Design For Patients and Families LogoDesign for Patients and Families

We will care for people in  a compassionate and personalized way, wherever they are, whenever they need us. 


Statement of Importance:

List of patient desiresHistorically, the processes of health care have been designed around the health care enterprise. When the processes of health care are designed around the needs of patients and their lifestyles, engagement and outcomes improve. We will iteratively redesign health care to touch our patients and their families continuously, whenever or wherever they need us, to address their needs within the flow of their daily lives. Furthermore, defining personalized care offers us a clear competitive advantage—it builds a reservoir of positive memories that can generate loyalty over time.

  • Our collaborative culture to be inclusive and to express empathy and compassion in all interactions
    • Incorporating empathy mapping into Medical Center lean events.
    • Training the Medical Center community in unconscious bias (UCB) and added UCB-sensitive metrics to patient satisfaction surveys.
    • Developing Medical Center-wide climate policies and processes on uncivil behavior and how to respond.  Rolled out the program for addressing sexual harassment and developed the Patients’ Rights and Responsibilities.  Developing a plan for medical center wide bystander training.
  • Coordination of clinical teams and systems to close gaps in care and set a higher bar for safety, reliability, and effectiveness
    • Developing and scaling a system-wide approach to closing gaps in care with the right intervention by the right team member during the right patient interaction.   Examples include population health’s Bridge initiative and the CMS funded Mid-South Practice Transformation Network (PTN).
    • Continually reducing patient care clinical variation through standard care pathways.  Examples from FY20 include Enhanced Recovery After Surgery for colorectal, urology, OB and GYN.
    • Developing and expanding the Hi-Rise Clinic to optimize the preoperative clinical status of high-risk surgical patients.
    • Developing a process to leverage pragmatic effectiveness trials to design, test, and deploy interventions in real-world operational settings with feedback and update loops. 
    • Developing processes to identify the patient’s health team members, their role in the team and relationship to one another, and their status (on/off).  Piloting by medicine primary care in eStar during FY20.
    • Developing processes to create shared care plans collaboratively by clinical teams with the patient. Plans may include the patient’s goals, needs and preferences, and track past challenges and future goals for treatment and well-being.  Piloting with Vanderbilt Familiar Faces, care coordination plans created by case management and social work, and transitional care plans (inpatient to post-acute) in FY20.
    • Developing processes to embed predictive analytics and artificial intelligence into Medical Center workflows to improve safety, efficiency, and alter the course of disease or preserve health.  Implemented HeartFlow in coronary CT to identify patients requiring diagnostic angiography or CABG in FY20.
    • Developing a patient-centered scheduling model that aligns the patient with the right provider at the right location, the first time.  Developed decision trees for 21 areas in FY20.
    • Operationalizing a care control center spanning inpatient services to provide a clear chain of command, aggregate and visualize data, and converge clinical and administrative monitoring.  Initial priorities include patient throughput, capacity management, transfer center, and transport.
  • Patient Care Centers (PCCs) to coordinate multidisciplinary care for conditions managed by the Medical Center
    • Refining the PCC structure, decision rights, and management processes.
    • Aligning goals and expectations related to pillar performance for each PCC
    • Establishing a Primary Care PCC to oversee care management and culture change for team-based adult primary care.
    • Developing a Medical Center standard for integrated practice units, patient-centered structures to care for a cluster of conditions that require a multi-specialty team to improve outcomes and reduce cost. Examples include Medicine PCC - Eskind Diabetes Center; Women’s Health PCC - Fetal Center, Maternal Cardiac Clinic, Coagulopathy Clinic, Polycystic Ovary Syndrome, DNA Diagnostic Center.
  • Opportunities for community stakeholders and patients to participate in research and learn how to improve their health and engage as partners in their care
    • Developing the Person-centeredness of Research Scale to assess the degree to which research reflects the needs, values, and priorities of patients, families, and communities.
    • Developing the Community Engagement Studio Toolkit.
    • Launching the NIH’s All of Us Research Program Engagement Core to include participants as partners in the oversight, governance design and implementation to ensure it is inclusive, relevant and culturally sensitive to diverse communities and everyday people.
  • Prevision MedicinePersonalized medicine to integrate social, behavioral and environmental factors with the full range of molecular characteristics
    • Framing the concepts of The Vanderbilt Inventory, a repository of all data sets needed to support whole-person precision medicine, and visual risk displays to help clinicians and patients assess options.
    • Convening the Precision Medicine Strategy Session to identify the path toward a vision where all clinicians at the Medical Center can counsel and, as needed, refer their patients regarding germ-line risk and drug selection.
    • Developing a coordinated clinical genomics consultation and testing pipeline and data management strategy encompassing Predict (pharmacogenomics), Whole Exome Sequencing (WES for rare diseases and germline panels), Cancer Genomics (somatic & germline), and Genetics Consult Service.  Added six new Predict drug-genome interactions, implemented WES in house, implemented Tempus next generation sequencing-based cancer genome profiling and piloting one-stop genetic consults in FY20.
  • Population health by engaging in cross-sector community partnerships to improve community health and well-being
    • Convening the Community Health Worker Collaborative, a group of organizations focused on advancing the Community Health Worker (CHW) profession in Tennessee facilitated by the Meharry-Vanderbilt Alliance (MVA).
    • Engaging with health departments and other non-profit hospitals, federally qualified health centers, and community organizations for collaborative Community Health Needs Assessment.
    • Coordinating with the State of Tennessee to create QuizTime educational modules on opioid management for all physicians in the state.
    • Engaging with State and Metro to coordinate COVID-19 assessment centers, testing, preparation to convert Music City Center into inpatient beds, and reopening phases.

