January 31, 2019 The healthcare industry is being disrupted by major shifts in the marketplace. With advances in technology, plus many more options for coverage, customers now have much higher expectations of quality of care. In response, the San Francisco Health Network (SFHN) has been working to improve its patient experience. An arm of the San Francisco Department of Public Health, SFHN is composed of primary, specialty, mental health, and emergency care facilities, including an acute care hospital and trauma center, a skilled nursing and rehabilitation hospital, and more than 35 ambulatory clinics throughout the city. SFHN also manages substance use disorder services, a jail health program, and an array of health services for the homeless. Overall, the network serves one in eight residents — more than 100,000 people annually — including 42 percent of the city’s Medi-Cal and Medicaid patients. Many of its clients are low income, and, as the city and county’s safety net system, SFHN provides care to everyone, regardless of ability to pay.
“The Patient Journeys was like having another voice at the table that spoke to the importance of the patient experience.” — Amy Peterson, care experience manager
With such an expansive network and a growing number of patients, maintaining a positive, consistent customer experience across SFHN facilities has been a challenge. During the past several years, SFHN has trained employees on the principles of service excellence and relationship-centered communications, and it has implemented patient-satisfaction surveys.
SNAPSHOT
The San Francisco Health Network (SFHN), which serves 100,000 residents, has a growing number of patients, many of whom are low income and dealing with chronic diseases. Maintaining a consistent customer experience across SFHN facilities has been a challenge. FUSE executive fellow Cori Schauer helped determine strengths and weaknesses in the SFHN system and recommended ways to improve.
But SFHN knew it needed to do more. To craft and implement an approach to patient-centered service, organization leaders assembled a Care Experience Advisory Council (CEAC) with representatives from across SFHN. Leaders also partnered with FUSE executive fellow Cori Schauer, who helped structure the CEAC for optimal functionality. Additionally, Schauer worked to determine the strengths and weaknesses of the SFHN system in order to recommend ways to improve.

Framing the Problems

To comprehend this vast and diverse ecosystem, Schauer employed a human-centered design approach, which looks at issues from the perspective of the people involved and devises solutions based on their concerns. This approach helped her identify needs, frame problems, and explore potential solutions for both patients and staff. Schauer began by observing and interviewing patient-experience teams at SFHN’s two hospitals and various primary- and specialty-care facilities. From these interviews, two important insights emerged that shaped her approach to the rest of the fellowship. First, the way feedback is collected across SFHN is siloed and not uniform, so no one was able to see the big picture of how SFHN did — or did not — meet patient needs. This also meant that SFHN staff didn’t know the experience of a patient traveling through the network, especially from one department to another, such as from primary to specialty care.   
MEET THE FELLOW
Cori Schauer is a user-experience researcher from the private sector whose work was grounded in design thinking and the customer-experience model. Prior to that, she was a service designer with the City and County of San Francisco, a design researcher at Dropbox, and she previously held research positions at NASA and Mozilla.
Second, each facility had a unique culture, which resulted in varying priorities for the patient experience across the network. The patient population and priorities in a long-term stay facility, for instance, were different than an emergency room setting. Schauer was able to identify the strengths unique to each of the care teams, but she also noted that differences in cultures sometimes resulted in silos and conflicts among various parts of the network. Armed with this knowledge, Schauer wanted to understand specific needs, so she conducted ethnographic research, interviewing patients and staff and performing 29 hours of in-clinic observations and job shadowing. As it turned out, interviewing patients was no easy task; privacy laws did not allow access to patient files or health records, and many patients’ contact information was not accurate. However, she eventually obtained a list of 30 people to contact. Schauer found that patients tended to have chronic health problems, which in some cases were compounded by mental-health or substance-abuse issues. Moreover, patients with chronic health problems had an especially hard time understanding how and when to access different doctors across the network. These patients also related that the handoff from primary to specialty care left them feeling as if they were starting the care process all over again, with new doctors asking the same questions for another set of paperwork. The more difficult the process, the less satisfied and, ultimately, more distrustful of the system patients became. Patient experiences were also influenced by their understanding of health issues, their cultural beliefs, and a variety of socio-economic factors, including income, place of residence, and education. From staff, Schauer learned that they had a difficult time providing feedback to one another, especially if they crossed departments or roles. For example, a medical assistant didn’t feel comfortable providing feedback to doctors about how they handled patient interactions, because, “They are doctors, and I’m not.” Similarly, doctors didn’t feel like they could provide direct feedback to team members, because the doctors didn’t want to break union rules by going around a manager. Staff also discussed what they call “burnout.” Although exposed to trauma on a daily basis, staff was doing little to deal with the personal effects of that trauma. The result was what they referred to as quick burnout, which led to shorter tempers and, in some cases, negative interactions with patients.
PLAYBOOK TIPS
Use Visual Cues for Impact. By providing a visual outline of the steps and emotions that patients experience when seeking care, Schauer gave a voice to patients all along their journeys rather than at one point. The care-experience map proved to be eye-opening for SFHN leadership and staff, and it served as an outline for improving workflows. Switch Your Thinking. At one of the SFHN hospitals, Schauer leveraged an existing patient council to hold ideation workshops. But instead of asking patients about complaints, the council’s typical format, she encouraged patients to identify opportunities for improving their stay. Many of the suggestions, such as allowing patients to adjust the water temperature in their rooms, required only minor adjustments from the staff but greatly improved the patient experience.

