Advance Care Planning at UChicago Medicine
Using a human centered design approach to redesign UChicago Medicine’s Advance Care Planning process
2024
Service Design
The
Brief
This project was a collaboration between the Institute of Design’s Equitable Healthcare Action Lab, and UChicago Medicine (UCM), to try and improve the rate of completion of Healthcare Power of Attorneys (HPOAs). While UCM has made efforts in the past to improve the rate of completion of HPOA, most of these have been disparate, with the current rate of HPOA completion far below the national average. By taking a human centered design approach, we aimed to integrate these interventions into the patients’ journey, and be designed around what patients need at any point in time.
I started this project at the Institute of Design, where I worked with Brayan Pabon, Dennis Siegert, Shirin Navgire, Snehal Khavatkar and Yiwen Teng and I continued the work at my time in UChicago Medicine, working with Dr. Monica Malec and Teresa Van Oort.
Primary Research
81 People Surveyed
65 Intercept Interviews
40 “Think Alouds”
02 Patient Panel Interviews
02 Clinic Visits
Secondary Research
Literature Review
Review of Patient Materials from other Health Institutions
Review of Illinois State Materials
Review of Illinois State Laws
Review of UCM’s Existing Policies
Initial Survey
We started the project by conducting a survey to understand public perception of HPOAs and get a baseline for what people know and understand about the process.
Target Audience: Young students and professionals, aged 25 - 40.
Sampling Method: Snowball
Distribution Method: Online Survey, distributed via survey link and QR Code
No. of Respondents: 81
Through the survey , we were able to understand some of the barriers to completion:
Lack of Awareness
40% of our survey sample had never heard of an HPOA
Not Seen as a Priority
Even amongst those who know about HPOA’s, many (66%) don’t see it as a priority.
Unaware of the Process
54% of people that know about HPOAs, don’t know where to get one.
58% didn’t know the process of filing an HPOA.
The Patient’s Journey
Based on the findings from our survey, we divided the patient’s journey into 3 distinct phases. The ideal solution would be a system of interventions across all 3 stages of the patient journey. This requires multiple steps, including improving patient awareness around HPOAs, addressing barriers and concerns with the form, providing support materials to encourage patients to initiate a difficult conversation with their chosen health care decision maker, and streamlining the submission process to ensure that every form that is distributed gets filled and is input into the system.
For each phase, we collected questions and concerns that a patient may have, and designed interventions to address those concerns.
Discover
How a patient learns about Advance Directives/HPOAs, how they learn more about Healthcare Power of Attorney, and who/where they go to get questions answered.
Concerns
Touchpoint / Intervention
Distinctive + Inclusive Poster and Messaging Strategy
What is an HPOA?
Why is it important to sign one?
Do I need to sign an HPOA?
New Patient Education Brochure
It seems complicated.
Do I need to talk to a lawyer about this?
Updated Advance Care Planning Webpage
New dedicated HPOA Webpage
Where do I get one?
Who can I go to for more information?
Poster
Strategy
A range of posters styles and messages were developed and tested through intercept interviews. The final design is a contemporary, illustrated style poster featuring two people having a conversation. This was chosen as both patients and doctors felt that it was visually distinctive, especially compared to UCM’s existing posters and visuals, and it appealed to a younger audience. The visuals were also inclusive, as the posters feature a diverse range of people and relationships. The visuals could also be easily adapted for different contexts, for example showing an expecting couple for use in the Family Birth Center.
These visuals were paired with the tagline “Who’s your Person”, which was adapted from an existing tagline. The messaging focused on the relationship between the (named) people in the poster, and why the Healthcare Power of Attorney is important to them. A final call-to-action directs people to the UCM website for more information.
Option A - Poster
Option B - Poster
Option C - Poster
Option D - Poster
Option A - Screen
Option B - Screen
Option C - Screen
Option D - Screen
Option A - Vertical Screen
Option B - Vertical Screen
Option C - Vertical Screen
Option D - Vertical Screen
Option A - Standee
Option B - Standee
Option C - Standee
Option D - Standee
Updated
Patient Brochure
& Webpages
While the poster is designed to inform people about what a Healthcare Power of Attorney is, the single page patient brochure is designed to educate people about the details of the HPOA process, and alleviate concerns.
The visuals mirror the poster. The format mirrors the updated HPOA form, and is intended to be given along with the forms (acting as a “top sheet”). The text is laid out as questions a patient may have (What, Why,Where, Who, How) with the relevant answers alongside.
A new dedicated webpage for HPOAs was also created, with the same information as the form. The current webpage for Advance Care Planning (ACP, the larger process of which HPOA is one part) was also updated to focus on Advance Care Planning and Advance Directives as a whole, directing patients to the HPOA webpage for HPOA related information.
Concerns
Touchpoint / Intervention
Updated Form Design
Which forms can I use?
What do I need to know while filling out the form?
Who needs to sign the form?
Who can be a witness?
Do I need to get it notarized?
