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Patient-Centered Care: What Does It Take?

Authors:
  • Shaller Consulting Group

Abstract and Figures

Patient-centered care has become a central aim for the nation's health system, yet patient experience surveys indicate that the system is far from achieving it. Based on interviews with leaders of patient-centered organizations and initiatives, this report identifies seven key factors for achieving patient-centered care at the organization level: 1) top leadership engagement, 2) a strategic vision clearly and constantly communicated to every member of the organization, 3) involvement of patients and families at multiple levels, 4) a supportive work environment for all employees, 5) systematic measurement and feedback, 6) the quality of the built environment, and 7) supportive information technology. The report illustrates how these factors can be successfully implemented through case examples of two organizations, MCG Health System in Georgia and Bronson Methodist Hospital in Michigan. The report concludes with a discussion of strategies at the organization and system level that can help leverage widespread implementation of patient-centered care.
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PATIENT-CENTERED CARE:
WHAT DOES IT TAKE?
Dale Shaller
Shaller Consulting
October 2007
ABSTRACT: Patient-centered care has become a central aim for the nation’s health system, yet
patient experience surveys indicate that the system is far from achieving it. Based on interviews
with leaders of patient-centered organizations and initiatives, this report identifies seven key factors
for achieving patient-centered care at the organization level: 1) top leadership engagement,
2) a strategic vision clearly and constantly communicated to every member of the organization,
3) involvement of patients and families at multiple levels, 4) a supportive work environment for all
employees, 5) systematic measurement and feedback, 6) the quality of the built environment, and
7) supportive information technology. The report illustrates how these factors can be successfully
implemented through case examples of two organizations, MCG Health System in Georgia and
Bronson Methodist Hospital in Michigan. The report concludes with a discussion of strategies at
the organization and system level that can help leverage widespread implementation of patient-
centered care.
Support for this research was provided by The Commonwealth Fund. The views presented here are
those of the author and not necessarily those of The Commonwealth Fund or its directors, officers,
or staff. This and other Fund publications are available online at www.commonwealthfund.org.
To learn more about new publications when they become available, visit the Fund’s Web site and
register to receive e-mail alerts. Commonwealth Fund pub. no. 1067.
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CONTENTS
About the Author ...........................................................................................................iv
Acknowledgments ..........................................................................................................iv
Executive Summary......................................................................................................... v
Introduction ....................................................................................................................1
Key Attributes of Patient-Centered Care..........................................................................2
How Close Are We?........................................................................................................5
Factors Contributing to Patient-Centered Care................................................................8
Models of Success .......................................................................................................... 13
Strategies for Leveraging Change ................................................................................... 17
Conclusion .................................................................................................................... 21
Appendix A. List of Interviews ......................................................................................22
Appendix B. Interview Guide........................................................................................ 23
Notes............................................................................................................................. 24
LIST OF FIGURES
Figure 1 Doctor–Patient Communication: Doctor Listened Carefully,
Explained Things, Showed Respect, and Spent Enough Time,
National and Managed Care Plan Type ..........................................................6
Figure 2 Patient-Centered Hospital Care: Staff Managed Pain, Responded
When Help Was Needed, and Explained Medicines, by Hospitals, 2005......... 8
iii
ABOUT THE AUTHOR
Dale Shaller is principal of Shaller Consulting, a health policy analysis and management
consulting practice based in Stillwater, Minnesota. Shaller Consulting provides education
and technical assistance to national, state, and local health care coalitions, purchasing
groups, and provider organizations in their efforts to measure and improve health care
quality. He can be e-mailed at d.shaller@comcast.net.
ACKNOWLEDGMENTS
The author wishes to thank The Picker Institute, Inc., for supporting the research and
writing of this report, and The Commonwealth Fund for helping to publish it. The Picker
Institute is an independent, not-for-profit organization dedicated to the advancement of
patient-centered care. For more information on the Institute, visit www.pickerinstitute.org.
The author also wishes to thank the many individuals who contributed their valuable time
and expertise through the interviews that form the foundation of this paper. These
individuals are helping to provide the leadership needed at both the organizational and the
policy levels to create a health care system built around the values, preferences, and needs
of individual patients.
Editorial support was provided by Joris Stuyck.
iv
EXECUTIVE SUMMARY
The concept of patient-centered care has gained increasing prominence in recent years as a
key aim of the U.S. health care system. Yet despite growing recognition of the importance
of patient-centered care, as well as evidence of its effectiveness in contributing to other
system goals such as efficiency and effectiveness, the nation’s health care system falls short
of achieving it. Data from national and international studies indicate that patients often
rate hospitals and medical care providers highly, but report significant problems in gaining
access to critical information, understanding treatment options, getting explanations
regarding medications, and receiving responsive, compassionate service from their caregivers.
This paper was commissioned by The Picker Institute to explore what it will take
to achieve more rapid and widespread implementation of patient-centered care in both
inpatient and ambulatory health care settings. The findings and recommendations of this
paper are based largely on a series of interviews with opinion leaders selected for their
experience and expertise in either designing or implementing strategies for achieving
excellence in patient-centered care.
Key Attributes of Patient-Centered Care
A high degree of consensus exists regarding the key attributes of patient-centered care. In
a systematic review of nine models and frameworks for defining patient-centered care, the
following six core elements were identified most frequently:
Education and shared knowledge
Involvement of family and friends
Collaboration and team management
Sensitivity to nonmedical and spiritual dimensions of care
Respect for patient needs and preferences
Free flow and accessibility of information
Factors Contributing to Patient-Centered Care
The interviews and literature reviewed for this project identified seven key factors that
contribute to achieving patient-centered care at the organizational level:
v
Leadership, at the level of the CEO and board of directors, sufficiently
committed and engaged to unify and sustain the organization in a common
mission.
A strategic vision clearly and constantly communicated to every member
of the organization.
Involvement of patients and families at multiple levels, not only in the care
process but as full participants in key committees throughout the organization.
Care for the caregivers through a supportive work environment that
engages employees in all aspects of process design and treats them with the same
dignity and respect that they are expected to show patients and families.
Systematic measurement and feedback to continuously monitor the impact of
specific interventions and change strategies.
Quality of the built environment that provides a supportive and nurturing
physical space and design for patients, families, and employees alike.
Supportive technology that engages patients and families directly in the process
of care by facilitating information access and communication with their caregivers.
These factors can be found at work in a small but growing number of hospitals and
medical groups across the country. Among the examples identified through the project
interviews, a few were mentioned repeatedly as outstanding illustrations of organizations
that have focused on these factors to achieve measurable excellence in performance. Two
specific cases highlighted in this paper are the MCG Health System in Augusta, Georgia,
and Bronson Methodist Hospital in Kalamazoo, Michigan. These two organizations
demonstrate how most or all of the factors identified can be addressed in an integrated,
comprehensive way to achieve high levels of patient-centered care, as measured through
independently collected patient survey data as well as through other important health care
outcomes and organization objectives.
Strategies for Leveraging Change
Key strategies identified as necessary to overcome barriers and to help leverage widespread
implementation of patient-centered care can be divided into the following two groups.
Organization Level. Strategies designed primarily to strengthen the capacity to
achieve patient-centered care at the organization level include:
o Leadership development and training
vi
o Internal rewards and incentives
o Training in quality improvement
o Practical tools derived from an expanded evidence base
System Level. Strategies aimed at changing external incentives in the health care
system as a whole, to positively influence and reward organizations striving to
achieve high levels of patient-centered care, include:
o Public education and patient engagement
o Public reporting of standardized patient-centered measures
o Accreditation and certification requirements
The findings from this project indicate that, while there are many promising
examples of organizations achieving excellence in patient-centered care, these innovators
are not yet the norm. The challenge lies in elevating the norm through strategies at both
the organization and system level that leverage the experience of these innovators to
motivate large-scale implementation of patient-centered care.
vii
PATIENT-CENTERED CARE:
WHAT DOES IT TAKE?
INTRODUCTION
In its landmark 2001 report, Crossing the Quality Chasm, the Institute of Medicine (IOM)
named patient-centered care as one of the six fundamental aims of the U.S. health care
system.1 The IOM defines patient-centered care as:
Health care that establishes a partnership among practitioners, patients, and
their families (when appropriate) to ensure that decisions respect patients’
wants, needs, and preferences and that patients have the education and
support they need to make decisions and participate in their own care.2
Studies show that orienting health care around the preferences and needs of
patients has the potential to improve patients’ satisfaction with their care, as well as their
clinical outcomes. Patient-centered care also has been shown to reduce both underuse and
overuse of medical services.3
Despite the recent prominence given to patient-centered care, and the growing
evidence of its importance, the nation’s health care system appears to fall short of
achieving it. For example, according to a recent Commonwealth Fund survey of patients
in five countries (Australia, Canada, New Zealand, the United Kingdom, and the U.S.),
one-third of sick patients in the U.S. leave the doctor’s office without getting answers to
important questions.4 And across all countries in the study, one-third to one-half of
respondents said their doctors sometimes, rarely, or never tell them about treatment
options or involve them in making decisions about their care.5
This paper was commissioned by The Picker Institute to explore what it will take
to achieve more rapid and widespread implementation of patient-centered care in both
inpatient and ambulatory health care settings. The Picker Institute was an early leader in
developing surveys designed to measure patients’ experience with their care. Since the late
1980s, the Picker surveys and those modeled after them, such as the Consumer Assessment
of Healthcare Providers and Systems (CAHPS) surveys, have been used to gather
information from millions of patients in hospitals and physician practices in the U.S.,
Canada, the United Kingdom, Germany, and other European countries. After all this
investment in measurement, a clear need remains to determine how such information can
be used to actually make and sustain improvements in the patient’s experience with care.
1
The aim of this paper is to summarize a consensus of opinions and perspectives
from key health care leaders regarding what it will take to achieve high levels of patient-
centered care in the U.S. These opinions and perspectives were gleaned from a series of
telephone interviews conducted by the author from June through September 2006.
