After an hour of describing a recent admission to hospital for treatment of pneumonia, ‘Mary’ paused and said “You know, I couldn’t fault the technical care, but…I was treated like a lump of clay…people came and went…they did things to me ... staff didn’t tell me what they were doing, who they were or how I was going…and that is my lasting memory of my care.” ‘Patient-centred’ has become a catchphrase being used liberally in healthcare policy, guidance and local management strategy. Yet how truly focused on patients are current efforts? To what extent do these endeavours engage patients in planning and making improvements?
The history of healthcare services sheds some light on the lack of ‘customer’ engagement in healthcare improvement. In the acute sector, the military legacy can be traced back to about 100 BC when the Romans established hospitals (valetudinaria) for the gladiators, slaves and sick and injured soldiers. Modern clinical language still uses terms based on a military model of healthcare delivery (eg ‘discharge’ and ‘triage’). Yet the patients have changed, with a shift towards largely chronic conditions linked to the increasing burden of ageing populations.
While we may acknowledge that change is needed, making it happen in a complex, well-established system is difficult, and requires new approaches to tackle resistance. Healthcare services that have taken a strategic, organization wide approach to patient-focused change have witnessed benefits for patients, clinicians, management and operational metrics (eg cost savings, staff satisfaction, improved staff retention rates). Research highlights the importance of health services taking a comprehensive approach by noting the positive association between patient experience, clinical outcomes and resource utilisation (eg impact on length of stay).
One such approach is to recognise the challenge presented and to take a long term strategic view of transforming services as they ‘rise to the challenge’. The Clinical Excellence Commission in New South Wales (NSW), Australia, developed and issued such a challenge to healthcare services within the state in 2012. Working with a range of stakeholders to develop the Patient Based Challenge, including patient advisers, clinicians, policymakers and managers, 26 strategies were recommended under 9 key domains (see Box).
Aligning with new local service accreditation standards, strategies emphasised the importance of engaging with patients, families and carers at the bedside as well as in organisational governance. In recognition that attaining a patient focus within a service can take 5-10 years to achieve, it was suggested that health services initially implement 2-3 strategies, supported by an online guide and local education and meeting sessions involving experts from the Commission. The Challenge was designed to provide a strategic framework to health services based on evidence of effective approaches used by high performing patient-centred services.
Regions within the state of NSW, divided into geographic districts, took up the Challenge by signing up at Board level as an indication of governance support and executive commitment. Being a flexible framework, service districts selected their own priority areas for initial focus and used a range of tools to implement change. Health services reviewed local data sources about patient experience (eg patient surveys, compliments and complaints), incidents and staff satisfaction to help determine areas for improvement. Engagement of local clinicians, patients and carers in subsequent changes was crucial to success.
Changes put in place as a consequence of rising to the Challenge included reviewing local service policies to determine patient focus. For example, services that received negative feedback about patient visiting hours conducted focus groups and surveys with patients, family and staff to gain a greater understanding of the issues from the service user perspective. On reviewing current visiting policies and auditing facility visiting hours across the district, an inconsistency in current approaches became apparent. Taking up the challenge to implement a patient based visiting policy resulted in district wide policy change endorsed by the governing Board and the introduction of a flexible patient-focused approach to visiting. One district introduced a care partner plan with 24/7 access rights. Local evaluation conducted after the policy change found high levels of satisfaction attained amongst both patients and staff as a consequence of the new approach, which valued family and carers as care team members.
Other districts actively involved patient advisors in the co-design of new processes, new services and facilities. In a broader recognition of the health literacy barriers presented to patients by health services, local health districts undertook patient shadowing activities to experience navigation and signage issues from the patient perspective (ie ‘walk in my shoes’). Other services that had witnessed previous incidents of ‘missed deterioration’ of patients chose to implement the Clinical Excellence Commission’s programme for patient and family activated escalation (“REACH”), empowering patients or family to call for emergency help through direct access to a rapid response team. Internationally, health services are recognising that they can transform the patient experience through strategic and lasting improvements within their facilities. Many such changes can at first appear confronting, as they challenge us to think differently about healthcare delivery and governance. Examples from around the world include:
Open Notes (providing patient access to clinician notes within medical records via online portals);
Patient involvement in clinical staff selection panels for new appointments to healthcare delivery services;
Patient Preferences Passport (Planetree tool for capturing patients’ personal preferences relating to their healthcare, health and goals promoting partnership between patients and healthcare professionals); and
Real-time text messages within hospital (eg SMS from operating theatres to family members to inform them of progress with the patient’s surgical procedure or preadmissions reminders
We know that quality in hospital settings is affected not only by the quality of technical care received, but also by the quality of the interpersonal relationships and the degree of engagement with the ‘customer’ of the service. At the same time, patient expectations of quality service provision are on the rise. As Mary’s story points out, patients want more than good ‘technical’ care and a good clinical outcome. High performing health services are providing safe and reliable care that is also patient-focused. The next time you hear the words “Of course I’m patient-centred, what else would I be? I’m a doctor!” – stop and ask “But are we really patient-centred…?”