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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000388265.57051.e6
Feature Articles

Putting Patients First: Patient-Centered Care: More than the Sum of Its Parts

Frampton, Susan B. PhD; Guastello, Sara

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Author Information

Susan B. Frampton is president of Planetree in Derby, CT, where Sara Guastello is manager of designation and resource development. Frampton coordinates Putting Patients First: sframpton@planetree.org.

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Abstract

This is the seventh and last in a series of articles from Planetree, an international non profit organization founded in 1978 that's "committed to improving medical care from the patient's perspective." For more information, go to www.planetree.org. To register for a free Webinar based on this series that starts on September 21, go to http://bit.ly/aezmEu.

When a nurse at the Celilo Cancer Center at the Mid-Columbia Medical Center in The Dalles, Oregon, found out that his patient was scheduled to receive chemotherapy on her wedding anniversary, he asked the woman and her husband what song they'd first danced to on their wedding day. It was "Save the Last Dance for Me," and the next day, when the couple rose from their chairs after the patient's six-hour infusion, the song began playing. Right there in the infusion area, with their arms around each other, they danced.

Figure. Kurt Rohrbac...
Figure. Kurt Rohrbac...
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This story illustrates the kind of care that has become the norm at the 10 hospitals in North America recognized since 2007 as patient-centered hospitals by Planetree's Patient-Centered Hospital Designation Program. At these hospitals "patient-centered care" is more than a buzzword. Rather, it's reflected in their mission statements, strategic plans, models of nursing care, and day-to-day operations.

While many organizations, including the Institute of Medicine,1 the Institute for Healthcare Improvement,2 and Planetree,3 have endeavored to define patient-centered care, no definition conveys its essence as well as the patients at these hospitals can. "This place has a special character," one patient said in a focus group. Others have said, "You can tell the nurses here care about you as a person," "They are a special breed of people here," and "I don't think it's just a job for them; they're here for a reason."

Over the past year, this series, Putting Patients First, has explored several aspects of the patient-centered approach—encouraging patients to review their medical records, lifting restrictions on family involvement in care, and lowering noise levels in hospitals, among others. We believe they show that, ultimately, patient-centered care is more than the sum of its parts.

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PROVIDING A FRAMEWORK

Planetree's goal for the designation program is to make patient-centered care less of an ambiguous notion and more of an attainable goal (for more information, go to http://planetree.org/consultation.html). Many facilities have aspired to become more patient centered as the concept has garnered attention in recent years. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, for example, compiles patients' assessments of hospital care and makes them available online (see www.hospitalcompare.hhs.gov). Also, the major health care reform legislation passed this year includes financial incentives to hospitals that meet certain standards of patient-centeredness, "such as the use of patient and caregiver assessments or the use of individualized care plans."4

Still, there's a gap between aspiration and reality at many organizations when it comes to patient-centeredness. The designation program provides a framework for evaluating a hospital's systems and processes, one that's based on Planetree's three decades of work with hospitals in the United States and abroad, and especially on data gathered from focus groups conducted with thousands of patients, family members, and health care professionals. Using these perspectives, Planetree shaped 50 criteria for designation in 11 categories (see Table 1).

Table 1
Table 1
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Criteria include whether hospitals balance patients' needs with their safety, whether transparency remains a priority even when something unexpected occurs, whether the work environment is supportive of staff, and whether patient-centered approaches are applied to billing and community outreach. The designation process begins with a self-assessment that requires hospital leaders to appraise the organization's culture—an appraisal that can be valuable, regardless of whether it's part of the designation process. After all, Planetree designation recognizes a job well done, not a job all done. (Designation lasts for three years.)

After the self-assessment, a hospital provides to Planetree documentation of its patient-centered practices. Next, a team including representatives of facilities that have achieved designation make an on-site visit; the written documentation is verified through a facility tour and feedback from patients, family members, and staff. This team's assessment is then reviewed by an independent committee of health care leaders, with representatives from the American Hospital Association, the Institute for Healthcare Improvement, and patient advocacy groups, among others. This feedback informs a decision to designate a hospital as patient centered.

Involving patients, family members, and staff in the assessment supports a facility's efforts to foster a patient-centered culture. At the on-site visit at Northern Westchester Hospital in Mount Kisco, New York, for example, it was revealed that although the hospital had a number of means in place for meeting patients' nutritional needs, patients were largely unaware of their options. Consequently, the "Just Ask Campaign" was born. Now, signs assure patients: "If you're thinking it, ask it." Examples of questions include, "May I request a different meal selection?"