  • Self-service tools for health improvement, access to care, and engagement in care
    • Integrating MH@V into the Vanderbilt Health experience.  Making the portal the primary way our clinicians and staff communicate with patients between face-face visits and the first-place patients turn for their health needs.  Enrollments jumped from 9,000 per month to 25,000 per month with COVID-19.  
    • Implementing online scheduling for return appointments and appropriate new patient visits. Scheduled 95% of return visits and 5% of new patient visits on-line in FY20.
    • Launching Vanderbilt Health On Call, a Medical Center innovation that uses a smartphone app allowing patients in Davidson County and the cities of Brentwood, Franklin, Hendersonville, or Nolensville to order a $149 home visit from a Vanderbilt nurse practitioner.
    • Integrating mobile apps and web tools with MH@V to help people manage their health goals and care plans in collaboration with their health team (e.g., Carium); connect with a clinician in the app to evaluate symptoms & receive prescriptions; connect to nurse-on-call; or direct schedule to a walk-in or a care team (e.g., AmazonCare).
  • Accessible regionally integrated patient-centered health care systems to bring Vanderbilt to people where they are
    • Providing access to care and consultation remotely through technology unless a face-to-face (F-F) visit is required (more).  Standardize telehealth templates, elements of a telehealth visit that surround the clinician interaction, payment policy and pre-visit clearance (clinical and financial).   Jumped from <10 ambulatory televisits per day to >2,500 during COVID-19.
    • Optimizing the mix of ambulatory capacity (21st Ave & OHO, big box, small box, walk-in/retail, telehealth) to increase convenience and tune acuity to cost structure.  Currently operating and providing clinical services at 14 retail Vanderbilt Health clinics within Walgreens stores located across Middle Tennessee (more), and managing over 120 walk-in and urgent care centers in central Tennessee.
    • Develop the appropriate mix of inpatient facilities (quaternary, acute community, post-acute, home) to tune acuity to cost structure and increase convenience and market share.  Acquired Vanderbilt Wilson County Hospital in 2019.
    • Expanding the Vanderbilt Health Affiliate Network (VHAN) to more than 6100 clinicians and 60+ hospitals in 5 states, caring for over 300,000 people through partnerships with insurers.   
  • Team Based CareModels of team-based care with the right set of professionals collaborating with the patient at the center
    • Developing a model of team-based, coordinated adult primary care including collaborative behavioral health.  Flex role mix (MDs, APPs, RNs, LPNs, Mas, LCSW) and panel size to match population risk, regional density.
    • Gaining agreement to develop infrastructure to provide continuum of Population Health ó Primary Care ó Specialty Care, leveraging precision medicine and predictive services for automated risk assessment of early intervention.
    • Behavioral HealthEngaging in strategic planning for behavioral health (more).  Gained agreement to embed behavioral health in 1° care and to build institutional competency for accurate identification, safe care and efficient disposition of high-risk patients with mental illness and matching integrated care support to patient need across all care centers.
  • Clinical integration across VHAN, including quality improvement, information technology connectivity and contracting
    • Facilitating clinical integration across the VHAN and providing service to support other networks.
    • Developing four Medicare Accountable Care Organizations (ACOs).  The Vanderbilt Medical Group is a participant in the Middle Tennessee ACO.
    • Gaining agreement of the VHAN Board on the aspirational goal of VHAN becoming the region’s preferred value-based clinically integrated network delivering innovative solutions, learning opportunities, and strategic advantages to our partners, who are patients, providers, employers, and payors. 
  • Systems to measure and respond to social, behavioral and environmental factors; individual values and goals; and outcomes that matter to patients and families
    • End of Life CareBroadening the initiative to ensure dignified, personalized end-of-life care includes improving communication about goals of care, including goals for end of life.
    • Incorporating Patient Reported Outcome Measures (PROMs) into the Medical Center systems of measurement to include patients’ perspectives of their health, enhance real-time shared decision-making, and improve the quality, outcomes, and value of care. Medicine PCC piloted adult inflammatory bowel disease, Surgery PCC piloted advanced prostate cancer, and Children’s PCC piloted asthma. Each PCC will implement PROMs as part of the measurement system for at least one condition by December 2021.
    • Incorporating health equity into the quality improvement strategies of the clinical enterprise by addressing systematic, avoidable and unjust distribution of social, economic, and environmental conditions needed for health. 
  • Care systems engineered to provide a consistent high-value experience based upon understanding patient and family
    • Working with the U.S. Centers for Medicare and Medicaid Services to implement an Oncology Care Model that incorporates extended hours to care for patients, patient navigators to help guide patients through the health system, palliative care, psychosocial support, and hospice counseling.
    • Designing and standardizing the ambulatory visit, so each visit flows smoothly from access through the clinic visit, delivering the right personalized experience for the patient’s preferences reliably and efficiently.
    • Capturing administrative and patient-reported data digitally in the right workflow, from the right person, at the right time, and make them accessible with the right context in eStar and My Health at Vanderbilt (MHAV).  Piloted in Women’s Health at One Hundred Oaks in FY20.
    • Designing and delivering value-driven, comprehensive & specialty-based health care experiences directly to employers.  Maternity bundle launched for Nashville Public Schools and VUMC health plan in FY20.
  • Ways to engage all stakeholders to improve patient and family experience
    • Engaging the Patient and Family Advisory Councils in the early stages of planning.
    • Launching “Defining Personalized Care-Elevating Our Culture of Service” to provide the coaching, knowledge and skills we need across the Medical Center workforce to deliver exceptional service with every interaction. A new learning segment is rolling out each quarter.
    • Incorporating medical students in the healthcare team to optimize telehealth for patients during the COVID epidemic
    • Incorporating Patient and Family Advisory Council members into the Undergraduate Medical Education Committee