Problem Addressed

• Failure to gather, incorporate comprehensive patient feedback: Many institutions seek feedback from patients and families in only a limited way (such as through standardized satisfaction surveys), and most have no formal, sustained approaches to incorporate such feedback into hospital policies and programs.¹
• Failure to capture patient "voice": The power of the patient voice is sometimes lost when reduced to quotations in typical written reports. Ethnography—a method of qualitative data-gathering developed by social scientists based on interviews and observations—can yield important information related to the patient experience and make the patient's voice more real and salient to improvement audiences.² Yet very few organizations employ this technique.

Description of the Innovative Activity

• Multidisciplinary, topic-specific interview teams: Multidisciplinary groups of Kaiser Permanente employees (including physicians, nurses, pharmacists, quality improvement experts, social scientists, and/or other staff) plan and conduct a video ethnography project based on the requirements and characteristics of a particular high-priority topic. With input from quality improvement staff and other relevant personnel, the group defines the area for improvement, outlines a project time frame, develops a budget, designs an interview and observation guide, outlines criteria and a process for selecting interviewees and processes to observe, and identifies a project team. Typical teams consist of 2 to 4 core team members who conduct interviews, observations, and analysis, while a larger team is involved in analyzing video-recorded data to translate learnings into improvements.
• Patient consent: Members of the project team discuss the purpose of the project with the patient/family and ask if they would be willing to participate. If so, the team has the patient and/or family sign a form that authorizes the collection and sharing of protected health information as part of the project. The form also serves as written consent to be videorecorded.
• Videorecorded interviews and observations: For each topic area, the designated project team conducts and videorecords interviews and/or observations of care delivery with patients and family members, as well as relevant staff members. These interviews and observations are purposefully designed to occur within a short time frame, typically within 2 to 3 days, to meet the operational realities of rapid-cycle change in health care. One team member leads the interviews while a second videorecords the discussions using a small digital hand-held camera. A third team member may be included to take notes or provide additional observations. Interview duration varies, with bedside or clinic interviews typically taking 15 to 30 minutes and at-home interviews taking 1 to 2 hours. Interviewers pose questions outlined in the interview guide, which tend to be open-ended questions designed to elicit detailed, nuanced responses. Teams use different strategies to draw people out and/or help them convey their story. For example, members may ask patients to draw a simple sketch of their support network or outline a timeline of their illness and recovery. A patient interviewed at home may be asked to give the team a tour of the house or show the team where medications are kept. Examples of questions used as part of the care transitions interview guide include the following (with each question being followed by prompts to elicit further details):
  • “What are you doing now as follow up to your hospitalization?”
  • “Tell us about any conversations you may have had in the hospital with doctors or nurses regarding your health condition. How did those conversations go? What topics were covered?"
  • “Tell us about conversations you’ve had with friends since you got home from the hospital. What do you say to them? How do you describe your experience to them?”
  • “Can you tell us about any times you may have felt you didn’t know what to do regarding your health care since you left the hospital?"
  • "Is there anything your providers might have done better for you?”
• Interview analysis: The project team, quality improvement staff, social scientists, and other relevant staff watch the videos. Using a simple Excel spreadsheet, they organize patient, family, and staff member comments to identify recurrent themes and patterns (e.g., related to communication, information, medications, food, providers) that can inform quality improvement initiatives. For example, during the care transitions project, patients repeatedly noted that they could not focus on or absorb all the discharge-related information provided in the hospital because they already had “one foot out the door.” During a second care transitions project geared toward heart failure patients, the team detected a consistent pattern of patients being confused about medication use.
• Summary video production and viewing: Once the team identifies the recurring themes and patterns, they produce a short (5- to 10-minute) summary video. The team may also produce written reports, patient touchpoint maps, and/or PowerPoint slides summarizing key findings with patient stories. The team shares the video and other relevant materials with hospital/health system leaders, employees, and teams involved in the quality improvement initiative.
• Quality improvement projects: Those who view the summary videos use them to better understand patient and family needs, build the will to change, and spur the creation of patient-focused quality improvement projects. For example, after learning about the difficulties that many patients face in absorbing information provided at discharge, the care transitions improvement team developed a “My Concerns” checklist to help patients articulate their needs and ask questions of clinicians. The team also implemented a process change in which nurses repeat information provided at discharge during a followup telephone call or home visit to high-risk patients. The heart failure care transitions team revamped the medication reconciliation process in response to patients' consistent confusion about their medications. (See the Story section for more details).