Patient-centered care requires flexibility and discourages a one-size-fits-all approach. For instance, despite a policy in support of open medical records at Waverly Health Center in Waverly, Iowa, only a few of the hospital's patients reviewed their charts. The hospital sought out an alternative and created the Personal Health Information notebook, given to every medical–surgical patient. Over the course of a hospitalization, the notebook accumulates laboratory results, medication lists, consultation reports, and DVDs of scans. The hospital gets the notebook into the hands of a far greater number of patients than it did the medical record.

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The Designated Hospitals

As of June, Planetree had designated the following 10 hospitals as patient centered:

* Centre de réadaptation Estrie, Sherbrooke, QC, Canada

* Delnor Hospital, Geneva, IL

* Griffin Hospital, Derby, CT

* MidColumbia

* Northern Westchester Hospital, Mount Kisco, NY

* Sharp Coronado Hospital, Coronado, CA

* Valley View Hospital, Glenwood Springs, CO

* Waverly Health Center, Waverly, IA

* Windber Medical Center, Windber, PA

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THE ROLE OF NURSES

Everyone working in a health care facility can contribute to a patient-centered approach. Yet partnerships between nurses and patients are a cornerstone of patient-centered care. This is reflected in the questions on the HCAHPS survey, which includes patients' perceptions of nurses' communication and responsiveness.5 A number of the designation criteria also focus on the involvement and leadership of nurses, for example, in their support of family members as "care partners" who participate in care.

As nursing theorist Jean Watson, PhD, RN, has written: "Clinical care and health care practices are grounded in human communication, human interactions and relationships. At the same time, approaches to system solutions are often disconnected from relationships and caring."6 The Planetree program's emphasis on relationships can help to remind nurses of what drew them into the profession, especially when the entire organization is committed to supporting nurses' adoption of patient-centered practices. "For me," one nurse said in a focus group, "it's returning back to what nursing was when I started. It's being able to have the time to spend with patients and families, to do the little back rubs we used to do, to give that little bit more of yourself. We're saying to nurses that you do have time for that."

Nurses have long championed patient-centered care and continue to study its value. Susan Stone, former chief nursing officer and chief operating officer at Sharp Coronado Hospital in Coronado, California, engaged the nursing staff there in meeting the designation criteria and conducted research on the impact of patient-centered care in the facility. The study retrospectively examined data from two comparable medical–surgical units over five years—one that had implemented the Planetree model and one that had not.7 In each of the five one-year cohorts studied, the Planetree unit consistently demonstrated

* shorter average lengths of stay.

* statistically significant lower costs per case (this resulted largely from the shorter lengths of stay but also from "slightly reduced" RN hours per patient day and an increased use of "lower-cost personnel," such as aides).

* higher average overall patient-satisfaction scores.

* higher scores in nearly all the dimensions of patient satisfaction measured.

When bedside staff appear to be burdened, patients notice, and they might, as a result, hesitate to ask for help or make their needs known.8 As one patient in a focus group said of a nurse, "I asked her about getting a pain medication. She responded in a rude manner—'You didn't have that pain med.' I gave them the benefit of the doubt that they were having a bad day, that they were overworked." Nurses and the general public alike have identified overworked, fatigued staff as contributing to the potential for medical errors.9,10

Given the alarming rates of turnover,11 vacancy,12 and burnout13-15 among nurses, the experience of staff is a critical consideration in the Planetree designation. Giving bedside staff rewards and recognition, retreats, access to minutes of leadership meetings and other information on organizational priorities, a say in how care is delivered, and services supporting work–life balance are among the ways that hospitals uplift staff while putting patients first. Griffin Hospital in Derby, Connecticut, for instance, makes an on-site fitness center available to staff, sponsors a farmer's market at the facility during the summer, and offers prepackaged "meals to go" in its cafeteria.

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CONNECTING PATIENT-CENTEREDNESS AND QUALITY

Care safety and quality go hand in hand in any patient-centered approach. Accordingly, Planetree evaluates outcomes as a part of the designation process by comparing a hospital's scores with national benchmarks. We've found that collectively the 10 designated hospitals exceed the Centers for Medicare and Medicaid Services (CMS) national averages on several "core measures" (see Figure 1). This conforms to the Institute of Medicine's conclusion that patient-centered care is a part of the foundation of high-quality care.1 Also, as a group, the nine U.S. designated hospitals perform above the CMS national average in nine of the 10 publicly reported HCAHPS categories and at the national average in the "quiet at night" category (see Figure 2). The most significant differences appear in the overall rating and in likelihood to recommend the facility, suggesting a link between patient-centered care and patient satisfaction.

