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Issue of the Month: Bringing Patients to the Center of Hospital Care

By Sarah Klein

With the exception of health care, the customer is king. In hospital settings a focus on the technical aspects of delivering care often trumps a patient's need for information and personalized service. Patients are asked to wait in emergency rooms, without any information about delays. Families are required to arrange their visits around an institution's schedule. And communication between clinicians and patients is so poor that many patients can't even identify their doctor.

Patients, who may be too vulnerable to object and tacitly encouraged not to, often accept such treatment as the norm and remain passive participants in their care. "They expect that things get done to them, not with them," says Alison S. Clay, M.D., assistant professor of surgery at Duke University Medical Center in Durham, N.C., who has written and lectured about her experiences as a hospital patient. This remains true today, despite decades of work by patient advocates to inform hospital administrators and clinicians about the value of sharing information with patients, involving them in medical decision-making, and responding to their unique needs and values. Patient-centered care, as defined by the Picker Institute, also involves a commitment to provide rapid access to reliable health care advice, attend to the physical comfort and emotional needs of patients, and ensure care is well coordinated within health care settings and not disrupted during transitions between them.

Limited research suggests that using such techniques to engage patients in their care yields better outcomes, particularly when the techniques improve communication between doctors and patients. A study of 24,609 adult patients with chronic or serious conditions found those who participated in good collaborative care had better control of their blood pressure, blood glucose levels, and serum cholesterol than patients who had less confidence either in the information they received from doctors or their ability to care for themselves.[1] Another study, involving 2,272 patients hospitalized for acute myocardial infarction, found patients who rated hospitals poorly on Picker Institute measures of patient-centered care had poorer health outcomes than those who experienced more patient-centered care.[2]

There is some evidence that hospitals that employ these patient-centered techniques to engage patients also report fewer medical errors, and can have shorter lengths of stay and reduced overall costs. In 2003, MCG Health System in Augusta, Ga., redesigned its intensive care unit for neuroscience patients to encourage families to stay with their relatives at all times. Families that did provided useful observations to the medical staff on their relative's condition and needs, says Pat Sodomka, senior vice president at MCG and director of the Center for Patient- and Family-Centered Care at the Medical College of Georgia, MCG's affiliate. "Communication got so much better."

Medication errors in the neuroscience unit dropped by 62 percent, to six per year, from an average of 13. The length of stay fell 50 percent, and the staff vacancy rate fell to zero, from 7.5 percent. At the same time, the unit's patient satisfaction rating rose to the 95th percentile, from the 10th. Employee satisfaction went up as well. "We never have a nurse vacancy in that unit," she says. The families "helped us help their loved ones," Sodomka says. "It isn't rocket science."

Barriers Considerable
So why isn't such an approach more widely accepted? It turns out that implementing a patient-centered care program in the hospital setting is much harder than it appears at first blush. "Unlike [improving] clinical processes, you have to remake the entire organization if you really want to see improvement," says Dale Shaller, principal of Shaller Consulting, a health policy analysis and management consulting practice, and managing director of the National Consumer Assessment of Healthcare Providers and Systems (CAHPS) Benchmarking Database. The hospital version of this survey, HCAHPS, measures how responsive doctors and nurses are to hospital patients' concerns and how well they communicate information about medication and discharge plans.

A Commonwealth Fund analysis of the HCAHPS 2005 data, for example, found only 60 percent of patients reported that hospital staff explained what a prescribed medicine was for and warned of side effects in a way they could understand. Further, only 63 percent of hospital patients reported that they got help as soon as they wanted after pressing a call button. (However, one hospital did manage to explain the risks and benefits of prescribed medication 100 percent of the time, demonstrating such excellence is possible.)

Part of the problem is that most hospital administrators mistakenly believe they are providing patient-centered care. They only realize their institution's shortcomings when asked to identify specific, patient-centered services and find that they are lacking, says Jim Conway, senior vice president of the Institute for Healthcare Improvement. Such process-oriented questions include: Can patients' families join in rounds or the change-of-shift report? Do patients and families participate in quality, safety, and risk meetings? Do patients have a voice in determining the hospital's strategic or operational goals?

Even after recognizing deficiencies, hospital administrators encounter significant resistance to making changes. Providers are often worried "that the inclusion of the family will take up time, get people focused on areas that are not of significance, and get in the way of nimble decision making," Conway says. "They are also worried about what happens when patients find out what it is really like...that people will not see their clinicians the same way they saw them before."

Starting Slow
To overcome that fear, hospitals have to implement the necessary cultural changes slowly, Conway says. "You don't start on day one putting in place a patient and family advisory committee. You start [by involving patients] with a project," he says. That's fairly easy because, "in virtually every hospital in the country, they are renovating something," Conway says. Initial resistance typically fades when administrators and clinicians see the value of patient contributions and realize most patients are kindly disposed to them and want relatively modest changes. "They want to know what time you're going to do rounds; can you post that? They aren't gazillion dollar changes," Sodomka says.

Addressing complaints that patients aren't treated with dignity and respect requires more systemic change. Institutions that excel at customer service have careful hiring practices and tend to flatten out the institution's hierarchy, Shaller says. They describe themselves as a family or team, he says. But finding physicians, health care workers, and hospital employees who work well with others and deliver high levels of customer service isn't easy. "My personal experience with this is that there are some people who totally get it. It is totally innate. Then there is a percentage that could get it, if only they had the proper training. Then there are some people who will never do it," Shaller says.

"We've spent five years explaining to people what patient- and family-centered care is and we're still not there. We still have whole departments that are just resistant," says Joy Bennett, the co-chair of the Family Advisory Council at Cincinnati Children's Hospital.

Sometimes education is required on both sides. Bennett says departments that have implemented more patient-centered practices—including rounding with family members—alerted the council to another problem: patients don't understand what is expected of them. Many think they don't have anything to contribute and remain silent during rounds. "So we are shifting our focus to educating parents about the culture of the hospital," Bennett says.

Elevating patients' expectation for care, as well as their knowledge of the system, is another part of the solution. "We need to help them understand what they should expect, what is good care," Clay says. "We have a lot of work to do."

[1] J. H. Wasson et al. (2006) Patients Report Positive Impacts of Collaborative Care. Journal of Ambulatory Care Management 29, 199–206.

[2] A. M. Fremont et al. (2001) Patient-Centered Processes of Care and Long-Term Outcomes of Myocardial Infarction. Journal of General Internal Medicine 16, 800–818.

Related Publications
M. C. Beach et al. (2006) Is the Quality of the Patient-Provider Relationship Associated with Better Adherence and Health Outcomes for Patients with H.I.V? Journal of General Internal Medicine 21, 661–665.

N. Keating et al. (2002) How Are Patients' Specific Ambulatory Care Experiences Related to Trust, Satisfaction and Considering Changing Physicians? Journal of General Internal Medicine 17, 29–39.

M. Stewart et al. (2000) The Impact of Patient-Centered Care on Outcomes. Journal of Family Practice 49, 796–804.

I. Wilson et al. (2005) Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries between 1998 and 2000. Journal of General Internal Medicine 20, 715.

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