Aim
In 2021, the Emergency Department at Zuckerberg San Francisco General Hospital and Trauma Center wanted a tool to measure its longstanding goal to make sure it treated its patients fairly regardless of race, age, gender, sexual preference or other factors. The department also wanted to track its progress as it implemented measures to bring increased equity to its operations.
Partners
Christopher “Toff” Peabody, MD, an emergency room physician with a background in consulting, leads ZSFG’s quality improvement work. He had helped start an Acute Care Innovation Center to bring technology into the Emergency Department, and worked with SOM Tech on two other projects because of the organization’s ability to build things on-site and without the red tape involved if they used an outside consultant.
One project was the “E Drive,” a bedside tool that doctors use to access clinical guidelines while they're on shift. “We started with COVID because COVID was changing so much we needed to have a fast way for people to get up-to-date information,” Peabody says. The information had been available in email, but no doctor wants to check their email while they’re working in an ER. “Now you can get the testing and isolation algorithm within three clicks.”
Instead of an algorithm that leads the user through a bunch of questions—which is not how physicians operate—SOM Tech designed an elegant display that gives the doctor the complete picture, color-coded and easy to read.
SOM Tech also helped develop a Performance Improvement Portal that tracks how the ED is doing in areas such as staffing, patient satisfaction, ambulance diversion, and how long patients must wait for EKGs. With a clear view of the data, ED employees can see what needs fixing.
“SOM Tech is very good at helping us define problems and then leading us through a thoughtful design process,” Peabody says.
Approach
For the Equity Dashboard, SOM Tech designer Jonathan Prugh, who specializes in user experience (known as UX), led weekly meetings with people from the ED to develop a vision statement.
“People come to us and they often think they have a problem and a solution,” Prugh says. “We say, ‘Back up. What is the problem?’”
That’s because often, just because someone is a brilliant doctor or scientist, they may not know all the tools that will help design a product for the people who need to implement it. “Let’s tease out what you’re trying to do and who you’re trying to reach,” Prugh says.
He calls that phase “design discovery.” “I do a lot of interviewing,” Prugh says, as well as building mockups, prototypes and wireframes of what the project might look like.”
Prugh first walks the team through a “pre-mortem,” imagining what it would look like if the project failed. That helps identify potential pitfalls. They then imagine what a successful project will look like, and try to build those features.
Using a white board and sticky notes, Prugh learned the ED’s goals, what data it had access to, and how it would use any project he developed. Peabody and two junior associates—a medical student and a resident—were particularly engaged with Prugh’s work. Working with them and other physicians, the dashboard took shape.
One goal was to see if ZSFG is serving the population its designed to serve: the most vulnerable people in San Francisco, those who typically do not have access to medical care.
In addition, huge goal of any emergency department is “flow,” Peabody says—how does a patient move through the department? How can the department reduce the time a patient must wait to see a doctor, or get a test, or get treated? How long does a patient stay in the department?
And most critically, for the equity component, do certain classes of patients get care more quickly than others? Are all patients treated the same?
Solution
Using data from the hospital’s computer system, EPIC, and the data visualization tool Tableau, Prugh and Peabody built a dashboard that automatically updates on a daily basis. “The whole point of this dashboard is to tell a patient story,” Peabody says—“to tell us about who comes to our Emergency Department. How long do they stay? How is their care? Are there any broader operational issues?”
The dashboard’s front page paints a picture of who comes to the ED: race, ethnicity, age, gender identity, sexual orientation, language, housing status, and whether there is any existing substance abuse problem or mental health condition. Users can then zoom in and see what parts of San Francisco the patients come from.
The results quickly verified that ZSFG is serving the targeted population, including large percentages of homeless people, people with substance abuse problems, and people from San Francisco’s most under-served neighborhoods.
The next step was to look for disparities. Peabody already knew from published studies that nonwhite patients tend to receive less pain medication. The dashboard confirmed it, with remarkable specificity.
“We're finding that we do have a disparity in the kind of pain medicine we give, especially when you look at our Cantonese-speaking population,” he said. “They seem to be outliers when it comes to getting pain medicine in a timely manner.”
“What we’re able to do is now identify that as a problem and start a performance improvement project to address it,” Peabody says.
The dashboard is open to anyone working in the department, so everyone can see just how well the department is doing. It has more data than just equity, but it puts the equity figures on the front page, to keep them at the top of everyone’s mind.
The medical literature is clear, Peabody says: “There are disparities within healthcare.” Sometimes it may be an unconscious bias that leads to different treatment of someone of a different race. Sometimes there’s a language barrier. Sometimes someone of a different gender or sexual orientation is viewed differently. “We want to make this as transparent as possible and close those gaps where we can,” Peabody says.
Before SOM Tech built the dashboard, Peabody says someone would have to wonder: Are we treating Cantonese people equitably? Then that person might pull six months of data, which may or may not show the disparity. If not, the project would get put on the back burner.
With the dashboard, the data is updated every day, and it’s presented in an easy-to-read graphical format that makes the conclusions impossible to ignore. So rather than seek out the problem, the team can focus on finding solutions.
“I think of SOM Tech as expert facilitators,” Peabody says. “They help guide the team into rigorously defining what they’re designing. And then they’ll execute that.”
Written by Dan Fost for SOM Tech (2022)