title: Use of patient ethnography to support quality improvement in benign prostatic hyperplasia.
abstract: BACKGROUND
  Patient-centeredness is a primary aim of quality improvement (QI) but optimal strategies to achieve that goal remain elusive. Benign prostatic hyperplasia (BPH) is one of the commonest urologic diagnoses and significantly affects quality of life. Patient ethnography is an emerging qualitative method of observation and dynamic interviews to understand the context through which the patient experiences care. We implemented patient ethnography to support our QI infrastructure and improve patient-centeredness in BPH.
  
  
  OBJECTIVE
  Little is known about how to measure whether processes of care are patient-centered. We did not know whether the care processes our patients experienced provided value from their perspective.
  
  
  OBJECTIVE
  We sought to discover previously unrecognized components of care that patients perceived to be of low value. Our primary goal was to develop QI initiatives that targeted low-value themes identified in the ethnography. Our secondary goal was a rapid rollout of three targeted initiatives.
  
  
  METHODS
  We used a 4-step patient ethnography: (1) created detailed process maps to define phases of care, (2) interviewed patients, (3) synthesized transcript data in focus groups using the Crawford Slip method, and (4) targeted undesirable components of care for QI. Semi-structured interviews with seven representative patients identified low-value themes. Focus groups, comprised of primary care physicians, case coordinators, nurses, and urologists, evaluated the interview transcripts and generated improvement opportunities prioritized based on feasibility, patient value, scalability, and innovation. We used affinity mapping and priority matrix techniques to prioritize QI opportunities.
  
  
  RESULTS
  We identified five low-value themes from the patient interviews and developed corresponding QI opportunities. These included issues surrounding the referral and consultation process as well as postoperative care, especially home urinary catheter maintenance. Six months after completing the ethnography three of five targeted improvement opportunities had been implemented.
authors.affiliation: Department of Urology, David Geffen School of Medicine at the University of California, UCLA 10833 Le Conte Avenue, Box 951738, Los Angeles, CA 90095-1738, USA. Electronic address: alkaplan@mednet.ucla.edu.
authors.forename: A L
authors.initials: AL
authors.lastname: Kaplan
authors.affiliation: Institute for Innovations in Health, UCLA Health System, USA.
authors.forename: M P
authors.initials: MP
authors.lastname: Klein
authors.affiliation: Department of Urology, David Geffen School of Medicine at the University of California, UCLA 10833 Le Conte Avenue, Box 951738, Los Angeles, CA 90095-1738, USA.
authors.forename: H J
authors.initials: HJ
authors.lastname: Tan
authors.affiliation: Performance Excellence, UCLA Health System, USA.
authors.forename: N P
authors.initials: NP
authors.lastname: Setlur
authors.affiliation: Performance Excellence, UCLA Health System, USA.
authors.forename: N
authors.initials: N
authors.lastname: Agarwal
authors.affiliation: Institute for Innovations in Health, UCLA Health System, USA.
authors.forename: K
authors.initials: K
authors.lastname: Steinberg
authors.affiliation: Department of Urology, David Geffen School of Medicine at the University of California, UCLA 10833 Le Conte Avenue, Box 951738, Los Angeles, CA 90095-1738, USA.
authors.forename: C S
authors.initials: CS
authors.lastname: Saigal
keywords: Benign prostatic hyperplasia; Patient ethnography; Patient-centered; Quality improvement; Value-based care redesign