The program, spearheaded by researchers at Kaiser Permanente's Care Management Institute, uses short videos to convey the patient experience, spark new ideas and propel improvement initiatives. Since the program's inception, the Care Management Institute has completed approximately 40 projects on such topics as medication management, care transitions, obesity and healthcare disparities.
Videos are roughly five to 10 minutes long, although they can be shorter, and they show patients and clinicians in the hospital, and patients in their homes, says Estee Neuwirth, a sociologist and the Care Management Institute's director of field studies. They're used by quality-improvement staff to motivate leaders and clinicians.
“These videos build a will for change,” Neuwirth says. “They allow people to see and understand patients with a new set of eyes. We bring the videos into leadership meetings, we show them to managers and team members, and we use them for training.”
The video projects are carefully planned and conducted by multidisciplinary teams of social scientists, physicians, nurses and pharmacists.
“We develop the study design collaboratively, we go out into the field together and we analyze the data together,” Neuwirth explains. “That makes it much more impactful.”
The footage is raw, shot by nonexperts using small hand-held cameras. And that's no accident, Neuwirth says. Video ethnography for quality improvement is supposed to give viewers a realistic, stripped-down view of a patient's treatment, condition, habits and lifestyle. It's not a tool for marketing, she adds.
“There is no script or staged environment,” according to the 56-page toolkit. “There is no predetermined message about improvement opportunities. The settings are real life, and ethnography teams spend time with patients and staff, seeing ‘through their eyes' as fully as possible.”
When the project teams shoot video in patients' homes, for instance, they employ a variety of strategies to draw people out and help them to convey their story. They often ask people to give them a tour of their house or show them where their medications are kept. Sometimes they ask people to sketch out their support network or make a timeline showing the points of their recovery.
One of the Care Management Institute's first video ethnography projects was in Kaiser's Southern California region, focusing on transitions of care for heart failure patients. The project shed light on a number of ways to better manage care and improve the discharge process, and it's now being used to train all new staff who interact with heart failure patients, Neuwirth says.
The institute's largest video project to date targeted preventable hospital readmissions and included a sample of more than 40 in-depth interviews with patients and family members, as well as 30 clinicians, in several regions of the country.
One such interview was conducted at Kaiser Permanente Fremont (Calif.) Medical Center, says Dr. Jyotsna Bomdica, assistant chief of hospital-based specialists.
Bomdica had seen the power of first-person patient experiences a few years earlier when she invited the family of a patient to come and speak to hospital staff. The patient had died during her stay and her family was unhappy with the care she had received. The subsequent in-person meeting with clinicians and the family was powerful, Bomdica says, but setting it up was difficult and time-consuming.
Then about a year and a half ago, when the Care Management Institute's team arrived as part of the readmissions project, Bomdica says she realized video could have that same resonance, but it could be done much more easily and could also reach a much larger audience within the organization.
This time, the project team interviewed a patient who had been readmitted to Fremont for inadequate pain management. Shortly after discharge, the patient had experienced severe pain but he and his wife were unable to reach by phone any of the hospital physicians who had treated him. The two returned to the hospital and the patient was readmitted.
“As a physician leader, when I take this message to my group and tell them we have a readmission from inadequate pain control, that's not nearly as powerful as watching a patient and his spouse eloquently tell their story,” Bomdica says. “Those physicians could clearly see what had gone wrong from the patient's perspective.”
Bomdica emphasized that videos should ideally show successful transitions of care as well as problematic ones that lead to readmissions. Physicians are far more likely to listen when presentations are balanced, she says.
Kaiser's rollout of the video program has not gone unnoticed by other healthcare organizations. VHA, a healthcare alliance and purchasing organization based in Irving, Texas, has been doing its own form of ethnography for the past several years, and after attending a recent presentation by Dr. Scott Young, co-executive director of the Care Management Institute, VHA officials wanted to learn more.
VHA applies ethnography for several purposes, including identifying lead performers and showing opportunities for improvement at member facilities within their organization. For instance, they recently produced a video showing routine interruptions that occurred during patient-clinician interactions, says Dr. Trent Haywood, VHA's senior vice president and chief medical officer.
“There's a visceral, immediate reaction with this approach that you don't see when you say, ‘We scored 85% on this measure,' ” Haywood says.
Kaiser Permanente's approach interested VHA because it employs social science principles rather than industrial improvement practices such as Lean and Six Sigma, Haywood says.
“The fundamental issue in healthcare is not the creation of a product, it's the social interaction between one group that is trying to help another,” Haywood says. “If we want to move to a more patient-centered, value-based system, we have to start developing skills that take that interaction into consideration.”
Haywood says VHA plans to work with Kaiser Permanente's model to help its members curb readmissions.
Officials at 909-bed Cedars-Sinai Medical Center in Los Angeles also reached out to Neuwirth for more information about the video ethnography program.
After reviewing the toolkit, Cedars-Sinai decided not to implement all aspects of the program because of resource constraints, says Fabricio Bermeo, the hospital's performance- improvement facilitator. But the hospital has taken some lessons from Kaiser, including interviewing patients to get their perspectives after readmission to the hospital.
According to Neuwirth, researchers at the Care Management Institute were nervous at the program's outset that patients and families would be less than willing to be observed and recorded during vulnerable moments. Instead, she says, the majority have been excited to share their stories, especially when they are told the videos are created to drive quality improvement.
“Qualitative data is powerful,” Neuwirth says. “In healthcare in particular, everyone is very focused on metrics and numbers, but there's a great quote from Einstein that says not everything that counts can be counted. We are sharing a new type of data that complements the other work we are doing and it really helps us understand the patient experience.”