Care Redesign

Designing and Implementing Better Patient Experiences

Case Study · June 12, 2018

In an effort to create a “wow experience” for its ophthalmology patients and its employees, salauno adopted a Human-Centered Design approach to define and implement operational activities and facility design improvements.

Key Takeaways

  1. The key phases of patient-centered design are: listen to the patient’s voice, create new ideas to solve their problems, and test those ideas with patients.

  2. Patient experience improvement is not a one-off event or initiative but rather a culture and mind-set.

  3. For patient experience improvement to stick, it is key to focus on implementation and standardization across your health system.

  4. To create a positive patient experience, you must address the other side of the clinical experience coin, the staff experience.

The Challenge

Salauno is an ophthalmology provider with 10 clinics and one surgical center in Mexico, where blindness is the second-leading cause of disability, with cataracts and diabetic retinopathy responsible for most of the cases. Salauno was founded in 2011 as a for-profit company with a mission to eliminate blindness in Mexico through a model of low-cost, high-quality, and high-volume care.

In June 2016, the institution wanted to improve patient experience, so it adopted a Human-Centered Design (HCD) methodology largely inspired by IDEO to define and deliver a wow experience for salauno’s patients, most of whom are low-income and many of whom are let down by the health care system. It then incorporated that methodology into its new surgical center design and applied the same thinking to the employee experience.

The bulk of Salauno’s services are medical consultations, cataract surgeries (for patients who are going blind), and retina and glaucoma services (for patients who are suffering from partial vision loss due to retina and glaucoma illnesses).

The Execution

Salauno’s continuous improvement team began by putting together an interdisciplinary team that included an ophthalmologist, optometrist, clinic assistant, clinic managers, and quality and process personnel. This team worked through the three phases of HCD: (1) Listen to the patient’s voice through ethnographic interviews, patient feedback analysis, analogous context visits, shadowing, and empathy exercises; (2) Create solutions through brainstorming sessions to address the problems identified during the listening phase; and (3) Test ideas developed through prototypes and iterations.

Based on everything we had learned from patients through the HCD process, we defined the wow experience as having three components: (1) Being treated like family; (2) Going through a clear process; and (3) Making a confident and informed decision. Concretely, this involved things like laminated information sheets and explanatory videos for each step in the consultation visit process; change of waiting room seats to a more comfortable model for our elderly patients; visual tools for doctors and counselors to explain diagnosis and treatment to patients more clearly; simulation goggles (now virtual reality headsets) for patients and family members to understand the impact of progression of eye diseases; video tours of clinics and operating rooms to give patients a preview and put them at ease; a process to publicly celebrate successful patient recovery post-op; and in-clinic signage with frequently updated numbers on our clinical experience, including patient and procedure volume.

After 4 months, the HCD development process was complete. Next, we focused on implementation and standardization so that the ideas and concepts would become a standard part of the patient experience. This involved creating staff awareness, training, manuals, audits, and other operational mechanisms to go from theory to practice. We launched the wow experience in October 2016 with a video for all staff, describing the experience from a patient’s point of view, and showed how at each step of the way staff could either positively (wow) or negatively (boo) impact the three components of the experience.

We then created 5 to 10 “standards” for each frontline position; these are reviewed and audited monthly so each staff member gets feedback on how they are doing on key aspects of the patient experience, and consequences are applied if the staff member does not improve performance. We created a rotating group of patient experience “ambassadors,” with one representative from each key area/clinic to continue to push the implementation of patient experience improvements at a local level, report challenges if they arise, and bring new ideas to the table to continually add to the wow experience.

When salauno started designing its new 4,000-square-meter (43,055-square-foot) surgical center, we went back to the definition of the wow experience to see how we could include those ideas in every aspect of the new facility.

We wanted to ensure that the outpatient surgical center would be unlike a typical hospital environment, which is often perceived by our patients as being austere, frightful, and intimidating. For example, in each area where important decisions are made or where we know anxiety will be high, we designed big, bright colorful messages that would help patients make an informed decision. Based on our understanding that every patient visit is actually a family outing, we designed a large patio area with outdoor seating and multiple fountains so that those who accompany our patients have a pleasant space to wait together.

During our patient experience improvement work, we realized that the other side of the clinical experience coin was the staff experience (including clinical and non-clinical personnel). It became clear to us that if we wanted our staff to treat patients right, the staff needed to first feel that they were being treated right. In 2016, we also received worrying results in our employee satisfaction survey. So, we committed to developing a staff experience project and decided to use the same Human-Centered Design methodology and structure. That effort began in April 2017 and was implemented in July 2017.

Once again, with a different multidisciplinary team this time (also clinical and non-clinical staff), we went through the three phases of HCD. Several elements emerged as key to the staff wow experience: (1) Growth and development opportunities, (2) Change management, (3) Staff empathy, (4) Well-being, and (5) Family involvement. With executive-level buy-in, we launched the staff wow through mid-level managers to whom it was presented as a set of leadership tools. We took advantage of the existing ambassadors in each team to push forward the staff-focused agenda as well.

The Metrics

Salauno measures patient experience through the Net Promoter Score (NPS). When the HCD project started in May 2016, salauno’s NPS was 83; in March 2018 the score was up 5 points to 88.

Improving Scores Through Human-Centered Design

  Click To Enlarge.

To ensure consistent implementation, the project also defined several metrics to track standardization of patient experience activities (e.g., staff introduce themselves, hand out information sheets, use visual tools to explain diagnoses, etc.) across the network of clinics. Compliance with the standardization activities is currently at an average of 89% across the organization, which we consider to be good at this stage as our goal is 90%. This metric is reviewed monthly and an action plan is put into place to improve areas or components that are below average in implementation.