Leaders were identified on the basis of their recognized expertise, either as leaders of
organizations that have demonstrated measurable excellence in patient-centered care or as
experts working to design and implement tools and strategies for implementing patient-
centered care. A total of 17 interviews were conducted, with the list of individuals
included in Appendix A. The core questions that were probed in the semi-structured
interviews are included in Appendix B. Throughout the interview process, the published
and unpublished literature on patient-centered care, as well as relevant Web sites identified
in the course of the interviews, were consulted as additional background and supporting
information to the views expressed by the individuals interviewed.
KEY ATTRIBUTES OF PATIENT-CENTERED CARE
Increasingly, patients are asking to be partners in their care. A patient-centered health care
system can help achieve that partnership in a variety of ways. Multiple models and
frameworks have been developed for describing patient-centered care, with many
overlapping elements. This section briefly summarizes three of the most influential models
that form the foundation of approaches to patient-centered care in the U.S. today: (1) the
Picker/Commonwealth dimensions, (2) the Institute for Family-Centered Care focus on
collaborative partnerships, and (3) the Planetree model. It then presents results of a
synthesis of key concepts cutting across these and other models.
Picker/Commonwealth Dimensions
The term “patient-centered care” was originally coined by the Picker Commonwealth
Program for Patient-Centered Care, which later became The Picker Institute.6 This
program conducted focus groups and national telephone interviews with patients and
families to create the Picker survey instruments that measure the patient’s experience of
care across the following eight dimensions:7
Respect for patient-centered values, preferences, and expressed needs,
including an awareness of quality-of-life issues, involvement in decision-making,
dignity, and attention to patient needs and autonomy.
Coordination and integration of care across clinical, ancillary, and support
services and in the context of receiving “frontline” care.
2
Information, communication, and education on clinical status, progress,
prognosis, and processes of care in order to facilitate autonomy, self-care, and
health promotion.
Physical comfort, including pain management, help with activities of daily
living, and clean and comfortable surroundings.
Emotional support and alleviation of fear and anxiety about such issues as
clinical status, prognosis, and the impact of illness on patients, their families and
their finances.
Involvement of family and friends in decision-making and awareness and
accommodation of their needs as caregivers.
Transition and continuity as regards information that will help patients care for
themselves away from a clinical setting, and coordination, planning, and support to
ease transitions.
Access to care, with attention to time spent waiting for admission or time
between admission and placement in a room in the inpatient setting, and waiting
time for an appointment or visit in the outpatient setting.
Institute for Family-Centered Care Model
The Institute for Family-Centered Care was founded in 1992 to ensure that principles of
patient- and family-centered care are reflected in all systems providing care and support to
individuals and families, including health, education, mental health, and social services.
According to the Institute, patient- and family-centered care is an innovative approach to
the planning, delivery, and evaluation of health care that is grounded in mutually
beneficial partnerships among patients, their families, and health care providers.8 The core
concepts of patient- and family-centered care include:
Dignity and respect. Health care practitioners listen to and honor patient and
family perspectives and choices. Patient and family knowledge, values, beliefs and
cultural backgrounds are incorporated into the planning and delivery of care.
Information-sharing. Health care practitioners communicate and share complete
and unbiased information with patients and families in ways that are affirming and
useful. Patients and families receive timely, complete, and accurate information in
order to effectively participate in care and decision-making.
Participation. Patients and families are encouraged and supported in participating
in care and decision-making at the level they choose.
3
Collaboration. Patients and families are also included on an institutionwide basis.
Health care leaders collaborate with patients and families in policy and program
development, implementation, and evaluation; in health care facility design; in
professional education; and in the delivery of care.
The Planetree Model
The mission of Planetree, founded in 1978, is to serve as a catalyst in the development and
implementation of new models of health care that cultivate the healing of mind, body, and
spirit; that are patient-centered, value-based, and holistic; and that integrate the best of
Western scientific medicine with time-honored healing practices.9 The nine elements of
the Planetree patient-centered care model are:
Explicitly recognizing the importance of human interaction in terms of
personalized care, kindness, and being “present” with patients.
Informing and empowering diverse patient populations through consumer-
oriented health libraries and patient education.
Integrating health partnerships with family and friends in all aspects of care.
Attending to the nurturing aspects of food and nutrition.
Incorporating spirituality and inner resources for healing into care of patients.
Incorporating massage and human touch.
Incorporating the arts (music, visual art forms) into the healing process.
Integrating complementary and alternative practices into conventional care.
Creating healing environments through architecture and design.
Synthesis of Key Attributes
In order to identify similarities and differences across the varying definitions and descriptions
of patient-centered care, Carol Cronin, an independent consultant under contract with the
National Health Council in 2004, reviewed nine models of patient-centered care
(including the three described above) to arrive at 45 concepts embedded in the definitions.10
The following six elements appeared in three or more of the definitions or descriptions:
Education and shared knowledge (in five of the definitions)
Involvement of family and friends (in five of the definitions)
Collaboration and team management (in four of the definitions)
4
Sensitivity to nonmedical and spiritual dimensions (in four of the definitions)
Respect for patient needs and preferences (in three of the definitions)
Free flow and accessibility of information (in three of the definitions)
Clearly, there is no lack of definitions of patient-centered care, and there is
substantial convergence and commonality across at least half a dozen key attributes.
According to one of the experts interviewed for this project, “We’ve gathered tons of
data, done many focus groups: We know what patients want. The hard part is delivering
it.” The next section will explore how close we are to getting there.
HOW CLOSE ARE WE?
How close are we in the U.S. to achieving a health care system that delivers on the
patient-centered aim called for by the IOM and so many others? This section briefly
examines the range of perspectives offered by the various leaders interviewed for this
project, and reviews some of the available empirical evidence based on national patient
experience surveys.
Leader Perspectives
Opinions of leaders interviewed ranged from a mildly optimistic assessment of the progress
that has been made toward patient-centered care to a conviction that the system is utterly
failing to deliver on this key aim. For example, one expert suggested that “we’ve made a
lot of progress…a lot has been mainstreamed since the first national Picker
Commonwealth study in 1989.” But most others were less optimistic about the system as
a whole, offering comments such as:
How close are we? Not even close. There are a few promising innovators
and early adopters out there, others on the way. Many are way behind.
About 80 percent to 95 percent are someplace in between.
We’re not even close to a tipping point. I’ve never seen us so far from
our customers.
The most consistent perspective that emerged among the leaders interviewed is
that remarkable progress has been made in a relatively small number of organizations, but
that the vast majority of hospitals and medical practices fall far short of achieving high
levels of patient-centered care. A large number of the most innovative organizations
mentioned include children’s hospitals or other programs with an emphasis on pediatric care.
A few specific examples are described in the section “Models of Success” (see page 13).
5
Empirical Evidence
Empirical evidence based on surveys of patients’ health care experiences provides another,
more quantitative assessment of progress. As noted earlier, rigorous and standardized
evaluations of patients’ experiences are now gaining increasing traction in the U.S.,
stimulated in large part by the early Picker surveys.
In the ambulatory sector, the CAHPS Health Plan Survey is now administered
annually by health plans enrolling more than 130 million Americans. Reports of national
results based on this survey show the majority of survey respondents rate their medical
care providers and overall health care highly.11 For example, in 2006, well over 50
percent of all respondents across all sectors (commercial, Medicare, and Medicaid) rated
their personal doctors and specialists either “9” or “10” on a 10-point scale where “0” is
the worst possible and “10” is the best possible. Over half of all respondents also rated
their overall health care highly.
However, in contrast to overall ratings, actual consumer reports of experiences
with health care providers show substantial room for improvement. For example, Figure 1,
compiled by The Commonwealth Fund, shows that just over 50 percent of U.S. adults
report that their health providers always listened carefully, explained things clearly,
respected what they had to say, and spent enough time with them.12
55 63 55
54 60 69 61
65 74 67
0
50
100
National (2002) Private Medicare Medicaid
10th percentile Mean 90th percentile
Figure 1. Doctor–Patient Communication: Doctor Listened Carefully,
Explained Things, Showed Respect, and Spent Enough Time,
National and Managed Care Plan Type
Percent of adults (ages 18+) reporting “always”
Data: National rate—2002 Medical Expenditure Panel Survey (AHRQ 2005a);
Plan rates—National CAHPS Benchmarking Database (data provided by NCQA).
Managed care plans (2004)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
6
Recent international surveys indicate other significant problem areas in ambulatory
care. The previously mentioned Commonwealth Fund survey of patients in five countries
revealed substantial gaps in doctor-patient communication related to treatment options
and other health care management plans.13 An international survey of primary care
physicians shows that only 40 percent of physician practices in the U.S. have arrangements
for after-hours care, compared to over 80 percent in the U.K., Australia, and the
Netherlands.14 Over 60 percent of sicker adults in the U.S. report difficulty getting
needed care on nights, weekends, and holidays without going to the emergency room.15
Similar national standardized survey measures of inpatient care are more difficult to
come by. The CAHPS Hospital Survey, recently endorsed as the national standard for
assessing inpatient care from the patient’s perspective by the National Quality Forum, is
now only in the initial stages of national implementation. Based on national test data
submitted in 2005 by 254 hospitals to the National CAHPS Benchmarking Database,
overall ratings of hospital care by discharged patients are high.16 For example, over 55
percent of survey respondents rated their hospitals either “9” or “10” on a 10-point scale
where “0” is the “worst possible hospital” and “10” is the “best possible hospital.”
Furthermore, over 94 percent of respondents would either “definitely” (71%) or
“probably” (23%) recommend their hospital to their friends and family.
Compared to the national CAHPS Health Plan Survey results noted above,
patients’ reports of doctor and nurse communication in the hospital setting are significantly
better. For example, nearly nine out of 10 respondents (86%) reported that doctors always
treated them with courtesy and respect (compared to 81% saying nurses did so), and 79
percent reported that doctors always listened carefully (nurses, 71%).