Figure 1
Figure 1
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Figure 2
Figure 2
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The benefits of designation. Accolades received by the designated hospitals include the 2007 Malcolm Baldrige National Quality Award, a presidential award for excellence given to the Sharp Healthcare System, of which Sharp Coronado Hospital is a part, and Magnet accreditation from the American Nurses Credentialing Center in recognition of nursing excellence at Delnor Hospital in Geneva, Illinois. Also, Griffin Hospital appeared on Fortune magazine's list of "100 Best Companies to Work For" in the United States from 2000 to 2009, and in 2009 Centre de radaptation Estrie, a rehabilitation hospital in Quebec, was recognized in Canada's Les Affaires magazine's Best Employers Challenge.

On its Quality Check Web site (www.qualitycheck.org), the Joint Commission recognizes hospitals that have received the Planetree designation. Planetree-designated hospitals have been featured in the Washington Post16 and the New York Times17. But the greatest benefits have little to do with publicity. Marcia Hall, chief executive officer of Sharp Coronado Hospital, said: "We are extremely proud of becoming one of the first five nationally noted Planetree Designated Patient-Centered Hospitals. But it's not about awards. They confirm that we're on the right track, but it's mostly about progress toward a vision to make a difference for the people we work with and the people we serve."

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NEXT STEPS

When Planetree launched the designation program in 2007, it was specific to acute care hospitals. Since then, advisory councils in behavioral health and continuing care have worked to revise the designation criteria so that they're applicable to a greater range of settings. The new criteria establish a consistent set of standards for what consumers can expect from any patient- or resident-centered provider.

Also, an International Designation Advisory Council is shaping a set of international criteria that are globally applicable. Designation programs are under way in Canada and the Netherlands and in development in Brazil and Japan.

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REFERENCES

1. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. http://www.nap.edu/books/0309072808/html.

2. Institute for Healthcare Improvement. Patient-centered care: general. n.d. http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral.

3. Frampton SB, Charmel PA, editors. Putting patients first: best practices in patient-centered care. 2nd ed. San Francisco: Jossey-Bass; 2008.

4. The Patient Protection and Affordable Care Act. 111th Congress, 1st session ed. 2010.

5. Centers for Medicare and Medicaid Services. Hospital compare. 2010. http://www.hospitalcompare.hhs.gov.

6. Watson J, Frampton SB. Human interaction and relationship-centered caring. In: Frampton SB, Charmel PA, editors. Putting patients first: best practices in patient-centered care. San Francisco: Jossey-Bass; 2008. p. 3-26.

7. Stone S. A retrospective evaluation of the impact of the Planetree patient-centered model of care on inpatient quality outcomes. HERD: Health environments research and design journal 2008;1(4):55-69.

8. Frampton SB, et al. Patient-centered care improvement guide. Derby, CT; Camden, ME: Planetree, Inc.; Picker Institute; 2008 Oct. http://www.planetree.org/Patient-Centered%20Care%20Improvement%20Guide%2010.10.08.pdf.

9. Buerhaus PI, et al. Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nurs Econ 2005;23(2):61-71, 96, 55.

10. Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health. National survey on consumers' experiences with patient safety and quality information. Washington, DC; 2004 Nov. http://www.kff.org/kaiserpolls/pomr111704pkg.cfm.

11. Kovner CT, et al. Newly licensed RNs' characteristics, work attitudes, and intentions to work. Am J Nurs 2007;107(9):58-70.

12. American Hospital Association. The 2007 state of America's hospitals—taking the pulse. Findings from the 2007 AHA survey of hospital leaders [PowerPoint presentation]. Washington, DC. http://www.aha.org/aha/content/2007/PowerPoint/StateofHospitalsChartPack2007.ppt.

13. Erickson RJ, Grove WJC. Why emotions matter: age, agitation, and burnout among registered nurses. Online journal of issues in nursing 2008;13(1).

14. Vahey DC, et al. Nurse burnout and patient satisfaction. Med Care 2004; 42(2 Suppl):II57-II66.

15. Aiken LH, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288(16):1987-93.

16. McAteer MJ. Virginia hospital treats the whole person. Washington Post 2009 Mar 24. http://www.washingtonpost.com/wp-dyn/content/article/2009/03/23/AR2009032301806.html.

17. Lombardi, KS. For patients, more comfort and a bigger dose of respect. New York Times 2008 Feb 17. http://www.nytimes.com/2008/02/17/nyregion/nyregionspecial2/17hospitalswe.html.

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