Creating patient-centric care

Patient-centric care is a central theme of the Darzi review - and hence a key part of the changes and vision for the NHS. This is absolutely right, and long overdue: patient-centric care is known to be effective in contributing to other health system goals such as efficiency and effectiveness.

However international studies show that it is easy to talk about such care, far harder to achieve it: 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".

Given the NHS's recent "conversion" to the mantra it is vital to learn from those who have already been shaping service delivery in such a way.

In 2007 the Commonwealth Fund and the Picker Institute in the US carried out interviews with opinion leaders selected for their experience and expertise in either designing or implementing strategies for achieving excellence in patient-centered care. The detailed report (pdf) gives clear guidelines for what is necessary for those in the UK seeking to deliver high quality, patient-centred care and identifies the following critical factors. How many of them does your organisation deliver on?

* Leadership, at the level of the CEO and board, 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.


Related articles:
NHS hospitals 'suffering from lack of compassion'

Teaching "strong relationships"

It is almost a cliche (but like most cliches, based on fact) that medical schools take varied, bright, positive, caring, students, fill them full of science and facts (with a bit of communication skills tacked on the side) and turn them into efficient machines for managing hospitals stays of patients. There is no evidence to suggest that the bad effects of this process have been addressed by recent changes in medical training.

Perhaps as a result of this, people have become increasingly disenchanted with their relationships with their doctors with complaints increasing, whilst many doctors move out of the profession or take early retirement - not finding the passion and fulfillment that they went into the profession for. But a few pioneering medical schools in the States are attempting to rewrite medical education and produce doctors who love their jobs and patients who love their doctors. (Seems like rather a sensible goal).

A study released in January's Academic Medicine profiles a program at Indiana University as well as four other U.S. medical schools that sought to teach faculty members a different way of instructing medical students. The curriculum highlights the human dimensions of care, such as the need to communicate effectively, show compassion and build strong relationships.

As covered before on "Experience Matters", such "human dimensions" predict great clinical outcomes, happy patients and satisfied doctors. Not only should they be a major part of all medical school training, but such education and support should be part of lifelong professional development for all healthcare professionals. Most doctors know this is essential and embrace it, the others might do well to question why it was that they went into medicine.

Poor communication predicts complaints against doctors

But more importantly, predicts unhappy patients not getting the care they need.

An excellent patient experience (as measured by quality of communication from their physician) not only predicts quality clinical outcomes, but is important in protecting the doctor (and her organisation) from complaints and reduces the risk of litigation.

Of course all good doctors already know this and make monitoring and continually improving their communication skills a priority. It is interesting to see "early-adopters" amongst doctors now embracing web-based feedback from their patients as another tool to ensure excellence.

This JAMA paper from 2007 (JAMA. 2007;298(9):993-1001) describes a detailed, ten-year prospective study of complaints against doctors, and then performs regression analysis against their exam results in clinical communication skills. Final line of the conclusion is clear and powerful support to all who understand that an excellent patient experience is an integral part of excellent care, and not just a "nice to have":
"...the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints."

Whilst communication skills are now an integral part of most medical schools' curricula, patient satisfaction scores are not increasing - is it time to make communication skills a core part of regular, re-training for all doctors?

NHS Constitution 2

The NHS Constitution makes the following demand of patients:
"You should give feedback – both positive and negative – about the
treatment and care you have received, including any adverse reactions you
may have had." (Section 2b of the NHS Constitution)

Interesting to think how much feedback this could result in if even 50% of patients took their obligations to the Constitution seriously? How could that much information be collected, what would the NHS do with it, and what tools and systems would patients need to "do their bit"?

The Wisdom of Patients

How can we best capture the wisdom, knowledge and insight of patients to shape the delivery of healthcare?

"The Wisdom of Patients: Health Care Meets Online Social Media", Jane Sarasohn-Kahn's engaging and well-informed report (full text available at the link), details how innovative collaborations online are changing the way patients, providers, and researchers learn about therapeutic regimens and disease management, as well as making ever more informed and pro-active choices about their care.

Including an extensive listing of health media resources and examples of best practice, the report makes it clear that it is now not just the "technologically savvy" who are generating and sharing content. The collective wisdom harnessed by internet social media "can yield insights well beyond the knowledge of any single patient or physician", writes report author Jane Sarasohn-Kahn.

According to the report, the growing expectation of patients for transparency will drive the evolution and rapid uptake of social media in health. The author concludes that the ongoing demands of a "consumer-driven health marketplace" (patient choice in the UK?) will inspire innovation in applications that integrate clinical...and ratings information.

Although a US-focused report, all the principles apply just as much to patients (and providers) in the UK. It will be interesting to see which UK organisations are first to see the potential of this shift in culture, and how they create new ways to engage with, learn from and inform their public and patients.