References/Related Articles

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Results

• Positive feedback from clinicians and improvement specialists: Anecdotal feedback from Kaiser Permanente clinicians and improvement specialists suggests the approach has strengthened the collective will to change across the organization by effectively conveying the voice of the patient in a powerful, meaningful way that has generated enthusiasm for quality improvement (as outlined below).
• Contribution to many quality improvement projects: As of August 2012, the video ethnography approach had spurred the development of more than 40 quality improvement projects that have led to tangible improvements in care processes and outcomes, including better coordination of care, fewer unnecessary readmissions, and better patient experiences. For example, a heart failure improvement project reduced the readmission rate from 13.7 percent to 9 percent within 6 months (see the Story section for more details).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtain Kaiser Permanente toolkit: Kaiser Permanente has developed a detailed toolkit, available free of charge, to guide potential adopters through the project planning and development process. (See Tools and Other Resources section for information on how to obtain this toolkit.)
• Form appropriate team(s): Teams should include a multidisciplinary group of providers and quality improvement specialists, along with appropriate representatives from the targeted area of improvement such as hospital, clinic or facility administration, risk management, patient safety, and/or quality. The team may also benefit from social scientists (if available) or health services researchers with experience in qualitative data collection and analysis.
• Obtain training and/or assistance: Kaiser Permanente offers a training program for its employees that has been attended by clinicians and staff involved in quality improvement. The training includes a full day of didactic teaching on the use and application of rapid video ethnography techniques including interviewing, observation, analysis, video creation, and quality improvement. This initial training is supplemented by two webinars, 1 day of hands-on coaching in the field, and in-studio coaching on assembling representative video clips to deliver actionable messages. (Some potential adopters may have social scientists—such as medical anthropologists or sociologists—on staff who can provide training internally using the aforementioned toolkit.) Organizations can also contract with consulting firms that offer video ethnography. (The toolkit includes a list of such consultants.)
• Develop informed consent process and document: Developers need to evaluate the ethical questions that may arise and then develop policies (such as an informed consent policy) to ensure the protection of those who participate. Some organizations use or adapt existing consent forms for focus groups.
• Determine priority improvement areas: The multidisciplinary team needs to identify priority areas for improvement (e.g., readmissions, care transitions) that can benefit from the gathering of qualitative data directly from patients and from observation of care processes.

Resources Used and Skills Needed

• Staffing: At Kaiser Permanente, existing staff in the evaluation and analytics department trained in qualitative methods first developed and applied this method in collaboration with quality improvement personnel. As interest in the method grew, it required the addition of one staff person who helped organize and lead the training program. Staff from other organizational departments are also incorporated as needed. For example, in-house multimedia staff assist with video editing. Other adopters should consider contracting with user design specialists, social scientists, and/or video editors if personnel with those skills are not already on staff.
• Costs: Initial costs associated with applying video ethnography techniques include purchasing consumer-grade, low-cost video equipment such as a small hand-held video camera ($300 to $1,000). Additional costs include time spent training staff and preparing for and conducting video ethnography data collection and analysis activities. Kaiser Permanente uses in-house video editors, with the estimated cost of video editing assistance being between $1,000 and $2,000 per project depending upon the nature of video deliverables. If video editors are not available, potential adopters may have to purchase editing software and allocate staff time for video editing.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Seek buy-in by emphasizing importance of patient voice: Most health care organizations are striving to become more patient-centered. Leaders will typically support the video ethnography approach once they understand its ability to capture the patient voice and hence promote patient-centered care.
• Embed within existing processes: Leaders and staff will be more likely to support video ethnography if it is embedded within the existing quality improvement frameworks and/or processes, such as at the start of an improvement project to capture the "voice of the customer." The power of video ethnography arises when it is used as part of an integrated approach to quality improvement; it should be aligned with other tools, such as the Model for Improvement promoted by the Institute for Healthcare Improvement.
• Avoid intimidating feel (and cost) of big video production: Use small, commercially-available handheld cameras rather than extensive video production equipment. This strategy helps ensure that videotaping does not become intimidating to patients, keeps costs manageable, and eliminates the need for trained videographers.
• Identify researchers who can help: Organizations may find it beneficial to employ or consult with user design specialists, design researchers, social scientists, and/or health service researchers who are familiar with conducting qualitative research using focus groups and individual interviews. These individuals can easily embrace video ethnography.
• Consider external consultants for first project: External video production consultants may be needed to assist in creating the video for the first project.
• Leverage existing materials: The Kaiser Permanente toolkit can help potential adopters get started with minimal development costs.
• Start small: Begin with a small project that will be easy to design and implement, and then move on to larger projects over time. For example, interviewing one patient and creating a "video story" from one interview can be a great way to get started.

Sustaining This Innovation

• Build on initial success: The first successful project will likely open the door to subsequent projects by building clinician and administrative support for ongoing use of video ethnography in quality improvement efforts.
• Spread skills across staff: Teaching video ethnography methods to multiple clinicians, improvement specialists, and health care team staff involved in quality improvement can help to spread the approach broadly throughout the organization.

Additional Considerations and Lessons