Written by: Center for Care Innovations

The Affordable Care Act gave health insurance to millions who previously had to depend on safety net organizations for care, and in doing so ushered in a new era of priorities for community health centers. In order to compete with private providers, FQHCs need to continually improve the patient experiences they offer. Through the Co-Design for Better Care program, CCI sought to push clinics to directly engage with the patients in making these changes.

The Co-Designing for Better Care Program

Experience-based co-design builds upon the principles of human-centered design to offer a systematic approach to incorporating the patient perspective and voice in improving care delivery. This strategy is rooted in understanding exactly what patients and families experience while receiving care, identifying key ‘touch points,’ and incorporating patients and family members directly in the improvement design process. In partnership with Blue Shield of California Foundation and the Patient & Family Centered Care Innovation Center (PFCC) at the University of Pittsburgh Medical Center (UPMC), the Co-Design for Better Care program offered four California clinics the opportunity to try this human centered design technique. PFCC guided selected health centers through a 10-month program of implementing this methodology, with a goal of engaging patients and families with cross-functional teams of care givers from all levels of the organization to co-design ideal care delivery.

What Is Shadowing?

After the Co-Design program was complete, program evaluators John Snow, Inc. (JSI) dug deeper with a comprehensive analysis of one part of the PFCC methodology that stood out as particularly useful and impactful for clinics: shadowing. Shadowing involves “direct, real-time observation of patients and their families as they move through a care experience in any healthcare setting.”

When performing shadowing, a clinic worker would ask a patient or family entering the clinic for permission to stay with them throughout their entire visit. This meant sitting next to them in the waiting room, following them to the exam room and waiting with them there, watching how providers and patients interact, and then following patients as they check out. Along the way, shadowers can hear from patients about their concerns and their frustrations with the care process and observe both subtle and emotional reactions.

More than objective observation, JSI found that shadowing is a “pathway to empathy, to true identification, and to authentic communication with patients and families.”

A Good Solution for All

Grantees reported that shadowing was accepted by staff. JSI found that “the patient-centered objectives of shadowing helped to reduce provider anxiety at being? monitored by supervisors, while making patients feel valued and part of a collaborative effort to improve healthcare.” The team-oriented way shadowing was presented also helped staff overcome anxiety about soliciting patient feedback. Another advantage of shadowing is that it takes only a short training for staff to successfully begin shadowing, and did not require the advance setup of focus groups or advisory councils.

Most patients, for their part, were willing to be shadowed. Some patients found the shadowing more engaging than traditional ways of getting feedback, such as surveys. After having the shadower sit with them for a while and see what they were going through first hand, patients were more likely to feel comfortable opening up about their feelings and their experiences. The act of shadowing even improved some specific care experiences, as shadowers were able to spot errors, cut through confusion, or share important information that the patient told them but failed to mention to their actual provider.

Unique Insights

According to grantees, shadowing provided a comprehensive understanding of the entire patient visit, allowed identification of areas for improvement, and revealed new insights about clinic practices. Shadowing reveals the gap between staff perceptions of patient experiences and the actual patient reality, or between care delivery as designed and care as actually implemented. It’s simply different to see the whole process unfold from the patient’s point of view.

The lessons from shadowing were often unique; grantees felt the insights they gleaned were unanticipated and would not have come to them without shadowing. Using shadowing to ground conversations early in the care improvement process provided a basis around which to facilitate discussions and encourage participation from staff members who might not otherwise speak up.


Staff time was the main limiting factor grantees faced in using shadowing. Following a patient around can be a time-consuming process in a busy, short-staffed clinic. Hiring new staff exclusively to shadow is inefficient, and prevents the staff providing the care from gaining the deep understanding that comes with experiencing their patients’ journeys first hand. Some grantees, however, did use volunteers or interns to do some amount of shadowing.

Sustaining the Practice

Half the program grantees planned to continue to use shadowing in the future. Some said shadowing had now become an integral part of their improvement process, even though it would be more difficult to use the technique outside of the directives of the program. One clinic is even expanding the practice to do staff-to-staff shadowing to help those participating in improvement processes understand other employees’ jobs.



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