this

visual alternative to television make it

an excellent addition to the ambiance of

this space.

6. Nature

Our data indicates that patients and fam-

ily members prefer environments that

are fitted with plants and other touches

of nature such as wood flooring, rooftop

gardens, and aquariums. Introducing

nature into the Family Lounge will have a

significant positive impact at a relatively

low-cost / high-value ratio.

7. Comfortable & Movable Furniture

Patients and families ranked comfortable

chairs higher than any other affordance

in the waiting room. Our research also

indicates that patients and families

prefer movable furniture and value the

flexibility it affords.

View from entrance Turn to the right

Turn to the left

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Solution5Redirected

We had a chance encounter with a waiting room in the Montefiore wing of the hospital that already had

electronic check-in kiosks, movable furniture, and even a dedicated family liaison to answer questions and provide

patient status updates to family members.

This revelation led us to consider the ramifications of such a discovery, having spent several weeks developing

what we thought were innovative concepts only to find our ideas already in place just down the hall.

We collectively decided that In order to facilitate improvement, we had to address this fundamental disconnect:

that in order to make informed decisions in terms of quality improvement, there first had to be a resource to

consolidate all of the best practices currently in place. This resource had to provide the capability to evaluate

current practices, document problems, and incorporate feedback.

U

The Design Hub is a central online repository of project research, ideas, and

solutions accessible to all UPMC employees. Maintained by a committee of

improvement specialists representing UPMC as a whole, the Design Hub will

accelerate future innovations while bringing the various parts of the UPMC system

up to speed on current best practices. Employees will have a venue to report

problems, offer suggestions, and give feedback on newly introduced practices.

Specialists will gain invaluable knowledge from the staff, who are closest to the

daily situations in the hospitals, while improving staff buy-in of new ideas.

UPMCDESIGN HUB

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Design Hub OverviewThe Design Hub aims to reconcile the fundamental disconnect between the various silos that make up UPMC.

As a repository for ongoing research, new ideas, and established best practices, the Design Hub will ultimately

enable UPMC to consolidate the silos and develop a consistent design language, one that will have evolved over

many iterations, each of which will have been validated by empirical data. Only then will UPMC be on its way to

becoming the “Hospital of the Future”.

UPMC Design Hub UPMC Design Standard UPMC Hospital of the Future

UPMC Silos

UPMC Staff

Patients and Families

provide suggestions reference designs

end goalyou are here

UPMC Design Labs

provide feedback

SolutionIdeation

ResearchExploration

Introduction

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Scenarios

Anne, from the Center for Quality

Improvement, is working on a project

with the Cath Lab at UPMC Presby.

Research is done which includes patient

feedback, surveys, nurse interviews and

documentation of the current problems

of the Cath Lab.

Anne documents the research findings

of the Cath Labs current status into the

Design HUB.

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3

1 2

1. Featured Best-Practices

The first thing users will see when

they load the Design Hub is a

slideshow of Featured Best-Practices

of the week. The purpose of this is

to increase awareness of the best

practices among UPMC staff. By

staying informed, staff can make

compelling arguments for proposed

changes and base their solutions on

proven Best-Practices.

2. Recent Practices

In this section, users get a

glimpse of what solutions other

departments have in place. Once

these practices are proven to be

successful, they have the potential

of becoming a Best-Practice. Some

useful features here include ability

to sort the practices, see comments

for each practice, and explore other

related practices by clicking on one

of several ‘tags’.

3. Current Projects

If the logged-in user is involved in

any quality improvement projects,

they will be listed on the right

side of the screen for easy access.

For every project, the user can

see when it was last updated,

the number of comments that it

received, and an indication of the

progress of the project.

1

3

SolutionIdeation

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4

5

4. Project Tools

These are some useful tools for

the user. Feedback manager is the

repository for all feedback related to

a particular project, including those

collected from staff, patients, and

visitors. Data Manager provides tools

to analyze and visualize research

data. Presentation creator is a tool

that generates a presentation based

on information aggregated from the

other aforementioned tools.

5. Project Profile Summary

This is a snapshot of the current

state of the project. It shows the

project process, tags, and another

set of data that the user chooses to

display. In this screenshot, the user

chooses to monitor the progress of

the surveys that she created.

6. Related Best-Practices

When a user inputs a project

profile, related best-practices are

automatically generated. They

act as a source of inspiration as

well as a reminder of the level of

quality to aim for.

6

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7. Profile Details

This section contains a list of

individual elements that make up a

profile of a project. By clicking on the

title of an element (e.g. ambiance),

user will see a detailed list of

requirements and descriptions of the

element.

8. Comments

Anyone can leave a comment about

any part of a project. The recent

comments occupy the bottom of

the page, thus becoming part of the

information of a profile or project.

8

7

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9. Suggestions

This is a venue for staff to make

suggestions or submit a problem.

The form is intended to be simple

and open-ended, allowing users

to leave quick suggestions or

long, elaborate ones. When a

suggestion form is submitted, it

goes to the CQII to be sorted into

the Feedback manager.

10. Recent Suggestions

Like “Comments”, users can see

what others are suggesting, and

perhaps new ideas will be born of

out this forum.

9

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PathwaysThe basic functionality of the Design Hub can be thought of in terms of four main pathways: submitting

a problem, a best -practice , a new design or feedback. Each of them involves both online and offline

activities and as the Design Hub expands, we imagine that there will be many more possible pathways.

identifya problem

area

researchand

documentproblem

enterdata and

define‘tags’

createa new

problemprofile

createa newproject

problem pathway

identifypotential

‘bestpractice’

documentpotential

‘bestpractice’

collectdata tovalidate

‘practice’

datasupports

‘bestpractice’

enterdata and

define‘tags’

createa new

‘practice’profile

‘best practice’

pathway

‘practice’archivedwith data

design pathway

search fora problem

reviewrelated‘best

practices’

Submitsuggestion

form

ideatein design

room

implementdesign

solutions

enterdetails of‘currentpractice’

enterdata and

define‘tags’

feedback pathway

Encounter a problem

Fill out survey

Receive email about survey

datarejects

‘practice’

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46

Design LabThe Design Lab is a collaborative physical space for all members of the design team, which will be made up of a

group of stakeholders including hospital staff and improvement specialists, to generate ideas inspired by the best

practices showcased on the Design Hub and test concepts in a creative environment.

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ConclusionWhile it may seem like a daunting task to build a resource like the Design Hub, it is important to recognize

that the long-term benefits will positively impact the patient-centered experience. An investment in this

technology today will potentially save UPMC a significant amount of money as they consolidate silos,

reconcile the disparity between variably funded departments, and develop the design language that will

take them a giant leap forward in the race to become the “Hospital of the Future”.