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When a Shadow Brings Light

Posted By Administration, Thursday, April 28, 2016

Patient and family shadowing can be an easy and low-cost way to get started on improving patient experience of care,
and subsequently, patient safety.

by Patricia McTiernan, MS

Michelle Bulger
Michelle Bulger will discuss patient
and family shadowing at the
NPSF Patient Safety Congress.


Patients’ experience of care is increasingly thought to contribute to safety and health outcomes. A recent paper summarized 55 studies of patient experience, concluding in part that “patient experience is consistently positively associated with patient safety and clinical effectiveness across a wide range of disease areas, study designs, settings, population groups and outcome measures.”


Health care organizations committed to improving the patient experience of care may choose from a number of tools to help assess opportunities for improvement, including patient surveys and Patient and Family Advisory Committees.


Another tactic is patient and family shadowing. Unlike other methods of assessing experience, shadowing gives a picture of a patient’s experience in the moment, while it’s happening. “You’re seeing things from the end-user point of view, and in real-time, which is something that we really have not done in health care,” says Michelle Bulger, a trainer at the Patient and Family Centered Care (PFCC) Innovation Center of University of Pittsburgh Medical Center (UPMC).


Shadowing was developed under the guidance of Anthony M. DiGioia III, MD, a practicing orthopaedic surgeon and the medical director of the Bone and Joint Center at Magee Womens Hospital of UPMC. Dr. DiGioia is medical director and founder of the PFCC Innovation Center of UPMC and creator of the 6-step PFCC Methodology and Practice (PFCC M/P™), a process that, Bulger says, can help “take you from your current state of any care experience to a more ideal state of care. Shadowing comes to us from Step 3 of the PFCC Methodology – Evaluate the Current State – and it enables care givers to view care through the eyes of the patient and family.”

As Ms. Bulger explains, the patient and family are the only common denominator in the health care process, and they experience everything from inpatient care, outpatient care, and rehabilitation to making appointments, dealing with insurance, and more. By shadowing patients and families, care providers get a truer sense of the experience and how it can be improved, and can sometimes begin to effect improvements on the spot.


“We define caregiver as anyone in a care setting who directly or indirectly touches the patient and family experience,” says Ms. Bulger. “So, it’s not just the traditional care givers like doctors, nurses, and therapists; all of us are supporting the experience, whether we work in dietary, security, parking, facilities or elsewhere.”


Ms. Bulger emphasizes that shadowing is flexible in that different members of the care team can shadow the patient and family through different steps in their care. “It’s not necessary to tax any one shadower or any one patient, as long as you cover the entire care experience,” she says.


Ms. Bulger emphasizes that shadowing can also be an effective way to enhance patient safety, by revealing gaps or opportunities to reduce risk that are not easy to spot or appreciate from a care provider’s usual role. One example is of a patient still groggy from surgery trying to get out of bed. The person shadowing that patient was not only able to act in the moment to prevent a fall, but the protocol in that unit now calls for a companion to remain with the patient until they are cleared to get out of bed.


When caregivers shadow patients and families, they are acting on a one-to one basis, which generates empathy, which in turn drives an urgency to spark to change when they see something that could be improved. “What we find is that shadowing really re-engages the caregivers,” says Ms. Bulger “The connections made and perspective gained through shadowing reminds them of why they chose to be a care giver in the first place.

Ultimately, shadowing can be a driving force in the co-design of care, getting patient and family members’ direct input on how to improve processes for a better experience, and potentially better outcomes.


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Michelle Bulger will be speaking on the topic of shadowing and training attendees on techniques during Breakout Session 103 at the 18th Annual NPSF Patient Safety Congress. Get details about the full Congress program  at


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Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  2016 NPSF Congress  patient experience 

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