The Approach

Equipped with these findings, Schauer determined that her focus should be on helping SFHN improve patient transitions, during which disparate cultures and processes would often increase stressors for patients. Furthermore, she provided SFHN staff with insights from her patient interviews to help them understand the patient experience. As such, Schauer devised the following priorities and recommendations. Use visualization to see the big picture: Schauer created a patient journey map, which provided a visual outline of the steps and emotions that patients experience when seeking care. The map was the first time SFHN had seen what it was like for a patient to travel throughout the network and transition between doctors and departments. It was eye-opening. SFHN was able to see the emotional highs and lows of the process and where it wasn’t meeting the needs of its patients. In one example, patients who had waited months for surgery were given two weeks’ notice that their procedures would have to be moved, delaying the surgeries for several additional months and resulting in great stress. “The Patient Journeys was like having another voice at the table that spoke to the importance of the patient experience,” said Amy Peterson, care experience manager in primary care. “Cori introduced a new vocabulary and new way of presenting information. The visualizations and patient-experience map felt very evidence-based and offered a practical perspective on improving a specific workflow.” Additionally, Schauer’s direct interaction with patients helped many of them work through issues, feel more hopeful, and realize the agency is on their side. Co-design solutions: Schauer held a series of participatory design workshops with primary care staff, giving them the tools to develop patient advisory councils and incorporate regular patient feedback into their workflow. At one of the hospitals, Schauer leveraged an existing patient council to hold ideation workshops. But instead of following the council’s typical format, which was to raise patient complaints, she encouraged patients to identify opportunities for improving their stay. Many of the suggestions, such as recognizing significant holidays (Dia de los Muertos, for example) and allowing patients to adjust the water temperature in their rooms, required only minor adjustments on the part of the staff. But they provided outsized impact on the patient experience, contributing to their sense of dignity and happiness. Schauer also provided guidance on standard practices for soliciting feedback, such as required consent forms, compensation, or other incentives for patient participation.
This process map for improving the patient experience illustrates where smoother transitions between different services within the healthcare network were needed.
 
THE PAYOFF
  • The voice of patients in decisions about their care.
  • A greater focus on customer-centered service.
  • A shift in the organization’s mindset, which led to innovative yet practical new approaches to challenges, like user research and design thinking.
  • Two new grant-funded positions to help the city’s most vulnerable populations navigate the healthcare system.
  • An openness to engaging in new ideas throughout SFHN, with an understanding that failure simply means learning to improve and trying a different approach.
  • Increased collaboration across the SFHN network.
Understand department differences: To fix a problem, it needs to be understood. So Schauer shared her findings with the various care-experience teams about the ways in which cultural differences, both real and perceived, could affect collaboration. The findings were well-received. “A less tangible but important aspect of this project was having Cori work across the Network to bridge some of the historical silos we have,” said Dr. Alice Chen, SFHN chief medical officer. “The cross-sharing and adoption of a common framework was a positive cultural shift.” Make it real: Many of Schauer’s higher-level recommendations were handed over to CEAC, the group tasked with developing a network-wide framework for care experience. Meeting times were formalized, and Schauer was able to facilitate a strategy session whereby CEAC members identified and prioritized their goals and objectives for the coming year, which included standardizing the grievance process across the network.

Impact and Insights

An intangible yet impactful aspect of Schauer’s fellowship was a shift in SFHN mindset. By introducing SFHN to human-centered design strategies and practices, Schauer demonstrated the value of user research and design thinking, which led SFHN to create two internal service design positions funded by a state Whole Person Care grant. The purpose of these positions is to help the city’s most vulnerable populations navigate the healthcare system. “Cori encouraged us to try something new without the fear of, ‘This might not work.’ Coming from the private sector, she brought the mentality of, ‘Try it, and, if it fails, try something else.’ The healthcare environment is very conservative, but short of something that’s going to result in regulatory incompliance or death, Cori showed us that it’s okay to try a new idea,” said Quoc Nguyen, assistant hospital administrator, Laguna Honda Hospital and Rehabilitation Center. The patient experience can go a long way in improving overall health outcomes. By designing a framework to change SFHN’s approach to patient service, Schauer helped move the organization toward the highest levels of patient-centered care. As a result, SFHN is now more collaborative and well positioned to continue with its mission of helping all San Franciscans live vibrant, healthy lives.   [Photo credit: Matheus Ferrero]