However, several significant problem areas remain. Figure 2, compiled by The
Commonwealth Fund and based on the 2005 CAHPS Hospital Survey data, shows that
on average only 60 percent of respondents reported that hospital staff always described
possible side effects of new medications in a way they could understand. Moreover, large
differences exist in pain management, staff responsiveness, and communication about
medications between the highest and the lowest performing hospitals.
7
70 63 60
93 91 100
79 74 70
61 52 49
0
50
100
Staff managed pain well Staff responded when
needed help Staff explained medicines
and side effects
Average Best hospital 90th percentile hospitals 10th percentile hospitals
Figure 2. Patient-Centered Hospital Care: Staff Managed Pain,
Responded When Help Was Needed, and Explained Medicines,
by Hospitals, 2005
Percent of patients reporting “always”
* Patient’s pain was well controlled and hospital staff did everything to help with pain.
** Patient got help as soon as wanted after pressing call button and when getting to the bathroom/using bedpan.
*** Hospital staff told patient what medicine was for and described possible side effects in a way that patient could understand.
Data: CAHPS Hospital Survey results for 254 hospitals submitting data in 2005. National CAHPS Benchmarking Database.
*** ***
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
Clearly, even though comprehensive national measures are not yet available for
hospital care and ambulatory practices, the existing preliminary evidence shows there is
substantial room for improvement in patient-centered care across a number of important
dimensions. National implementation of the CAHPS Hospital Survey, spurred largely by
the Centers for Medicare & Medicaid Services, will provide a source of continuing data
for monitoring hospital performance.
FACTORS CONTRIBUTING TO PATIENT-CENTERED CARE
The previous sections have defined what patient-centered care is and reviewed some of
the evidence regarding how close we are to achieving it in the nation as a whole. This
section summarizes seven key factors identified through the project interviews and
literature review that contribute to patient-centered care at the organization level. These
factors are: (1) leadership, (2) a strategic vision clearly and constantly communicated to
every member of the organization, (3) involvement of patients and families at multiple
levels, (4) care for the caregivers through a supportive work environment, (5) systematic
measurement and feedback, (6) the quality of the built or physical environment, and (7)
supportive technology.
Leadership
According to the majority of individuals interviewed for this project, the single most
important factor contributing to patient-centered care, whether in the hospital or in the
8
ambulatory care setting, is the commitment and engagement of senior leadership at the
level of the CEO and board of directors. The organizational transformation required to
actually achieve the sustained delivery of patient-centered care will not happen without
top leadership support and participation. In the words of one observer, “There is no
chance to succeed without it, and maybe not even with it.”
The importance of leadership has been well documented in the literature on
organizational development.17 The noted organizational theorist Edgar Schein has
identified the close connection between leadership and culture in an organization,
suggesting that:
Organizational cultures are created by leaders, and one of the most decisive
functions of leadership may well be the creation, the management, and if
and when that may become necessary, the destruction of culture. Culture
and leadership, when one examines them closely, are two sides of the same
coin and neither can really be understood by itself.18
Jack Silversin and his colleague, Mary Jane Kornacki, nationally recognized experts
on physician culture, have applied these concepts specifically to health care organizations
through a model of organizational change that focuses on the elements of leadership,
shared vision, culture, and the concept of an explicit “compact” between management
and the medical and supervisory staff.19 According to Gary Kaplan, MD, CEO of Virginia
Mason Medical Center in Seattle, Washington, leaders must become “change managers”
that help transform the traditional, implicit compact between physicians and the
organization from one based on “entitlement, protection, and autonomy” to one focused
entirely on “putting the patient first.” In the case of Virginia Mason, Dr. Kaplan applied
Silversin’s framework to the creation of both a leadership compact and a physician
compact that clearly delineate mutual responsibilities and expectations regarding patient-
centered care. These compacts became the cornerstone of a wholesale transformation of
the medical center from a culture focused on accommodating physicians to one directed
toward placing the patient at the center. While organizational change of such magnitude
cannot be attributed to a single individual alone, Dr. Kaplan’s leadership was instrumental
in guiding board members, senior executives, and medical staff to embrace a new vision.
A Strategic Vision Clearly Communicated
With exceptional, committed leadership in place, the organization needs to develop a clear
vision and strategic plan for how patient-centered care will fit into its priorities and
processes on a daily operational basis. Experts interviewed for this project emphasized the
9
importance of articulating a vision and mission statement with clear, simple elements that
can be easily repeated and embedded in routine activities that all staff members carry out.
Management consultant Kathleen Jennison Goonan, MD, Executive Director of the
Center for Performance Excellence, describes the importance of achieving a “line of
sight” that is always visible from “the boardroom to the bedside,” meaning an ability to
communicate the leadership’s strategic goals systematically throughout all levels of the
organization. Goonan cites SSM Health Care, 2002 winner of the distinguished Baldrige
Award in health care, as a “practice leader” in this area. For example, SSM has
standardized all of its meetings so that all sites follow the same protocols that include
constant reminders of the organization’s mission and values. According to Goonan, who
bases her consulting work on the Baldrige model, such standardization of processes helps
“translate vision into ways people behave. . . . All successful organizations do this.”
Involvement of Patients and Families
In patient-centered care, if patients are to be truly involved, so must their families. These
are broadly conceived as close friends and significant others, not just family relatives, who
can provide vital support and information throughout the care process. According to Bev
Johnson, president of the Institute for Patient- and Family-Centered Care, patients and
families should be involved in care at several levels, consistent with the IOM’s
recommendations in the Crossing the Quality Chasm report. The first level is the point of
care delivery, where patients and families can contribute to the process of gathering
information about perceptions of care and assist in analyzing and responding to treatment
strategies. The second level is the clinical microsystem, where patients and family advisers
should participate as full members of quality improvement and redesign teams,
participating from the beginning in planning, implementing, and evaluating change.
The third level is the organization leadership, where the perspectives and voices of
patients and families are vital to quality improvement, planning, and policy and
programmatic development. Patients and families should participate on key committees
dealing with issues such as patient safety, facility design, quality improvement,
patient/family education, ethics, and research. One example of patient and family
involvement at this level is the patient and family advisory council. Such a council creates
an opportunity for patients and families who represent the constituents served by the
organization to become members of a permanent group that meets regularly with senior
leaders.20 While they do not function as boards, patient and family advisory councils can
play a vital role in problem-solving, since they often identify opportunities or solutions
that professional managers may overlook. Finally, at the fourth level, the perspectives of
patients and families are critical to the development of local, state, and national policies
10
affecting the finance and delivery of care, and should inform accreditation and licensing
bodies, the design of reimbursement policies, and medical education curricula.
Supportive Work Environment: Care for the Caregivers
If health care organizations want to become patient-centered, they must create and
nurture an environment in which their most important asset—their workforce—is valued
and treated with the same level of dignity and respect that the organization expects its
employees to provide to patients and families. The relationship between employee
satisfaction and patient or customer satisfaction has been well documented.21 Experts
interviewed for this project stressed the importance of hiring, training, evaluating,
compensating, and supporting a workforce committed to patient-centered care. An
important way to achieve this commitment and engagement is to involve employees
directly in the design and implementation of patient-centered processes. According to
Peter Coughlan, transformation practice leader at IDEO, one of the world’s most sought-
after design consulting firms, health care organizations should strive to be “human-
centered”, not just patient-centered, meaning that all stakeholders (including managers,
medical staff, nurses, and other frontline staff) should be engaged in creating effective,
responsive systems of care.
In a similar vein, Erie Chapman, president and CEO of the Nashville-based Baptist
Healing Trust, suggests that the “single biggest responsibility of caregivers is to take care of
people that take care of people.” He describes a “wave theory” of behavior that can
contribute to a positive work culture, based on the premise that the majority of people in
an organization or on a team model their own behavior in accordance with those around
them.22 Positive behavior modeled by team leaders will encourage similar behavior in
other team members, which will in turn contribute to the ability of the entire team to
provide responsive, service-oriented care to patients and their families.
Systematic Measurement and Feedback
A frequently used axiom in health care quality improvement is, “You cannot manage
what you cannot measure.” A major factor contributing to patient-centered care is the
presence of a robust customer-listening capacity that enables an organization to
systematically measure and monitor its performance. According to Kate Goonan, such a
listening capacity should comprise a “balanced scorecard” that includes multiple
measurements of performance, such as patient experience surveys, complaints, and
“patient loyalty” assessments based on rates of voluntary disenrollment from a practice.
Other important “listening posts” include walk-throughs, a process in which staff members
play the role of patients and experience a service or procedure in the same way that
11
patients and families do.23 The implementation of patient and family advisory councils,
described above, provides another way to gather systematic feedback from patients.
The value of such measurement and feedback lies in using them to design and
implement specific interventions or processes to improve the patient experience. Whether
the intervention is large (for example, redesigning the appointment process in an office
practice) or small (adding signs to help patients and families find their way through the
building), it is vital to continuously measure the effect of the change to determine whether
it is working and, if not, how to modify the process for a better result. The systematic use
of measurement in planning an intervention, implementing it, reviewing its effects, and
modifying it as needed constitutes the cycle of quality improvement often referred to as
PDSA, for “plan, do, study, act.” According to Peter Coughlan, the success of this process
depends on having real-time feedback, in order to be able to trace results back to specific
actions or processes that can be studied, altered if necessary, and spread throughout the
organization if successful.
Quality of the Built Environment
One of the most important factors contributing to patient-centered care is the quality of
the physical environment in which care is provided. Since its founding in 1978, Planetree
has pioneered new approaches to architecture and design that recognize the vital link
between physical space and the healing process. The Planetree approach to health facility
design encourages settings that:
Welcome the patient’s family and friends.
Value human beings over technology.
Enable patients to fully participate as partners in their care.
Provide flexibility to personalize the care of each patient.
