The Essentials For Patient
Centered Care:
A United States’ Perspective
Lee Hilborne, MD, MPH
UCLA 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 Health
System 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
Patients Receiving ACE Inhibitors When Indicated
For Treatment of Congestive Heart Failure
100%
Academics
All Participants
80%
60%
40%
20%
0%
Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun02
02
02
03
03
03
03
03
03
JCAHO ORYX Measures
Nor All The Information Needed To
Optimize Care At Home
Patients Receiving All Discharge Instructions Following HF Admission
80%
70%
60%
UCLA
Academics
National
50%
40%
30%
20%
10%
0%
Oct-02 Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03
JCAHO ORYX Measures
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
Sources Consumers Are Likely To Use
Similar Patients
Family & Friends
Nurses
Co-Workers
Toll Free Live
Church/Community
Doctor's Office Info
Quality Ratings
Newspapers
Web Site
Radio or TV
Video At Home
Toll Free Recordings
0%
10%
20%
30%
40%
50%
60%
Likely To Use
Preliminary RAND/CHCF Report
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
Do Not Want CPR
Desire CPR
100%
80%
60%
40%
20%
0%
Patients
Physicians For Their
Patients
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
P a tien t R igh ts &
O rg a niza tio n a l Eth ics
P a tie n t R ig h ts
Ac ce ss
•Access to
care
T re a tm e nt
•Psychosocial
•Cultural
•Spiritual
•Advance
Directives
•Active
participation
•Conflict
resolution
•End of Life
Support
O rg a niza tio n a l Eth ics
R e s p e ct
Conduct
& C o n flic t
•Confidentiality
•Spatial
•Property
•Complaint
resolution
•Communication
•Disclosure of
conflicts of
interest
•Contracting
Code of
E ith ics
O rg a ns
•Marketing
•Admission
•Transfer
•Discharge
•Billing
•Providers
•Payers
•Educational
efforts
•Procurement
•Donation
R e s ea rch
•IRB when
appropriate
M a n g in g S ta ff
R e q u e s ts
•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 by
physicians
• 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
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The Essentials For Patient Centered Care: A United States