The therapeutic interaction and partnership between the patient and nursing have long been a topic of interest. Research has demonstrated the influence between the nurse-patient collaborative partnership and patient outcomes such as satisfaction, length of stay (LOS), and adverse outcomes in the hospitalized adult patient.1-10 Patient-centered care (PCC) has engaged the interest of leaders in healthcare organizations, research institutions, and public policy centers who advocate that patients’ interests and concerns should be at the center of the healthcare experience. Forces emphasizing a focus on the quality of patient care include rising healthcare costs, medical liability, staffing shortages, and limited access to care. True PCC should reflect patients’ values and engage them as partners and collaborators in care as these issues are addressed. To facilitate patient involvement in decision making, the healthcare team must provide adequate education, information, and coaching. PCC represents not only the caring science incorporated in healthcare, but also the coordination, transition, and continuity of healthcare services provided.11 In the Institute of Medicine’s 2001 Report, Crossing the Quality Chasm, PCC is listed as one of the prominent 6 aims for the future quality of healthcare.12
Multiple factors have converged to create the perfect storm for the American healthcare system. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)13 is one factor prominently impacting the future of healthcare delivery. The HCAHPS initiative provides a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. Although many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspectives of care information that would enable valid comparisons to be made across hospitals.13 HCAHPS is being utilized as a mechanism to create financial incentives for hospitals to improve the quality of care. Public reporting serves to enhance accountability by increasing the transparency of data to the public. The Patient Protection and Affordable Care Act establishes a value-based purchasing plan beginning in FY 2013 based on hospitals’ performance in 2012 on measures that are part of the hospital quality reporting program.14 This system will transition providers from pay-for-reporting to pay-for-performance, increasing the interest in PCC models.
In an effort to improve patient experiences and enhance quality care and organizational reimbursement for care, a PCC model should be explored. Organizations are quickly discovering that patient and family perceptions of care rendered greatly influence the culture of the care environment. To this end, the relationship-based care (RBC) model, endorsed by Jean Watson in Koloroutis15 and the Studer Group,16 presents a model to transform the care environment to one of collaboration and patient-centered quality excellence.16 The model is organized around 3 key relationships: (1) the provider’s relationship with patients and families, (2) the provider’s relationship with self (self-awareness), and (3) the provider’s relationships with collaborative colleagues. The RBC model promotes organizational flexibility in the critical areas that measure success inclusive of clinical safety and quality, patient and family satisfaction, physician and staff satisfaction, effective recruitment and retention of staff, and robust financial health of the organization. The RBC model operationalizes the concepts of responsibility, authority, and accountability in a decentralized organizational structure.15 There are 6 essential dimensions to the RBC model, all interacting and surrounding the patient as the center of targeted activity (see Figure 1).
The RBC model provides not only a philosophical foundation for practice, but also an operational framework for structure and process of care delivery. Through the patient-focused work of the care team based on common values, vision, and anticipated outcomes, excellence in care can be delivered. This study contributes to the current body of knowledge, assessing whether the RBC model influences improved patient satisfaction, decreased LOS, and decreased readmission rates in hospitalized patients.
The project design includes a retrospective secondary analysis of aggregated patient satisfaction data, facility averages for LOS, and readmission rates at a small rural Texas hospital, selected on the basis of convenience. The data collected were derived from returned Press Ganey™ patient satisfaction surveys that were sent to patients receiving services in the selected rural hospital setting. The data were reported in aggregate as monthly averages. Items that were reportable to HCAHPS and descriptive of patient-centered, collaborative care and reflective of direct nursing relationships have been selected for study inclusive of (1) communication with nurses, (2) responsiveness of hospital staff, (3) pain management, (4) communication about medicines, and (5) discharge information. Further data regarding average LOS and readmission rates were derived from the hospital database and reported in aggregate as monthly averages.
No patient-specific information was reported or recorded. All data were reported in aggregate. As a retrospective review of patient satisfaction data, no patient consent was required or obtained. The study was approved as exempt by the organizational institutional review board.
For statistical analysis of the data, SPSS 17.0 (Chicago, Illinois, 2009) was used, with frequency and Pearson correlations computed for each project variable, comparing the preimplementation phase of the RBC model with postimplementation data to statistically demonstrate the impact of the model on the chosen variables. Data were reviewed retrospectively for the year 2009 and 2010, as the initial implementation of PCC methodologies began at the end of 2009; this offered an initial comparison of the efficacy of the model.
The RBC Model
RBC must support the importance of the individual-caregiver relationship, person centricity in care, and the emphasis on individualized quality of care. Within the RBC framework, the patient should have significant influence on the determination of his/her individual course and experience of healthcare. The role of the healthcare provider is to supplement the skills and the knowledge necessary to enable independence. The provider should render assistance in the maintenance of health and wellness. When the provider and patient are collaborative partners in care, the provider ensures that caring will be centered on the patient. For the leader, there is a commitment to the gravity of the task of being in the lead directing the provision of healthcare. Leaders must insist that care is rendered in an accountable and fiscally responsible manner, no more and no less than what is required.15 Leaders and providers must be committed to change, transforming the culture from what was efficient in past healthcare environments to the PCC model.
Leadership and Management Implementation Strategies
Implementation of the RBC model began at Moore County Hospital District (MCHD), Dumas, Texas, in 2010 as a method for mitigating the impact of healthcare reform. It was recognized that to support the implementation of interdisciplinary communication there must be positive, healthy working relationships. Leader and manager education began with tools for team building and enhanced customer service, inclusive of rounding, service recovery, respect, ownership and accountability of team work, and collaborative communication styles. An integration of the model presented in the book “Relationship Based Care: A Model for Transforming Practice”15 was incorporated as the practice model for the facility, and a copy of the book was provided to each nursing leader as a means of support and reference. In an effort to solidify a new culture of caring, leaders and managers were educated about a shared vision, the infrastructure to support the new ways of working, the benefits of professional and personal growth and development, and tangible evidence of the success of the new culture and methodology.17 These objectives were achieved through interdisciplinary meetings consisting of sharing and problem solving, as well as data dissemination of tangible improvements and obstacles.