Encourage caregivers to be responsive to patients.
Foster a connection to nature and beauty.
Over the past several decades, these design principles have been incorporated into
a variety of health care settings, and have been shown to correlate highly with improved
measures of patient experience and other important health and business outcomes.24 In
2000, the Center for Health Care Design launched the Pebble Project as a research effort
to systematically document the evidence that supportive and nurturing physical
environments are therapeutic for patients, conducive to family involvement, promotive of
12
staff efficiency, and restorative for workers under stress.25 By carefully documenting
examples of health care facilities whose design has made a difference in the quality of care
and financial performance of the organization, the Pebble Project intends to create a
“ripple effect in the health care community” that will lead to more widespread adoption
of such evidence-based design. Currently, more than 40 organizations are participating,
and each is committed to systematic documentation of the results of its design innovations.
Preliminary data from these projects have shown demonstrable improvements in clinical
outcomes, economic performance, productivity, and customer satisfaction.
Supportive Technology
A final contributing factor permeating virtually all of the above elements is supportive
technology, especially health information technology (HIT) that engages patients and
families directly in the care process by facilitating communication with their caregivers and
by providing adequate access to needed information and decision support tools. Numerous
applications of health information technology have emerged in recent years, from simple
e-mail communication between patients and clinicians to more sophisticated patient Web
portals that enable patients to interact with their physicians’ electronic medical records.
Such applications range widely in complexity as well as in cost. Most of the experts
interviewed for this project agreed that supportive information technology is generally
underused and that organizations at the forefront of developing patient-centered HIT
applications are demonstrating that they can enhance physician-patient partnerships in
care. The key to success is to make adoption easy for both patients and clinicians, and to
implement applications gradually in order to avoid fears that new technology will abruptly
undermine the quality of the patient-caregiver interaction.
MODELS OF SUCCESS
The factors contributing to patient-centered care outlined in the previous section can be
found at work in a small but growing number of hospitals and medical groups across the
country. This section briefly highlights several examples to illustrate how most or all of the
factors identified can be applied in an integrated, comprehensive way to achieve high
levels of patient-centered care, as well as other important health care and business
outcomes.
MCG Health System
The MCG Health System (MCG), in Augusta, Georgia, provides a remarkable example of
what can be achieved in a large academic health system over a relatively short period of
time. MCG includes an adult and a children’s medical center, both of which are affiliated
with the Medical College of Georgia. In 1993, MCG began a process of transforming its
13
organizational culture, starting with the development of its new children’s hospital. An
internal assessment revealed that the care delivered addressed primarily the needs of
providers and did not adequately respond to patients’ and families’ needs and concerns.26
Senior leaders at MCG made a commitment to improving patient-centered care in its new
pediatric inpatient units. The ensuing transformation, which evolved to include adult
health care services and medical education as well, comprised the following key elements:
Leadership. According to Pat Sodomka, senior vice president for patient- and family-
centered care at MCG, “Leaders are the guardians of the ideals related to the patient
experience of care.”27 The commitment and participation of senior leadership were
instrumental in initiating and sustaining the organization’s commitment to patient-
centered care.
Strategic Vision. In 1993, hospital leaders convened a visioning retreat, where
participants developed a philosophy and values statement for the new MCG Children’s
Medical Center and built a consensus for patient- and family-centered concepts and
priorities. Attendees included hospital- and community-based physicians, other clinical
staff, administrators, and families.
Involvement of Patients and Families. A focus on involving patients and families
has been the cornerstone of the MCG transformation. MCG began by establishing the
Family-Centered Care Steering Committee, which included staff, faculty, and families.
Training sessions were held to help committee members learn how to work
collaboratively. The original committee evolved into the Family Advisory Council,
which continues to provide guidance for policy and program development. More than
125 patient and family advisers are currently involved in collaborative endeavors at
MCG. Another example of including patients and families is the MCG policy of
inviting families to stay with their loved ones 24/7, especially in the intensive care unit.
Supportive Work Environment. Patient-centered behaviors among the MCG
workforce are both modeled and rewarded. Staff members are integrally involved in all
aspects of organization planning and process design. The MCG human resources
department ensures that new employees possess attitudes and skills consistent with
patient- and family-centered care. Behaviors for customer service and for patient- and
family-centered care have been defined, and both sets of behaviors are included in
position descriptions and MCG’s performance-review system.
Systematic Measurement and Feedback. MCG’s efforts to advance patient- and
family-centered care have been closely monitored through several measurement
activities. Through the patient and family councils, the efforts of the director of Family
Services Development, and a program called “Speak Up!”, leaders regularly receive
14
patient and family input on the experience of care. Patient feedback is also obtained
through independent surveys, and the results are compelling: MCG Children's
Medical Center has consistently ranked in the 90th percentile or higher among more
than 50 children’s hospitals in a national survey of patient satisfaction.
Quality of the Built Environment. Patients and family members were integrally
involved in the architectural design of the new Children’s Medical Center,
collaborating with architects, physicians, nurses, and others. Patient perspectives also
were incorporated in the redesign of several areas in the adult hospital, including the
mammography area of MCG Breast Health Services, a PET/CT unit and the
Neuroscience Intensive Care Unit. The redesign of these units created warm and
welcoming spaces to help increase patient comfort, privacy, and convenience.
Since the transformation process began in 1993, patient- and family-centered care
has become the core business model for the entire organization, leading to positive results
on each one of MCG's fundamental business metrics: finances, quality, safety, satisfaction,
and market share. MCG has been recognized as a pioneer in patient- and family-centered
care by the American Hospital Association and the Institute for Family-Centered Care,
and was recently featured in the PBS series Remaking American Medicine.28
Bronson Methodist Hospital
Bronson Methodist Hospital (BMH) is the flagship organization of Bronson Healthcare
Group, a large community health system serving the nine-county region surrounding
Kalamazoo, Michigan. As a result of its commitment to patient-centered care, BMH has
been the recipient of numerous awards, including the Malcolm Baldrige National Quality
Award in 2005. Factors contributing to the success of BMH include:
Leadership. Frank Sardone, President and CEO of Bronson Healthcare Group,
exemplifies the qualities of senior leadership required to articulate a strong vision that
places patients at the central focus of the organization, and that engages a collaborative
management team to carry the vision forward. Sardone describes a “three-legged
stool” of leadership excellence, consisting of the board of directors, senior
management, and the medical and nursing staffs. Leaders at the management level
meet for a two-day retreat three times each year for planning and strategy
development. Board members actively participate and are consulted throughout the
process. Medical and nursing staff leaders work on “goal-sharing” and align strategic
objectives to foster collaboration.
Strategic Vision. According to Sardone, excellence is embedded in BMH’s culture
and is the thread running through its mission. Three strategic goals, known as the
15
“Three Cs,” comprise the vision—Clinical Excellence, Corporate Effectiveness, and
Customer and Service Excellence. The one-page Plan for Excellence, distributed to all
employees, captures the mission and Three C vision, and outlines the personal
accountability that “every staff member has every day, with every interaction, with
every customer.”29 The plan serves as a constant “line of sight” reminder of the
principles critical to BMH in delivering high-quality care and excellent service.
Supportive Work Environment. Since the mid-1990s, BMH has focused on
becoming the employer of choice in the region. The hospital’s Workforce
Development Plan includes the strategies needed to develop and retain the current
workforce as well as those needed to address future staff recruitment, retention,
development, and diversity. For example, to meet a critical need for respiratory
therapists, BMH provides interested staff members with financial assistance, including
benefits and payment for tuition and books, while they are attending classes.
Evaluation of individual performance is aligned with the organization’s Three Cs,
annual objectives, and action plans; reward and recognition are directly related to the
results achieved. For several years running, BMH has been included in Fortune
magazine’s “100 Best Companies to Work For.”30
Quality of the Built Environment. A major redevelopment of the BMH physical
space initiated in 1993 has resulted in a state-of-the-art, all-private-room facility on a
28-acre, easily accessible health care campus. The facility includes a medical office
pavilion, an outpatient pavilion, and an inpatient pavilion that come together around a
central garden atrium. BMH is currently using evidence-based design to develop a
new birthing center and neonatal intensive care unit. As a participant in the Pebble
Project, described earlier, BMH is measuring employee turnover, outcomes, length of
stay, cost per unit of service, waiting times, patient satisfaction levels, nosocomial
infection rates, and organizational behaviors in the new versus the old facilities.
Systematic Measurement and Feedback. BMH employs multiple measures to
achieve a “balanced scorecard” of its patient-centered care results, including patient
surveys, post-discharge telephone calls, focus groups, and community surveys. In
addition, BMH leaders and patient relations staff conduct “rounds” to talk to and learn
from patients and visitors. According to results from a national patient survey vendor,
patient satisfaction at BMH has improved from approximately 95 percent in 2002 to
almost 97 percent in 2004.
Supportive Technology. On the wireless campus, all visitors, patients, and staff can
access the Internet via workstations. While on site, patients and visitors have access to
maps, service directories, and other information through interactive kiosks and the
public Web site. All BMH employees have access to e-mail and to the BMH intranet
16
as well. In addition, the system allows physicians to provide patient care from off-site
locations by accessing patient information through a secure Internet connection.
