The Essentials For Patient Centered Care:

A United States’ Perspective

Lee Hilborne, MD, MPHUCLA Center for Patient Safety &

Quality

The Institute of Medicine Provides a Framework

• Two landmark reports from the Committee of the Quality of Health Care In America– To Err Is Human: Building a Safer

Health System (Sept 1999)– Crossing the Quality

Chasm: A New HealthSystem for the 21st

Century (Mar 2001)• www.iom.edu

These Reports Have Stimulated Profound Interest In Improving Quality

• The first report received the most public attention– Addressed issues most important to

people– Focused the agenda on safety rather

than quality

• The second report, however, drew more important and broader conclusions

The Quality Chasm Report Drew Sweeping Conclusions

• “ In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.”

• Addresses change needed across the health care system

Health Affairs 2002;21:80-90

Why Is It Suddenly So Difficult To Do The Right Thing?• Science and technology are increasingly

complex– New treatments and medications– Increased diagnostics and now genomics

• More are living with chronic conditions– A consequence of longer life expectancy– 17-20% of Americans must limit activity– 44% have more than one chronic condition– Effective treatment must be patient centered

And US Systems Struggle To Put The Patient At The Center• Our systems are not really systems

– Most still practice in small groups– Patients are left to navigate through the

healthcare arena with little guidance

• Structures limit improvement opportunities– Evidence based guidelines are inconsistently

followed– Organizations are still designed for acute care,

not to take time needed to address chronic conditions

– Challenges and delays in seeking clinical expertise remain

Despite Evidence, 20-30% Of Patients Do Not Receive Therapy

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100%

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Academics All Participants

Patients Receiving ACE Inhibitors When IndicatedFor Treatment of Congestive Heart Failure

JCAHO ORYX Measures

Nor All The Information Needed To Optimize Care At Home

JCAHO ORYX Measures

Patients Receiving All Discharge Instructions Following HF Admission

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UCLAAcademicsNational

The Committee Recommends We Better Exploit Technology • Providers and patients should have better

access to evidence through the web– 40% of Americans had access in 2000– 90% are expected to have access by 2010

• Decision support tools• Promote appropriate sharing of clinical

information• Reduced errors through standardization and

automation• Improved communication

– On line access to information and providers

Healthcare Professionals Are Not The First Source of Healthcare Information

0% 10% 20% 30% 40% 50% 60%

Toll Free RecordingsVideo At Home

Radio or TVWeb Site

NewspapersQuality Ratings

Doctor's Office InfoChurch/Community

Toll Free LiveCo-Workers

NursesFamily & Friends

Similar Patients

Likely To Use

Preliminary RAND/CHCF Report

Sources Consumers Are Likely To Use

The Quality Chasm Report Aims For Improvement In Six Healthcare Quality Dimensions

• Safety – Free from injury by the healthcare system

• Effectiveness – Care based on evidence

• Patient-centeredness – Honor patient preferences for care

• Timeliness– Reduced delays for patients and providers

• Efficiency– Reduced waste and maximize resource use

• Equity– Close racial and ethnic gaps

Today We Focus on Patient Centered Care• How well do we meet the patients’ (not

our) needs?– Ambulatory care– Intermediate care– Hospital care– Hospice care– Transitions of care

• Is the care we give consistent with what the patient values and believes?

• Can and do our systems respond to patient preferences?

Consider Six Dimensions Of Patient Centered Care• Coordination and integration of care• Respect for patients’ values, preferences

and expressed needs• Provision of appropriate information,

education, and communication (transparency)

• Physical comfort• Emotional support• Family and friends involvement

Geretis M, Edgman-Levitan S, Daley J. (1993) Through the Patient’s Eyes. Understanding and Promoting Patient-Centered Care

Coordination of Care Has Been A Challenge For Fragmented Systems• Whenever there are handoffs, patients

are at risk– Transition from inpatient to outpatient care– Coordination among specialists and allied

health providers– Movement from one acuity level to another

• When surveyed, patients were most dissatisfied with continuity and transition

We’ve Responded In Several Ways• Physicians partner with other caregivers

– Clinical nurse specialists– Physician assistants– Social workers and other staff

• Instructions with each encounter are more explicit– Standardized, web available discharge instructions– Information provided in simple languages (we have

some documents in multiple languages)

• Staff incentives are tied to satisfaction scores

Respect For Patient’s Values, Needs, and Preferences Seems So Simple• Patients become a partner through shared

decision making– Preferences for aggressive care or comfort care– Patients’ right to participate in ethical decisions

related to care– Culturally sensitive care

• Respecting patient preferences requires listening to each patient– Yet physicians interrupt patients after 15-20

seconds

• Meaningful participation also requires adequate informed consent

Most Elderly Patients Wanted CPR

• Study of 1266 patients at least 80 years old in academic hospitals

• Patient estimates of prognosis were higher than their physicians’ estimations

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Patients Physicians For TheirPatients

Do Not Want CPR

Desire CPR

O'Donnell H, et al. Preferences for cardiopulmonary resuscitation among patients 80 years or older: the views of patients and their physicians. J Am Med Dir Assoc. 2003;4:139-44.

Accredited Hospitals In The US Are Required To Explicitly Address Patient Rights

Access Treatm ent Respect

Patient Rights

Conduct& Conflict

Code ofEithics

O rgans Research M anging StaffRequests

O rganizational Ethics

P atien t R igh ts &O rg aniza tio n a l Eth ics

•Access tocare

•Psychosocial•Cultural•Spiritual•Advance Directives•Active participation•Conflict resolution•End of Life Support

•Confidentiality•Spatial•Property•Complaint resolution•Communication

•Disclosure of conflicts of interest•Contracting

•Marketing•Admission•Transfer•Discharge•Billing•Providers•Payers•Educational efforts

•Procurement•Donation

•IRB when appropriate

•Addressing staff discomfort with care of a specific individual

Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals (2003). Oakbrook, IL

Patient Centered Care Requires Active Dialogue• Individuals have certain basic information needs

– Diagnosis (what is wrong)– Prognosis (what is likely to happen)– Treatment options (what can be done)

• Information transfer should accommodate patients’ needs– Face to face encounters (regular, periodic)– Electronic (e-mail, web based) [a big debate now]

• Should be understandable– Explain technical terms– Culturally appropriate language– Sensitive to educational levels

We Standardized Informed Consent Documents For Consistency

• Developed byphysicians

• We now have about 300 covering common procedures

• Available in two languages

• Copy goes to the chart and the patient

• Not a substitute for a physician-patient discussion

Patient Centered Care Responds

To Patient Discomfort• Many patients fail to receive adequate

pain relief– When in older Americans, some allege this

to be elder abuse– Particularly for end of life care, dependency

should not be a concern

• Shortness of breath and other physical discomforts

• Attention to physical surroundings– Excessive light, noise, distractions

Care Is Complete When Sensitive to Patient Emotional Needs• Anxiety and fear often accompany illness• Outcomes are better when emotional

support accompanies physical treatments– Uncertainty regarding diagnosis or prognosis– Fear of pain– Concerns about separation or isolation– Financial well being– Impact on family dynamics

Patients Do Best When Family And Friends Are Engaged

• Appropriate at the discretion of the patient

• Providers should make time to explain the course of care to family and friends

• Involve family and friends as caregivers in appropriate phases of care

• Understand family sensitivities during the decision making process

• Acknowledge and appreciate family and friend input

How Many Countries Responded To SARS Suggests A Unique Patient Centered Focus

Our Patient Centered Approach Is Leading To Improvement