Why It Matters
In addition to helping make care more patient-centered, patient shadowing is now also being used to reduce waste and cut costs.
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Patient Shadowing: How to Reduce Costs While Improving the Patient Experience and Outcomes

By Tony Digioia | Wednesday, November 11, 2015

Shadowing – observing patients and families as they move through each step in their health care journey – is a well-established method for learning how to make care more person- and family-centered. In this post, Anthony DiGioia, MD, Medical Director of the Bone and Joint Center and The Innovation Center at Magee-Womens Hospital of UPMC, describes how shadowing is also used to increase value by reducing waste and cutting costs while simultaneously improving outcomes and the patient experience. 


Achieving value in today’s shifting health care environment requires improving outcomes and patient experiences while lowering costs. This shift from volume to value accelerates the need to accurately determine clinical pathways and engage patients and families in co-designing ideal care delivery.

Focusing on value also requires us to accurately determine the actual cost of care (as opposed to charges or reimbursement fees) for a specific clinical condition over the full cycle of care. What are the drivers of cost? How can we address them without compromising outcomes or patient experiences? Ultimately, we need to answer these questions and drive improvements in all three components of value — experiences, outcomes, and costs — by doing the following:

  1. Use tools that help the care team understand the current state of care delivery processes from the viewpoint of patients and families.
  2. Based on a more informed understanding of how patients and families experience current care processes, identify opportunities for improvement.
  3. Create a sense of urgency among the care team to drive and sustain change.
  4. Form high-performance care teams that break down the silos between care providers that are ubiquitous in health care.
  5. Build partnerships between patients, families, and the care team to inform ongoing improvements and support true co-design of care.   

Shadowing is a unique tool that helps care teams assess their current processes and develop improvements that are meaningful to patients and families. Developed in 2006 as a key component of UPMC’s six-step Patient- and Family-Centered Care (PFCC) Methodology and Practice, shadowing is a simple, easy-to-learn technique that helps care teams make direct observations of patients and families as they move through each step in their health care journey. Viewing care through the eyes of patients and families enables care teams to map the current state of care processes, pinpoint opportunities for change, and build collaborative care teams while creating the resolve to motivate lasting improvement. Real-time direct observation is the most efficient way to collect information on all of the resources (personnel, consumables, equipment, and space) used to deliver care for a specific clinical condition and, consequently, to determine the actual cost of care. 

Shadowing allows teams to gather both quantitative data (e.g., tracking interactions with patients or amount of resources used, using flowcharts, or time studies) and qualitative or experiential data (e.g., redundant steps in a process, processes that inconvenience and frustrate patients and families). Shadowing provides the opportunity to co-design processes that lead to higher patient activation and engagement to transform care delivery:

The following examples illustrate how several high-impact projects implemented shadowing to improve care processes.

  • Shadowing at the Mon-Yough Behavioral Health Clinic (in McKeesport, Pennsylvania, USA) revealed that patients needed three appointments before receiving a plan of care because of the intake steps implemented by separate functional silos (social work, psychology, nursing, etc.). Streamlining the intake process and providing a treatment plan on the first visit reduced the cost of intake by 43 percent. At the same time, patients’ experience of care improved and earlier treatment plans led to improved clinical outcomes.
  • Using shadowing at Alder Hey Children’s Hospital in Liverpool, England, identified the need to create a streamlined pathway for patients presenting in the emergency department with abdominal pain. Specific interventions developed included a multi-professional abdominal pain pathway and creation of a “surgical decision unit.” On average, the surgical team now sees patients in less than two hours, with a reduction in average length of stay for acute surgical patients to less than two days. The number of patients who reported that their pain was managed well increased from 48 percent to 100 percent. Additionally, 95 percent of families said their overall waiting time was as expected or less (compared to 45 percent at baseline), and 86 percent of families reported feeling well-informed (compared to 28 percent previously).
  • Shadowing total joint replacement patients at Magee-Womens Hospital of UPMC during their pre-operative testing visits revealed that all patients obtained a chest x-ray. When the organization determined that chest x-rays were not necessary for all patients, they developed a new protocol. Consequently, there was a 70 percent reduction of chest x-rays which resulted in approximately $7,500 in yearly savings for one surgeon, a significant savings when implemented for multiple surgeons. In addition to cost savings, this change improved the patient experience by lessening testing time and unnecessary radiation exposure.

Shadowing the patient and family through their care is a powerful (and often eye-opening) way to identify opportunities to enhance care experiences and improve clinical and operational outcomes while reducing waste and costs. Shadowing creates opportunities for co-design partnerships with patients and families and harvests the power of staff engagement in care redesign. Using shadowing can help care teams provide patients with exactly what they want and need — no more and no less.

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