Other Successful Models
Other important models of successful implementation of patient-centered care exist in
both the ambulatory and inpatient care settings. Some of the more prominent examples
identified through the project interviews include the following:
Virginia Mason Medical Center, where top leadership support guided a strategic
planning process that led to a total redefinition of the organization’s mission to put the
patient first, utilizing a set of “compacts” with medical staff and senior management to
specify roles and responsibilities, and incorporating concepts of “lean production” as
developed by world-class manufacturers such as Toyota.31
Cincinnati Children’s Hospital Medical Center, where partnering with patients
and families takes place on multiple levels (such as through the Family Advisory
Committee, on quality-improvement teams, on hospitalwide teams, and on unit-based
committees and task forces), creating an environment where families are no longer
viewed as visitors, units are open 24/7, and families are encouraged to be present for
rounds and given choices about how they would like to participate.32
Henry Ford Health System, where senior leadership cultivated collaboration across
organizational lines and within divisions to create a team approach to cancer care,
increasing patient satisfaction levels to 99 percent, and employed e-prescribing
technology to improve access, information, safety, and efficiency.33
Weill Cornell Medical College, New York, NY, where innovations in the
built environment for a new ambulatory care complex have led to documented
reductions in errors, improved workflow, alleviation of patient anxiety, and increased
staff productivity.34
These and other examples demonstrate how innovative organizations have successfully
applied the concepts and principles of patient-centered care to achieve dramatic
improvements in a wide range of measurable outcomes.
STRATEGIES FOR LEVERAGING CHANGE
As shown in the previous sections, multiple factors contribute to patient-centered care,
and there are a growing number of examples demonstrating how these factors can be
integrated into successful programs. Yet, also as noted earlier, the evidence suggests that
most organizations are far from achieving what is possible.
17
This section reviews some of the key strategies identified in the project interviews as
necessary to overcome barriers and to help leverage widespread implementation of
patient-centered care. These strategies are divided into two groups: (1) those designed
primarily to strengthen the capacity to achieve patient-centered care at the organization
level, and (2) those aimed at changing external incentives in the health care system as a
whole, to positively influence and reward organizations striving to achieve high levels of
patient-centered care.
Organization-Level Strategies
Leadership Development and Training. An overwhelming conclusion emerging from
this project is that senior leadership at the level of the CEO and board of directors is
essential to achieving patient-centered care. The importance of leadership suggests the
need to focus substantial resources on the development of capable, committed individuals
to fill these critical roles. To be successful, an overall strategy for leadership education and
development must encompass the entire pipeline of health care leaders, from graduate
education and entry level to mid-career, and finally to the senior level. It must also cross
disciplines, from administration to nursing to medicine, and span multiple sectors,
including health care delivery organizations, suppliers, and insurers.
Internal Rewards and Incentives. As capable, committed leaders are trained and
recruited, an equally important strategy will be to assure that they are retained and
rewarded for desired levels of performance. Experts interviewed for this project expressed
considerable dismay that hospital executives turn over far too frequently, sometimes as
often as every two or three years. Executive compensation is oriented primarily to
achieving bottom-line financial results based on quarterly earnings and market share;
currently less than 5 percent of hospital CEO compensation is tied to patient experience
scores.35 Clearly, compensation and incentives for CEOs and senior management must
shift to focus on measurements of patient-centered care as part of an overall performance
scorecard. Such a shift will require new levels of engagement and support by boards of
directors. Similar shifts in compensation and rewards must take place at all levels of the
organization, from the medical staff to frontline employees.
Training in Quality Improvement. Despite all of the emphasis on various quality-
improvement approaches in recent years, experts interviewed expressed concern that there
is still not a widespread, ingrained capacity for process improvement in most health care
organizations. While managers may possess some knowledge of clinical guidelines and the
PDSA cycle of quality improvement, few of these skills have been systematically applied to
improving the patient care experience. Staff members at multiple levels in the organization
18
need training in quality-improvement concepts and methods that will enable them to
effectively make, measure, and manage change. Physicians may be the ones most in need
of such training, since most do not receive such instruction in medical school. Historically,
physicians have been trained largely to succeed as individuals but not as members of a
team. Yet team approaches are central to quality improvement, since almost everything
needed to achieve patient-centered care is dependent on successful relationships among
staff as well as among patients and their families.
Practical Tools Derived from an Expanded Evidence Base. For change to occur,
evidence regarding specific interventions that work to improve patient-centered care must
be documented and made available to managers and change leaders. Important progress
has been made in this direction, but more is needed, particularly in a form that is readily
accessible to staff in busy office practices and other care settings. For example, the Picker
Institute Europe makes available a set of improvement guides on various topics, aimed at
supporting managers responsible for interpreting and using patient survey results to
improve scores.36 Through its Quality Enhancing Interventions (QEI) project, researchers
at Picker Europe also have compiled evidence on the effectiveness of a broad spectrum of
patient-centered interventions.37 A similar effort is under way to update The CAHPS
Improvement Guide and to make it accessible to health plans and ambulatory care practices
as a Web-based tool. The Pebble Project, described earlier, is attempting to document the
evidence with respect to architectural and interior design strategies. Such practical
guidance, based on rigorous evaluations of effectiveness, is needed to support the efforts of
well-trained staff in supportive work environments.
System-Level Strategies
Public Education and Patient Engagement. According to Nancy Schlichting, president
and CEO of the Henry Ford Health System, consumers are the single most important
drivers of change in health care organizations. Strategies for educating and engaging
patients to take a more active role in the care process will provide an important
complement to the efforts of health care organizations to become more patient-centered.
Recent national polls indicate that most Americans want to become more involved in
their care and be active partners with their health care providers in making decisions.38
Information and tools to support patients in this expanded decision-making role are
becoming increasingly available through the Internet and other media. The evidence
suggests that decision-making approaches shared between patients and providers can lead
to improved patient knowledge, more realistic perceptions of potential benefits and harms,
and greater ease in reaching decisions that reflect patient values and preferences.39 Yet the
availability of these tools is still quite limited in the population as a whole, and many
19
Americans are not aware of their features and benefits. Strategies for promoting awareness
of tools are needed to stimulate their demand and use. Involving patients and families at
the various levels described earlier will also lead to increased pressure for organizational
responsiveness to the need for patient-centered care.
Public Reporting of Standardized Measures. The importance of systematic
measurement and feedback to achieving patient-centered care was noted earlier. Such
measures are useful not only for monitoring and guiding improvement within
organizations, but for holding organizations accountable for their results through public
reporting. Ideally, such measurement and reporting should be based on the best available
scientific evidence and standardized to enable fair and accurate comparisons within and
across organizations and practitioners. Building on the foundation established by the
original Picker surveys, the evolving CAHPS suite of standardized instruments for
assessing the patient experience now spans the continuum of care, including health plans,
medical groups, individual physicians, in-center hemodialysis centers, hospitals, nursing
homes, home care services, and assisted living facilities.40
The Centers for Medicare and Medicaid Services (CMS) publicly reports data from
many of the CAHPS surveys on its Web site, and is planning to report results from
national implementation of the CAHPS Hospital Survey in March of 2008. A number of
regional initiatives, such as the Massachusetts Health Quality Partners and the Pacific
Business Group on Health, are also publicly reporting patient experience survey data to
help consumers make informed choices about providers. A limited but growing body of
evidence suggests that public reporting of quality measurements creates strong incentives
for organizations to improve their performance.41 The effectiveness of these data for
supporting consumer choice of health care providers is less clear.42 However, the experts
interviewed for this project agree that the public reporting of patient-centered care
measurements will play an increasingly powerful role in stimulating organizational change,
especially as they are incorporated into various pay-for-performance schemes designed to
link either cash payments or market share to comparative levels of performance.
Accreditation and Certification Requirements. Accreditation and certification programs
have historically provided significant external incentives for health care organizations to
improve. Increasingly, these programs are building measurements of patient-centered care
into their process. For example, the National Committee for Quality Assurance (NCQA)
is exploring how measurements of patient-centered care might be built into a physician
quality recognition program, in which physicians or physician groups interested in seeking
recognition submit the required data to NCQA for scoring against predefined standards.43
20
NCQA currently gives accreditation points to health plans that conduct and apply
ambulatory patient surveys for physicians or groups in their network. As another example,
the American Board of Medical Specialties (ABMS) is working with its Member Boards to
develop revised maintenance-of-certification requirements that would include
measurements of patient-centered care. Although the data would not be publicly reported,
physicians would be required to use them to complete specific quality improvement
modules to obtain certification. The American Board of Internal Medicine, the largest of
the certifying boards, is currently using a tailored version of the new CAHPS Clinician &
Group Survey in its system for certifying specialists in internal medicine.
CONCLUSION
The findings and evidence presented in this paper demonstrate that considerable consensus
exists regarding the attributes of patient-centered care and the key organizational factors
required for attaining them. Although patient-centered care can be defined, measured, and
achieved with great success in some organizations, national data suggest that the system as
a whole can do much better. While there are many promising examples of organizations
achieving excellence in patient-centered care, these innovators are not yet the norm. The
challenge lies in elevating the norm through strategies at both the organization and the
system level that can leverage the experience of these innovators to motivate large-scale
implementation of patient-centered care.
21
APPENDIX A. LIST OF INTERVIEWS
Leaders of Organizations Demonstrating Excellence in Patient-Centered Care
Gary Kaplan, M.D.
Chairman and CEO
Virginia Mason Medical Center
Katharine Luther, R.N., M.P.M., C.P.H.Q.
Director, Performance Improvement
Memorial Hermann Hospital
Julie Morath
Chief Operating Officer
Children’s Hospitals and Clinics of
Minnesota
Frank Sardone
President and CEO
Bronson Methodist Hospital
Nancy Schlichting
President and CEO
Henry Ford Health System
Patricia Sodomka, FACHE
Executive Vice President, CEO, Hospital
Operations
MCG Health, Inc.
Experts in Design and Implementation of Patient-Centered Care Strategies
Rosalyn Cama
President and Principal Interior Designer,
CAMA, Inc.
Chair, Center for Health Design
Erie Chapman
President and CEO
Baptist Healing Trust
Peter Coughlan
Lead, Transformation Practice
IDEO
Susan Edgman-Levitan, PA
Executive Director
John D. Stoeckle Center for Primary Care
Innovation
Susan Frampton, PhD
President
Planetree, Inc.
Kathleen Jennison Goonan, MD
Executive Director
Center for Performance Excellence
Beverly Johnson
President and CEO
Institute for Family-Centered Care
Heather J. Kopecky, PhD, MBA
Partner
Heidrick & Struggles
Wendy Leebov
Wendy Leebov, Inc.