We measure staff satisfaction with the Great Place to Work survey, which was at a level of 68.2% in 2016. In 2017, after the staff wow project, the survey reflected an improved staff satisfaction of 72%. We also track secondary measures like voluntary staff churn as an indicator of staff well-being. This voluntary churn was 27.5% in 2016 and 25.2% in 2017.

Where to Start

Through this process, we learned that even if you think you know your patients inside and out, to get started on the road to Human-Centered Design, you first need to observe, ask, and listen. When we were looking at waiting within the patient experience, we weren’t focusing on infrastructure but rather on service. Time and again, however, our elderly patients would mention our chairs when complaining about the waiting experience. We had picked out slick, low, metal, modern-looking chairs. They explained to us that for an elderly patient, they were the hardest, coldest, and most difficult to get out of. So we changed to some much more basic plastic waiting room chairs. Our patients told us it was a huge upgrade for them.

We also learned that during the create phase, iteration is key. It is very unlikely that an idea for a solution will be perfect from the start. It is much more likely that it will go through many iterations. At salauno, we thought it would be helpful to give patients little booklets with information on each step of the consultation process so they would know what to expect. We tried by printing out a few and handing them out to patients as they registered for their appointment. One after the other, we watched them flip through the booklet for a few seconds and then put it away. We realized it was overwhelming as a booklet and didn’t draw them in to look at it right there and then.

So the next day, we printed out just a single sheet for each step and handed them out right before the corresponding steps. Patients looked at it a few seconds more, folded it, and put it away, along with all the papers they already had. We realized that to the patient, this looked like one more thing to read once they got home. So we laminated the sheets. The next day, all of a sudden, we had patients reading the information in the waiting room. It was a small, unexpected change in our initial idea that made it viable, and we only discovered it through iteration.

Perhaps most important, staff buy-in and input through these efforts is key. By involving staff from every level and area in the working teams that develop the ideas from the beginning and creating a team of ambassadors across the organization to push the solutions, you ensure that changes take into account realities on the ground and that they stick and meaningfully change the way the organization works and thinks.

Next Steps

Both the patient and staff wow experiences are ongoing initiatives that salauno constantly works to develop and take to the next level. On the patient side, we are currently developing a mobile application to guide and accompany patients before, during, and after their visit to a clinic, educate them on their diagnosis and treatment, provide patients with a report card of each consultation, as well as make and manage appointments. On the staff side, the wow experience went through an initial rollout and implementation phase and is currently being further developed as part of a larger project to further align the organization’s culture with its mission and objectives.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Epic OB Hemorrhage PPH Risk Assessment Tool and Alerts at PSJH - Preventing Maternal Death

Improving Maternal Safety Through an EMR Risk Assessment

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to prevent future maternal deaths and injuries.

Most Health Care Organizations Have Palliative or End-of-Life Care Programs

Survey Snapshot: Challenging the Resistance to “Palliative”

NEJM Catalyst Insights Council members agree that palliative care is gaining traction, but one of many barriers is getting providers over their resistance to the word “palliative.”

The Assessment of Care Tool - Consisting of Six Visual Analog Scales Corresponding with the IOM Six Dimensions of Perfect Care

Real-Time Pursuit of Outcomes That Matter to Patients

A simple and affordable tool to use at the point of care to drive value creation within clinical microsystems.

Many Patients Who Would Benefit from Palliative - End-of-Life Care Do Not Receive It

Care Redesign Survey: The Power of Palliative Care

Our NEJM Catalyst Insights Council survey on palliative care reveals an interesting dichotomy: While the great majority of organizations have a palliative or end-of-life care program, 60% of patients who would benefit from such services don’t receive them.

Heart Safe Motherhood and Way to Health Two-Way Texting for Blood Pressure Monitoring for Postpartum Women with Preeclampsia

Heart Safe Motherhood: Applying Innovation Methodology for Improved Maternal Outcomes

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program for postpartum women with preeclampsia improved blood pressure management, reduced readmissions, and increased patient and provider satisfaction.

VHA Whole Health System diagram

Finding the Cause of the Crises: Opioids, Pain, Suicide, Obesity, and Other “Epidemics”

Until we redesign our health care system to address our patients’ personal determinants of health, we will continue to inadequately address our multiple chronic disease crises.

Leff06_pullquote home-based medical care for homebound patients

Using Quality to Shine a Light on Homebound Care

How two thought leaders in the fields of home-based medical care, geriatrics, and palliative medicine advanced a quality-of-care agenda for homebound adults.

Charlotte Yeh head shot - hearing aids hearing loss

“You’re Old Without Hearing Aids”— Addressing the Silent Epidemic of Hearing Loss

Hearing loss isn’t a normal consequence of aging. But it is associated with a higher risk of dementia, depression, and falls. The Chief Medical Officer for AARP Services talks about combating this huge but silent epidemic that impacts all ages.

Dentzer01_pullquote - Stone-Age Policies Stifle Modern Virtual Care Solutions

Stone-Age Policies Stifle Modern Solutions

Health care leaders must advocate for regulatory and reimbursement changes to unlock the potential of innovative technology and care team approaches to Parkinson’s and other suitable conditions.

Idiopathic Pulmonary Fibrosis IPF Multidisciplinary Collaborative Care Model

From Consulting to Caring: Care Redesign in Idiopathic Pulmonary Fibrosis

A multidisciplinary collaborative model to address the palliative care needs of patients with idiopathic pulmonary fibrosis resulted in improved end-of-life care and decreased hospital deaths.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


How a State Advances Whole-Person Health…

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations…

Quality Management

177 Articles

Improving Maternal Safety Through an EMR…

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to…

Design Thinking

18 Articles

Heart Safe Motherhood: Applying Innovation Methodology…

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now