What Matters to You: Learning About Patient Values & Goals

Overview

As part of the West Health Accelerator at MGB (WHA)’s initiative to transform care for older adults (read more here), we were asked to deeply explore the What Matters to You (WMTY) component of the Institute for Healthcare Improvement (IHI) 4Ms Frameworks of an Age-Friendly Health System. The WMTY framework focuses on learning a patient’s values and goals as part of their clinical care, believing that this can impact longitudinal care decisions specifically around end of life care.

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Discovery 

We held over 60 individual semi-structured interviews with nurses, advance practice practitioners, and physicians to understand their understanding and experience with WMTY. In working with palliative care and geriatric providers on this work, we learned that this was the most ambiguous and misunderstood of the 4Ms. This is because while the idea is simple—learning about patients can lead to better care—incorporating it into service delivery processes at a system level is challenging, due to constraints around provider time and training, and digital barriers. 
Role: interview providers; synthesis of feedback in Mural; presentation of insights to leadership

Clinician Interview Insights: Barriers to Systemetizing WMTY

Intervention Requirements

• To be completed by a single role group at a single occurrence to make initial buy-in easier 
• Without need for significant EMR changes to pilot 
• The WMTY questions selected would need to comply with the Center for Medicare and Medicaid Services (CMS) Age-Friendly Hospital Measure (AFHM) for hospital reimbursement.
• The responses would need to be recorded in the patient’s EMR in some format.
• The intervention would allow flexibility to be developed further with additional touchpoints and role groups involved after initial buy-in. 

︎Interview insights: This captures the current state understanding, use,  and appetite for WMTY in daily care workflows. Understanding this range of definitions by different providers and staff made us realize that any intervention would need a narrow focus for initial pilot to be successful.︎Interview insights: Additionally, we held future state interviews with WHA leaders to shape early ‘intervention requirements.’ While still broad, these led to greater alignment around values and goals. 

︎Survey results to determine feasibility and desirability in incorporating a select set of WMTY questions into existing workflows. Upon further stratification, we determined that nurses (RNs) were most comfortable asking these questions which influenced the choice to incorporate them into the nursing admission assessment.  

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Co-Design & Prototyping 

From there, we held multiple workshop sessions with WHA leadership to ideate on when, how, and how often What Matters to You conversations should be held.  
Role: lead workshop design, create visual materials, design workflows with clinician support
︎Personas: Because we were working directly with clinicians, we provided high-level personas that provided enough information for them to reference specific and real patient experiences they had had. We found this high-level approach allowed for greater engagement with the patient perspective, without distracting clinicians with the specifics of a more in-depth patient case.  

Workflow Proposal

Shaped by the insights collected through the design research, and in collaboration with clinical leaders, we proposed a workflow re-design that required nurses to ask 1-2 predetermined WMTY-related questions during the patient’s admissions assessment for their inpatient hospital stay. Responses would be recorded in the EMR and accessible to the patient’s care team. This nursing admissions assessment is a set of required questions, which allowed us to more simply build off an existing and well-established nursing workflow.The WMTY question would be added as a free text box added to the end of the assessment which would not require significant changes to the EMR. For pilot testing, there were identified alternatives in the EMR that could be used without any changes and would allow our team to determine feasibility and desirability of these efforts. 

The ‘MD/APP Follow Up’ would be an add-on to the initial assessment and will be iterated on once the assessment question goes live across the MGB system.
︎Intervention proposal and considerations for training, measurement, and integrations 

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Testing 

The West Health Accelerator employed select units at Brigham & Women’s Hospital to pilot this early phase intervention using the existing EMR structure. The pilot team found an increase in What Matters conversations which align with the Center for Medicare and Medicaid Services (CMS) Age-Friendly Hospital Measure (AFHM). Nurses and patients found these conversations meaningful through initial informal and qualitative feedback.

Scaling & Next Steps 

Our findings from this work have been submitted as a manuscript for publication currently under review. The next phase of this pilot will begin fall 2026 and will test the initial workflow across additional units in the MGB system. Once there has been greater proven success and buy-in, the final changes to the EMR can be made to incorporate these questions into the required nursing admissions assessment.