Marie Sinioris
President and CEO
National Center for Healthcare Leadership
Gail Warden
President Emeritus
Henry Ford Health System
22
APPENDIX B. INTERVIEW GUIDE
What are the key attributes of patient-centered care?
What are the most important factors that contribute to patient-centered care?
Are there differences in these factors for inpatient and ambulatory care settings?
What are the major barriers that stand in the way of achieving patient-centered care?
Can you describe one or two examples or success stories that illustrate what it takes
to achieve patient-centered care?
Are there important lessons from these examples or success stories that can be
applied more broadly?
What is it going to take to achieve widespread implementation of patient-
centered care?
Where will the leadership and/or leverage come from to drive this transformation?
23
NOTES
1 Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century
(Washington, D.C.: National Academies Press, 2001).
2 Institute of Medicine, Envisioning the National Health Care Quality Report (Washington, D.C.:
National Academies Press, 2001).
3 Agency for Healthcare Research and Quality, National Healthcare Quality Report, Publication
No. 06-0018 (Rockville, Md.: AHRQ, Dec. 2005).
4 C. Schoen, R. Osborn, P. T. Huynh, M. M. Doty, K. Davis, K. Zapert, and J. Peugh,
Primary Care and Health System Performance: Adults’ Experiences in Five Countries,” Health
Affairs Web Exclusive (Oct. 28, 2004):w4-487–w4-503.
5 Ibid.
6 J. Conway, B. Johnson, S. Edgman-Levitan et al., “Partnering with Patients and Families to
Design a Patient- and Family-Centered Health Care System,” background paper for invitational
meeting of patient-centered care leaders, June 2006.
7 M. Gerteis, T. L. Delbanco, J. Daley et al. (eds.), Through the Patient’s Eyes (San Francisco:
Jossey-Bass, 1993).
8 www.familycenteredcare.org. Last accessed October 17, 2006.
9 www.planetree.org. Last accessed October 17, 2006.
10 C. Cronin, “Patient-Centered Care: An Overview of Definitions and Concepts,” prepared
for the National Health Council, February 10, 2004.
11 Agency for Healthcare Research and Quality, National CAHPS Benchmarking Database,
2006 CAHPS Health Plan Survey Chartbook, Publication No. 06-0081-EF (Rockville, Md.:
AHRQ, Sept. 2006).
12 The Commonwealth Fund Commission on a High Performance Health System, Why Not
the Best? Results from a National Scorecard on U.S. Health System Performance (New York: The
Commonwealth Fund, Sept. 2006).
13 Schoen, Osborn, Huynh et al., “Primary Care,” 2004.
14 Commonwealth Fund Commission, Why Not the Best? 2006.
15 Ibid.
16 National CAHPS Benchmarking Database, CAHPS Hospital Survey Chartbook, Publication
No. 06-0049 (Rockville, Md.: AHRQ, Mar. 2006).
17 S. M. Shortell, J. Schmittdiel, M. C. Wang et al., “An Empirical Assessment of High-
Performing Medical Groups: Results from a National Study,” Medical Care Research and Review,
Aug. 2005 62(4):407–34.
18 E. H. Schein, Organizational Culture and Leadership (San Francisco: Jossey-Bass, 1992).
19 J. Silversin and M. J. Kornacki, Leading Physicians Through Change: How to Achieve and Sustain
Results (Tampa, Fla.: American College of Physician Executives, 2000).
20 S. Edgman-Levitan, “Healing Partnerships: The Importance of Including Family and
Friends,” Putting Patients First, S. B. Frampton et al. (San Francisco: Jossey-Bass, 2003), 51–69.
21 N. Rave, M. Geyer, B. Reeder et al., “Radical Systems Change: Innovative Strategies to
Improve Patient Satisfaction,” Journal of Ambulatory Care Management, Apr./June 2003 26(2):159–74.
24
22 E. Chapman, Radical Loving Care: Building the Healing Hospital in America (Nashville, Tenn.:
Baptist Healing Hospital Trust, 2003).
23 S. Edgman-Levitan, D. Shaller, K. McInnes et al. (eds.), The CAHPS Improvement Guide:
Practical Strategies for Improving the Patient Care Experience (Boston: Department of Health Care
Policy, Harvard Medical School, 2003).
24 B. Arneill and K. Frasca-Beaulieu, “Healing Environments: Architecture and Design
Conducive to Health,” Putting Patients First, S. B. Frampton, et al. (San Francisco: Jossey-Bass,
2003), 163–90.
25 www.healthdesign.org/research/pebble/. Last accessed October 25, 2006.
26 Conway, Johnson, Edgman-Levitan et al., “Partnering with Patients,” 2006.
27 www.ifcc.org. Last accessed October 25, 2006.
28 www.mcghealth.org/News/e-news/partnering_patients.html. Last accessed October 26, 2006.
29 http://baldrige.nist.gov/PDF_files/Bronson_Profile.pdf. Last accessed October 26, 2006.
30 Ibid.
31 R. M. J. Bohmer and E. M. Ferlins, Virginia Mason Medical Center, Harvard Business
School Case Study 9-604-044, January 11, 2006.
32 Conway, Johnson, Edgman-Levitan et al., “Partnering with Patients,” 2006.
33 www.henryford.com. Last accessed October 30, 2006.
34 www.healthdesign.org/research/pebble/. Last accessed October 25, 2006.
35 Personal communication with Heather Kopecky, Heidrick & Struggles, Inc., July 12, 2006.
36 www.pickereurope.org. Last accessed October 30, 2006.
37 A. Coulter and J. Ellins, Patient-Focused Interventions: A Review of the Evidence (London:
Picker Institute Europe, May 2006).
38 Peter D. Hart Research Associates, “Americans and Their Health Care” (Chicago: Blue
Cross and Blue Shield Association, Nov. 2004).
39 A. M. O’Connor, D. Stacey, V. Entwistle et al., “Decision Aids for People Facing Health
Treatment or Screening Decisions (Cochrane Review),” The Cochrane Library, Issue 1,
(Chichester, U.K.: John Wiley & Sons, Ltd., 2004).
40 www.cahps.ahrq.gov. Last accessed October 30, 2006.
41 J. H. Hibbard, J. Stockard, and M. Tusler, “Hospital Performance Reports: Impact on
Quality, Market Share, and Reputation,” Health Affairs, July/Aug. 2005 24(4):1150–60.
42 Shaller Consulting, Consumers in Health Care: Creating Decision Support Tools That Work
(Oakland, Calif.: California HealthCare Foundation, June 2006).
43 www.ncqa.org. Last accessed October 30, 2006.
25
RELATED PUBLICATIONS
Publications listed below can be found on The Commonwealth Fund’s Web site at
www.commonwealthfund.org.
Creating Payment Systems to Accelerate Value-Driven Health Care: Issues and Options for Policy Reform
(September 2007). Harold D. Miller.
Value-Driven Health Care Purchasing: Four States that Are Ahead of the Curve (August 2007). Sharon
Silow-Carroll and Tanya Alteras.
Evidence-Informed Case Rates: A New Health Care Payment Model (April 2007). François de Brantes
and Joseph A. Camillus.
Quality Matters: Patient-Centered Care (March/April 2007). Newsletter.
Beyond Our Walls: Impact of Patient and Provider Coordination Across the Continuum on Outcomes for
Surgical Patients (February 2007). Dana Beth Weinberg, Jody Hoffer Gittell, R William Lusenhop
et al. Health Services Research, vol. 42, no. 1, pt. 1 (In the Literature summary).
The Role and Relationship of Cultural Competence and Patient-Centeredness in Health Care Quality
(October 2006). Mary Catherine Beach, Somnath Saha, and Lisa A. Cooper.
Obtaining Data on Patient Race, Ethnicity, and Primary Language in Health Care Organizations: Current
Challenges and Proposed Solutions (August 2006). Romana Hasnain-Wynia and David W. Baker.
Health Services Research, vol. 41, no. 4, pt. 1 (In the Literature summary).
Promising Practices for Patient-Centered Communication with Vulnerable Populations: Examples from Eight
Hospitals (August 2006). Matthew Wynia and Jennifer Matiasek.
Technology for Patient-Centered, Collaborative Care (July–September 2006). Donald M. Berwick, John
H. Wasson, Deborah J. Johnson et al. Journal of Ambulatory Care Management Special Issue, vol. 29,
no. 3 (In the Literature summary).
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... PCC is care that establishes a patient-provider partnership; ensures respect for patients' needs, and preferences; assures that patients have the required literacy to make decisions; and supports patient involvement (3,4). The key dimensions of PCC are (a) Respect for patient values, preferences, and needs; (b) Coordination and integration of care, information, communication, and education; (c) Physical comfort, entailing pain management, assistance in daily living, and comfortable surroundings; (d) Emotional support and alleviation of fear and anxiety; (e) Involvement of family; (f) Transition and continuity of care; and (g) Access to care (5,6). Orienting care around patients' needs improved patients' clinical outcomes, reduced both under-utilization and overutilization of health services, and enhanced satisfaction of patients and providers alike (7). ...
... Research demonstrated that nurturing patient-provider interactions shape the quality of care (2,11). Nurturing interactions of providers with patients require inner resources and a human touch (6). PCC requires providers to understand patients' biopsychosocial context, ensure patient understanding of the clinical condition, and share power and responsibility (4,11,12). ...
... Despite the essential importance of PCC to higher quality of care, and despite the growing evidence regarding its importance to patients, providers, and health systems, hospitals are far from achieving PCC (6,11,(14)(15)(16)(17). Previous studies theorized the benefits of nurturing provider-patient interactions, and other studies tested the implementation of PCC in community settings, but studies that elucidate the perspective of patients and their explicit expectations of providers in acute care are scant (2)(3)(4). ...
