Towards patient and family centered care: Bridging the gap

How can hospitals and clinics deliver care that is patient and family centered? As an emergency physician, I’ve often pondered this question after my mother died of an untreated systemic infection in an out-of-state hospital. The experience, which I write about in the January 1 edition of the Washington Post as well as the December issue of Health Affairs, convinced me that healthcare still has room to grow when it comes to partnering with patients and families.  As a healthcare provider or administrator in your practice, what can you do to become more patient centered? Here is an action plan, at three levels, where you can make a difference.

1. At the level of the clinical interaction. Starting immediately, if you’re a provider you can begin by asking every patient “do you have any questions or concerns?” In my clinical practice, I’ve made it a habit to ask this of every patient, every time.  By doing so, I’ve undercover unexpected motivations for a visit or confusion regarding a care plan.  But you can go far beyond this practice. You can also start rounding at the patient’s bedside, which allows patients and families an opportunity to learn more about the plan of care, correct factual inaccuracies, voice concerns, or ask questions.  You can share your clinical notes with patients.  Opening clinical notes to patients has shown promising results, with a recent study indicating that patients who receive provider notes are more likely to adhere to their medications and feel more in control of their care.  On inpatient wards, you can empower family members to trigger rapid response teams.  At the University of Pittsburgh Medical Center, where a program called Condition H (for help) has been implemented, family members can call a hotline when they feel a patient is getting sicker.  A physician, patient relations coordinator, nursing coordinator, and floor staff respond and reassess the patient’s condition.  The program has been a success, and the model is spreading across the country.

2. At the administrative level.  You can involve patients and families on hospital and departmental committees.  In Massachusetts, where I practice, the state has mandated that hospitals have patient and family advisory councils.  Patients and family members join these councils after they are interviewed and selected based on their ability to constructively share experiences, empathize with other viewpoints, and provide thoughtful suggestions for solving problems.  Then they receive orientation and learn how clinics and hospitals function.   They become, in a sense, your “expert patients.”  In addition to working on advisory councils that help hospitals address some of their most challenging problems, these “expert patients” and “expert family members” also sit on quality, patient safety, and other hospital committees.  I’ve attended patient and family advisory councils at my hospital, and I’ve found that patient and family members, using their care experiences as a guide, provide valuable insights and ideas that I would have never considered.

3. At the level of healthcare delivery design.  You can redesign healthcare delivery from the patient and family’s perspective.  Unlike services in other sectors, much of healthcare delivery has not been designed explicitly from the user’s perspective.  Pioneers in patient and family centered care, however, are developing new methodologies for redesigning health care that incorporates the entire patient care experience. For example, Dr. Anthony DiGioia, an orthopedist at the University of Pittsburgh Medical Center, has developed a process for redesigning the delivery of hip and knee replacements, examining the whole care continuum and not focusing exclusively on the surgery.  Most interestingly, one step of the methodology calls for shadowing patients and families, following them through the entire cycle of care—from initial visit to hospitalization to rehabilitation and follow-up.  When Dr. DiGioia and his colleagues did this, they found surprising opportunities to redesign care that ultimately improved quality, safety, and cost.  The results in Dr. DiGioia’s clinic have been impressive.  For total hip replacements, for instance, his team’s average length of hospitalization was 2.4 days shorter than the national average, infection rates were less than half the rate nationally, and his team’s patient experience scores were in the 99th percentile nationally.

As individuals working in health care, we are naturally aligned toward a patient-centered agenda.  We all want to be remembered for helping people and improving lives.  Yet after my mother’s death, my surprising realization was that I lacked a set of tools to fully understand patients’ experiences and goals.  Without patient-centered approaches I couldn’t optimally combine clinical care, operational processes, and technologies to empower individuals to reach their objectives, as humanely as possible.  Tools for patient and family centered care can help us bridge this gap.  In employing them, we and our patients only stand to benefit.

Jonathan R. Welch is an emergency physician.  Welch’s Narrative Matters essay is available in Health Affairs.  

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