Fill
The process of choosing a medical decision maker and finding, printing and filling the actual HPOA form.
Updating the Form
The Illinois State Statutory Short Form is the standard form prescribed by the state of Illinois. It includes a lot of information that a patient may need, or may find useful as they fill up an HPOA, including what forms they can use, what they should look for in a Healthcare Agent, what they should tell their agent, and what they should do with the form once they’ve signed it. But a lot of the information is buried under poor formatting and design. Keeping the text the same was a legal requirement. But adapting the formatting based on feedback from patients and medical staff was an option.
First the form was divided up into sections. The sections were split with the questions on the left, and answers/details on the right. This allows patients to quickly scroll through the form. It also keeps the line length to 60 characters, making it easier to read. The order of these sections was also rearranged based on feedback from our usability testing.
The font size was kept at 12 point to ensure legibility, and used the Gotham typeface from UCM’s brand guidelines. Page numbers were added to the bottom, with text indicating which sections of the form were information, and which sections were the form itself, (i.e. the portion that needs to be filled out)
For the latter, we used feedback from the staff to help reduce any operational hiccups. A dedicated space for the patient MRN label was added, so staff could easily identify the relevant pages, and the label wouldn’t cover any important information. The Healthcare Agent’s contact information was also given a “highlight box”, so medical staff could quickly find the information in an emergency. The number of pages that needed to be filled and scanned was also maintained (3).
Both English and Spanish version of the form were developed for print and digital use.
Updated Form showing new format, sections and page numbers
Updated Form showing MRN Label Section and Healthcare Agent Highlight Box
Illinois State Form
Updated HPOA Form in Spanish
Concerns
Touchpoint / Intervention
Updated Upload Guide
What do I do with the form once I’ve filled it?
Updated MyChart Messaging
What happens after I’ve submitted it? Who approves it? How long will it take? Has it been approved?
Submit
The process of submitting an HPOA, either by self-uploading through MyChart, or by returning a physical copy to the health system.
Updated Upload Guide
Most patients can directly scan and upload their HPOA to their MyChart. But it’s important to guide them through the process. The upload guide was simplified and updated to include instructions on how to scan the document into a single PDF, which pages to scan, and how to upload to MChart. The layout was also changed to better match the updated form.
Updated MyChart Messaging
The MyChart messaging was also updated to be more patient friendly. It also uses behavioral design to expand reach, adding a message to reach out to a friend or family member and have them fill out an HPOA.
“Your Advance Directive has been submitted to MyChart. Congratulations on taking the first step to securing your future care! Now why not help someone else do the same?
Ask a friend or family member if they’ve filled out an HPOA form, and explain why it may be important for them to do so.”
Updated Upload Guide
Updated MyChart Messaging
Concerns
Touchpoint / Intervention
Recommended KPIs
What information needs to be tracked to ensure these changes are effective?
Updated Tableau Dashboard
How can this information be consolidated and interpreted?
Updated "Healthcare Power of Attorney for Healthcare Teams" presentation
How do we orient staff to these changes?
Updated CBT
How do we ensure consistency when talking about Advance Care Planning with Patients?
Updated Intranet page for Advance Care Planning
New Intranet page for HPOA / Advance Directives
How do we consolidate all this information and these materials for easy access
Tailored Clinical Pathway for HPOAs
How do we ensure a consistent process across all the departments of the health system?
Backend Processess
These patient facing interventions would also need to complemented by a number of interventions on the provider side.
KPIs, Dashboard and Pathway
Tracking the impact of these interventions is important, and a robust set of KPIs helps ensure that they’re having the right impact.
Total percentage of patients with an HPOA
Percentage of new patients with an HPOA
Effectiveness of HPOA Materials :
No. of patients accessing materials vs. number of form submissions. (%)
HPOA Conversation time: (<3) minutes
Total time to register a new HPOA:
From initial conversation to registration in EMR (within x days)
Printed vs. Digital:
The number of printed forms submitted at the hospital vs. the number of forms submitted directly to MyChart. Increasing the % of latter is ideal.
Number of Errors in HPOA Document Input
These KPIs were incorporated into an update of the existing Tableau Dashboard.
A new Clinical Pathway was also created in AgileMD. While not intended to be used directly, the pathway is to help teams incorporate HPOA conversations into their existing workflows.
AgileMD Clinical Pathway
Updated Tableau Dashboard
Updated Intranet Pages, CBTs
In order to ensure everyone in the health system had access to the updated information, the intranet page for Advance Care Planning was updated, and a new intranet page for HPOAs was created. The content on these page mirrored the content on the webpages, but with more information that would be useful for providers.
All past information was verified with the teams involved (Legal, Spiritual Care, Social Work, Health Equity) to ensure the information was accurate, up to date, and most importantly, useful for providers.
This information was also compiled into a presentation and a short computer based training (CBT)
New HPOA Intranet Page
Updated ACP Intranet Page
Updated Training Module