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Objective Patient-centered care calls to contain patients in their time of crisis. This study extends the knowledge of provider patient interactions in the hectic environment of acute care applying Bion's container-contained framework from psychoanalysis. Methods Following ethical approval, we performed a narrative inquiry of the experiences of ten patients upon discharge from lengthy hospitalizations in acute care. Interviews were conducted upon discharge and about one-month post-discharge. Findings Data analysis suggests four modes of containing of patients by providers. In nurturing interactions, typical of an active container-contained mode, patients experienced humanized care, symptom control, hope, and internal locus of control. This mode yielded patient gratitude toward providers, wellbeing, and post-discharge self-management of diseases. In rigid and wall-free modes of containing, patients experienced a sense of powerlessness and discomfort. A new mode of container-contained was identified, the “Inverted Container”, which extends Bion's theory and contradicts patient-centered care. In inverted containers, patients contained the providers yet reported feeling gratitude toward providers. The gratitude constitutes a defense mechanism and reflects a traumatic experience during hospitalization, which led to post-discharge distrust in providers and hospitals and poor self-management of illness. Conclusions To effectively provide patient-centered care, provider-patient interaction in lengthy hospitalizations must move along a clinical axis and a relationship axis. This shifting may facilitate containing patients in their time of crisis so essential processes of reflection, projection, and transference are facilitated in-hospital care.
... Quality patient-centered care is multi-faceted, but patients' experiences of care are at the cornerstone of this concept. 1 Key aspects of care are frequently measured through reports of patient experiences during healthcare encounters such as perceptions about ease, access, and coordination of care. 1 Research on patient experiences with care is important for assessing continuity of care, strong patient-provider relationships, and improved outcomes. 2 Positive patient experiences with care have been linked to increased treatment adherence, better clinical outcomes, and reduced unnecessary healthcare utilization. 3 Researchers have studied the association between patient experiences with care and patient demographic characteristics, [4][5][6][7] but little research has focused on examining the impact of clinical depression on patient experiences with care. ...
... 1 Key aspects of care are frequently measured through reports of patient experiences during healthcare encounters such as perceptions about ease, access, and coordination of care. 1 Research on patient experiences with care is important for assessing continuity of care, strong patient-provider relationships, and improved outcomes. 2 Positive patient experiences with care have been linked to increased treatment adherence, better clinical outcomes, and reduced unnecessary healthcare utilization. 3 Researchers have studied the association between patient experiences with care and patient demographic characteristics, [4][5][6][7] but little research has focused on examining the impact of clinical depression on patient experiences with care. ...
Article
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Purpose: We examined whether breast cancer survivors' experiences with care differed by a recent history of clinical depression, and whether associations differed by race/ethnicity. Methods: Using the Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset, we analyzed records of breast cancer survivors who completed a survey at least 12 months after their cancer diagnosis. We assessed clinical depression 12 months prior to survey completion using Medicare claims. We used separate multivariable logistic regressions to examine the associations between depression and excellent (vs. less than excellent) ratings of experiences with care (i.e., doctor communication, getting needed care, getting care quickly, getting prescription drugs, specialist and overall care). We also assessed interactions of depression by race/ethnicity. All models were adjusted for demographics and cancer prognostic and treatment factors. Results: Of the 2271 survivors, 7.6% were clinically depressed. After adjusting for covariates, survivors with clinical depression had lower odds of reporting excellent ratings of their ability to get needed care, care by their specialist, and overall care, compared to those without depression (AOR = 0.58, 95% CI: 0.40-0.84; AOR = 0.40, CI: 0.31-0.76; and AOR = 0.61, CI: 0.42-0.89, respectively). Among Hispanics, having depression was associated with higher odds of excellent ratings of one's ability to get needed care (AOR: 5.42, 95% CI: 1.02-28.81). No other statistically significant associations by race/ethnicity were found. Conclusions: Breast cancer survivors with depression report poorer patient experiences with care. Further research is needed to understand complexities of ratings of experiences with care among survivors of diverse backgrounds. Implications: Survivors with a recent history of clinical depression may benefit from additional supportive care services.
... To achieve high-quality care in medical services, patient-centeredness should be considered a key attribute of healthcare [2,3]. Patient-centered care is defined as (1) being responsive to patients' needs, values, and preferences; and (2) involving patients in decision-making [3][4][5]. Accordingly, efforts to improve PE through patient engagement in healthcare are intensified. PE involves several stakeholders, such as patients, caregivers, medical staff, and administrators, dealing with complex and diverse problem situations. ...
... DT themes introduced by Carlgren et al. (2016) deal with five important concepts for creative problem-solving: "User focus", "Problem-framing", "Visualization", "Experimentation", and "Diversity". They emphasize that creative problem-solving is possible through (1) the deep understanding or involvement of users in identifying their pain points or latent needs by using design ethnography such as user journeys, empathy map, and persona; (2) reframing the initial problem space to catch an unexpected potential solution with the techniques of how-might-we-questions, the five whys technique, and the problem statement; (3) transforming ideas into visual structures to effectively communicate ideas among users by using physical prototypes, sketching, and storyboarding; (4) iterative working for the refinement and testing feasibility of the solution for evaluation by conducting brainstorming; (5) involving multiple teams and the collaborative approach to reflect diverse perspectives in the decision-making process by using study visits, analogies, and demographics [20]. ...
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(1) There has been growing attention among healthcare researchers on new and innovative methodologies for improving patient experience. This study reviewed the approaches and methods used in current patient experience research by applying the perspective of design thinking to discuss practical methodologies for a patient-centered approach and creative problem-solving. (2) A scoping review was performed to identify research trends in healthcare. A four-stage design thinking process (“Discover”, “Define”, “Develop”, and “Deliver”) and five themes (“User focus”, “Problem-framing”, “Visualization”, “Experimentation”, and “Diversity”), characterizing the concept, were used for the analysis framework. (3) After reviewing 67 studies, the current studies show that the iterative process of divergent and convergent thinking is lacking, which is a core concept of design thinking, and it is necessary to employ an integrative methodology to actively apply collaborative, multidisciplinary, and creative attributes for a specific and tangible solution. (4) For creative problem-solving to improve patient experience, we should explore the possibilities of various solutions by an iterative process of divergent and convergent thinking. A concrete and visualized solution should be sought through active user interactions from various fields. For this, a specific methodology that allows users to collaborate by applying the integrative viewpoint of design thinking should be introduced.
... The similarities and differences have been identified in order to define and describe the level of family involvement in delivering PCC. Studies reported that out of nine different models and frameworks in which PCC was defined, family and friend's involvement was found to be 60% [48,49]. The values of love and respect for patients were seen to be the other aspects of PCC. ...
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Background Patient-centered care (PCC) approach has continued to gain recognition globally as the key to providing quality healthcare. However, this concept is not fully integrated into the management of primary health care (PHC) in existing nursing practice due to numerous challenges. Among these challenges is the perception of nursing on PCC in the Primary Health Care system. This study seeks to present the results of qualitative research performed at various selected PHC centres on nurses’ perceptions in PCC practice. This study aim was to explore the perception of nurses on PCC. Methods A qualitative action research approach was adopted. The study involved 30 local government PHC centres located in Osun State Southwest of the federal republic of Nigeria. Data was collected through a semi-structured interview guide questions. Thereafter, data analysis was performed using thematic analysis and NVivo 12 software to generate themes, subthemes, and codes. Results PCC perceptions of nurses that was revealed in our findings were categorised into positive and negative themes. The negative themes include: poor approach by the nurses and lack of enforcement agency. The positive themes that emerged include: outcome driven healthcare, valued care provider, communication to sharpen care and driven healthcare service. Conclusion There is need for continuous training, and upgrading of nurses in line with global recommended standards of providing quality healthcare service delivery to the people. Therefore, the federal and state governments and local government council through the Nursing and Midwifery Council body should regulate, supervise, monitor and enforce the use and implementation of PCC in the PHC healthcare system.
... Edgman-Levitan also discussed research that identified several organizational characteristics associated with good patient experiences: governance, leadership, and vision; partnerships with patients and families; human resources and employee engagement; systematic feedback, data management, and goal setting; use of best practices around communication strategies and technology support; and the built environment [24][25][26]. ...
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Background: The Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts. Topics covered.: Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience? Key themes: Providers and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.
... There is no doubt that patient and family centred care could improve the quality of care given to patients if implemented adequately; however the continuity of this model of care can be challenging and complex (Bergbom, 2008) and will not continue to be implemented without leadership, support and participation (Shaller, 2007). ...
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Aims. To explore the role relatives, play in the care of patients in medical ward settings in Australia and Saudi Arabia and to understand the nature of this involvement. Background. There is little known about how nurses and relatives respond to the involvement of relatives in patient care in a healthcare context, and the impact of the participation on the quality of care. Previous studies of relatives’ involvement focus on settings such as critical settings and paediatrics where relative involvement as advocates is most needed. Design. The study used a qualitative ethnographic approach based on an interpretive paradigm. Methods. Data collection was carried out in medical settings in two major hospitals, one in Australia and another in Saudi. Data were collected by observations and interviews over a six months period, with three months spent in each setting. Results. In both fields nurses and relatives faced ongoing ambiguity about the role relatives should play in the hospital environment and nurses were challenged by the unpredictability of relatives’ participation in patient care. The nurses’ fear of taking responsibility and uncertainty about the relatives’ role led them to take varied and individualised approaches to the involvement of relatives in patient care. Relatives were unclear about how to behave in the role, what the needs of patients were, and whether they were contributing to care and this resulted in frustration. Conclusion. The results show that ambiguity regarding the role of relatives led to problems in patient care such as safety concerns and conflicts.
Article
Objective: To develop and test of a measure of patient-centered care (PCC) culture in hospital-based perinatal care. Data sources: US perinatal hospitals; 1 provided survey development data and 14 contributed data for survey testing. Study design: We used qualitative and quantitative methods to develop the Mother-Infant Centered Care (MICC) culture survey. Qualitative methods included observation, focus group, interviews, and expert consultations to adapt items from other settings and create new items capturing dimensions of PCC articulated by The Commonwealth Fund. We quantitatively assessed survey psychometric properties using reliability (Cronbach's α and Pearson correlation coefficients) and validity (exploratory and confirmatory factor analysis [CFA]) statistics, and refined the survey. After confirming aggregation suitability (ICCs), we calculated "MICC culture scores" at the individual-, unit-, and hospital-level and assessed associations between scores and survey-collected, staff-reported outcomes to evaluate concurrent validity. Data collection: Survey development included 12 site-visit observations, one semi-structured focus group (five participants), two semi-structured interviews, five cognitive interviews, and three expert consultations. Survey testing used online surveys administered to obstetric and neonatal unit staff (N=316). Principal findings: Using responses from 10 hospitals with ≥4 responses from both units (n=240), the 20-item MICC culture survey demonstrated reliability (Cronbach's α=0.95) while capturing all PCC dimensions (subscale Cronbach's α=0.72-0.87). CFA showed validity through goodness-of-fit (overall chi-square=214 [p-value=0.012], SRMR=0.056, RMSEA=0.041, CFI=0.97, and TLI=0.96). Aggregation statistics (ICCs<0.05) justify unit- and hospital-level aggregation. Demonstrating preliminary validity, individual-, unit-, and hospital-level MICC culture scores were associated with all outcomes (satisfaction with care provided, within-unit team effectiveness, and relational coordination [RC] between units) (p-values<0.05), except for neonatal unit scores and RC (p-value=0.11). Conclusions: The MICC culture survey is a psychometrically sound measure of PCC culture for hospital-based perinatal care. Survey scores are associated with staff-reported outcomes. Future studies with patient outcomes will aid identification of improvement opportunities in perinatal care.
Article
Background Due to gender inequities that exist for women of childbearing age, there exists a need to deliver care tailored to their needs and preferences. Patient-centred care (PCC) can be used to meet these needs. This review aims to compare patient care delivery between PCC and obstetrical care. This can help us address how PCC should be delivered to women before, during and after pregnancy versus how it is delivered to patients regardless of sex. Methods A review of literature was conducted on MEDLINE, EMBASE, CINAHL and SCOPUS for English PCC and high-quality perinatal reviews published between 2010 and 2021. The data were analysed using a modified Walker and Avant framework. Results A total of 2138 unique studies were identified, with 11 PCC and 9 high-quality obstetrical care studies included. Common defining features between PCC and obstetrical care include respect and dignity, informed decision-making, therapeutic alliance, effective communication, social relationships and autonomy. PCC-specific features were holistic care, empowerment, individualized care, coordinated care and empathy. Unique high-quality obstetrical care themes included continuity of care, privacy and confidentiality, provider education and status, physical environment and equitable maternal care. Conclusions There are shared defining attributes between PCC and obstetrical care, including respect and dignity, informed decision-making, the therapeutic alliance, effective communication, social relationships and autonomy. However, there remain unique defining attributes for high-quality obstetrical care and PCC. This highlights the need for a unique approach to obstetrical care. More research on care for different physiological conditions in women is needed to address patient care that addresses different parts of the lifespan and develop frameworks that can influence health policy, patient care and health system evaluation. Patient or Public Contribution This study was one part of a larger, multicomponent study of how to implement PCC for women across the lifespan. While we did not specifically consult or involve women in this dual concept analysis, our larger study (content analysis of clinical guidelines and government policies, qualitative interviews with women and clinicians, Delphi study to prioritize consensus recommendations for achieving PCC for women) was guided by the experiences and input of a 50+ women advisory panel.
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As patient populations become increasingly diverse, health care organizations are looking for innovative ways to communicate effectively across cultures, languages, and health literacy levels. This study identified eight hospitals from across the country that have demonstrated a commitment to providing patient-centered communication with vulnerable patient populations. Through site visits and focus group discussions, the authors draw out "promising practices" from the hospital's efforts to lower language barriers and ensure safe, clear, and effective health care interactions. The promising practices include: having passionate champions to advocate for communication programs; collecting information on patient needs; engaging communities; developing a diverse and skilled workforce; involving patients; spreading awareness of cultural diversity; providing effective language assistance services; addressing low health literacy; and tracking performance over time. Hospital and health system leaders can use these practices as starting points to encourage patient-centered communication in their own organizations.
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This paper reports on a 2004 survey of primary care experiences among adults in Australia, Canada, New Zealand, the United Kingdom, and the United States. The survey finds shortfalls in delivery of safe, effective, timely, or patient-centered care, with variations among countries. Delays in lab test results and test errors raise safety concerns. Failures to communicate, to engage patients, or to promote health are widespread. Aside from clinical preventive care, the United States performs poorly on most care dimensions in the study, with notable cost-related access concerns and short-term physician relationships. Contrasts across countries point to the potential to improve performance and to learn from international initiatives.
Article
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Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.
Article
This paper is designed to assist health care payers and policymakers to restructure payment systems in ways that will improve the quality of health care and reduce (or slow the growth in) the costs of health care. Drawing on the research and proposals of many researchers and practitioners, it attempts to: summarize the key concepts involved in any discussion of ways to restructure payment systems; catalog the quality and cost problems that current payment systems create; list the key concerns that have been raised about pay-for-performance systems in health care; propose 12 goals that revised payment systems should seek to achieve in order to effectively address the problems; define the specific issues that need to be resolved in order to achieve these goals; describe the primary options for addressing each of these issues; and suggest a general strategy for making progress on payment restructuring.
Article
Decision aids are interventions designed to help people make specific and deliberative choices among options (including status quo) by providing (at a minimum) information on the options and outcomes relevant to a person's health status. A systematic review is needed to summarize what is known about their efficacy. 1. To create an inventory of existing decision aids. 2. To conduct a systematic review of randomized controlled trials of decision aids aimed at improving people's decision making and outcomes. The following electronic databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL, Aidsline, Cancerlit, the Cochrane Controlled Trials Register. In addition, individuals known to be active in the field of decision support were contacted. We screened titles and abstracts for all interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Information about the decision aids was compiled in an inventory and those evaluated in a randomized controlled trial were reviewed in detail. Using Cochrane review methods, two reviewers independently screened and extracted data on several evaluation criteria. Results of randomized trials were pooled using weighted mean differences and relative risks with all data analysed using a random effects model. Eighty-seven decision aids were identified. Twenty-three of them had been evaluated in 24 randomized controlled trials. Among the trials comparing decision aids to usual care interventions, decision aids performed better in terms of: a) greater knowledge of options in seven of seven studies (weighted mean difference (WMD = 19 out of 100, 95% confidence interval (CI): 13,25); b) more realistic expectations in two of three studies (RR=1.48 95%CI 1.02, 2.14); c) lower decisional conflict related to feeling informed in three of three studies (WMD = -9.0 of 100 95%CI: -15, -3); d) reducing the proportion of people who were passive in decision making in three of four studies (RR = 0.63, 95% CI: 0.5, 0.8). When simpler decision aids were compared to more detailed ones, the relative improvement was significant in: a) improved knowledge in two of seven studies (WMD = 4 out of 100, 95% CI: 2, 5); b) realistic expectations in two of two studies (relative risk (RR ranged from 1.5 95%CI: 1.3,1.8); and c) decisional conflict in one of two studies (WMD= -4 95% CI -8,-0.2). There was a consistent trend for decision aids to do no better than comparison interventions in affecting: satisfaction with the decision in five of six studies, satisfaction with the decision making process in four of five studies, and anxiety in four of five studies. Decision aids had a variable effect on which screening or treatment options were selected. Exposure to decision aids relative to controls resulted in a consistent non-significant trend toward reduced preference for major surgery over conservative options by 21 to 42 per cent in five of five studies; however, they had no impact on circumcision in two of two studies. For colon and prostate cancer screening choices, the results were inconsistent. Two studies have shown no impact on persistence with chosen option and few studies have shown significant benefits on general health outcomes (two of three studies), or disease-specific health outcomes (one of four studies). The number of decision aids is expanding, but there is considerable overlap in some areas leaving gaps in others. Trials of decision aids indicate that they are superior to usual care interventions in improving knowledge and realistic expectations of the benefits and harms of options; reducing passivity in decision making; and lowering decisional conflict stemming from feeling uninformed. When simpler versions of decision aids are compared to more detailed aids, the differences in knowledge are marginal but there are other benefits in terms of creating realistic expectations and in reducing decisional conflict. To date, decision aids have had little effect on anxiety or satisfaction with the decision making process or satisfaction with the decision. Their effects on choices vary with the decision. The effects on persistence with chosen therapies and health outcomes require further evaluation. The essential elements in decision aids for different groups and different types of decisions need to be established. Consensus needs to be reached regarding standards for developing and evaluating decision aids.
Article
A project was initiated at Northwestern Memorial Hospital in Chicago focusing on patient satisfaction in the outpatient setting and how to improve it. Eight outpatient diagnostic areas were selected and a steering committee was formed. The team used patient satisfaction scores and patient and staff interviews to identify areas for improvement. Innovations were implemented in communications and information technology, staff role design, and process flow. Successes were realized in patient satisfaction above the 95th percentile, improved staff satisfaction, productivity, and internal and external recognition. The program serves as an organizationwide model supporting the hospital's Best Patient Experience strategic goal. This patient-focused model is being replicated in other areas of the hospital and can be replicated elsewhere.
Article
This study builds on earlier work by assessing the long-term impact of a public hospital performance report on both consumers and hospitals. In doing so, we shed light on the relative importance of alternative assumptions about what stimulates quality improvements. The findings indicate that making performance data public results in improvements in the clinical area reported upon. An earlier investigation indicated that hospitals included in the public report believed that the report would affect their public image. Indeed, consumer surveys suggest that inclusion did affect hospitals' reputations.
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The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performing medical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.