Caring is at the center of PCC. Caring leaders understand that caring is not only an expression, but also a strong and conscious action. Leaders committed to the PCC vision create an environment in which caring relationships between collaborative providers and patients flourish. In order to sustain change and positive momentum, leaders evoking change must facilitate and positively influence the relationships between staff and patients through the modeling of caring interactions. In an effort to foster an engaged commitment to a collegial atmosphere, leaders and managers outlined behavioral expectations utilizing a contract statement. Figure 2 outlines the statement adopted by MCHD. Every aspect of collegial relationships, inclusive of responsibility, ownership, accountability, trust, respect, and support, impacts the success of PCC delivery.
To optimize performance and achieve healthcare transformation, the transformational leadership cycle, a methodology for leadership engagement facilitating cultural change, was utilized as the theoretical model (see Figure 3) and catalyst for change.15 The model consists of 6 steps:
* Begin where you are: Accept the current reality and commit to leading from this point onward.
* Lead with purpose: Purpose defines the contribution, clarifies roles, creates focus, and facilitates commitment.
* Create awareness: Bring out what is important and support others in doing the same, identifying gaps.
* Go with energy: Positive energy is inspiring, generative, and contagious.
* Inspire a shared vision: Shared commitment, conversations, and collaboration create a solid foundation for creating new conversations and possibilities.
* Learn by doing and reflection: Put words and plans into action, taking risks in the pursuit of what is of value.
The culture of PCC evolves best when executive leadership creates an environment in which individual and the team learning is promoted and where commitment is valued over compliance.18 To this end, leaders and managers were coached using the model to support PCC modalities. The decentralized infrastructure in the organization contributed to knowledge-based, individualized interventions at the point of care, encouraging direct communication and reaping increased staff input and engagement. Decentralization delegated authority to those at the level of the patient, who were in the best position to judge the adequacy and efficacy of the decisions they made in collaboration with the patient and care team.
Staff Implementation Strategies
In an effort to encourage staff participation and engagement, management implemented a shared governance structure, as a participatory decentralized model that strengthened authority and accountability for decisions at the point of care.19 In addition, a nursing professional development committee was created to support professional growth and development, as a vehicle to superior patient care through evidence-based learning.
In addition to supporting education and decentralization, leadership supported staff engagement with the RBC model through in-services, staff meetings, question-and-answer sessions, and dissemination of key tools for improved patient care quality and satisfaction, such as rounding and care collaboration. Staff engagement was supported through visual aids displayed on TV monitors, leadership rounding, and targeted questions regarding what was working well.
Data Collection and Results
To determine the efficacy and impact of RBC model, 3 indicators were selected to monitor:
* patient satisfaction with nursing care: measured by Press Ganey surveys;
* LOS: reported through the hospital database; and
* readmission rates within 24 hours: reported through the hospital database.
The Press Ganey patient satisfaction surveys were sent to patients receiving services within the selected rural hospital setting for the years 2009 (n = 300) and 2010 (n = 389). Press Ganey reported data in aggregate as monthly averages for each of the 12 months per reporting year. Further data regarding average LOS and readmission rates were derived from the hospital database and reported in aggregate as monthly averages for each of the 12 months per reporting year. LOS data for the year 2009 were derived from 1,392 admissions; 4,350 patient days; and for the year 2010, 1,165 admissions and 3,454 patient-days. Readmissions were likewise reported in aggregate as monthly averages for each of the 12 months per reporting year. Total readmissions reviewed for 2009 were 178 and for the year 2010 were 124.
Aggregate data from 2009 were preimplementation data. Data from 2010 were considered postimplementation outcomes. Descriptive statistics described in Tables 1 and 2 provide insight into the means for data collected during the preimplementation and postimplementation phases. As the results illustrate, the postimplementation phase of RBC model revealed less deviation among data points, suggesting increased consistency in care delivery. Additionally, minimum scores for patient satisfaction demonstrate perceived performance improvement during the postimplementation phase.
A Pearson correlation coefficient was calculated to examine the relationship between RBC model implementation and the variables LOS, readmission within 24 hours, and overall patient satisfaction with nursing. As shown in Table 3, a moderate correlation was found (r22 = −0.405, P = .05), indicating a significant relationship between increased readmission rates within 24 hours and the implementation of RBC model. A weak correlation that was not significant was found for the relationship between the implementation of RBC model and overall satisfaction with nursing (r22 = 0.058, P > .05) as well the LOS (r22 = 0.277, P > .05).
Limitations exist that may have impacted the outcomes and conclusions. The study site consisted of a small rural Texas hospital, and therefore results may not be generalizable to larger populations. In addition, the regional and culturally accepted physician admission and discharge practices and pattern norms may have skewed the potential and actual effect on data for LOS. Data utilized were reported in monthly aggregates and may not accurately reflect the actual correlation between the variables in question. Finally, the period of review was small; therefore, the correlations to the implementation of the RBC model are not reflective of a mature, culturally hardwired implementation.
Conclusion and Recommendations
True PCC should reflect patients’ values and engage them as partners and collaborators in care. PCC facilitates coordination, transition, and continuity of healthcare services provided. Thus, responsibility and accountability for health are shared among members of the provider team, representative of internal stakeholders, payers, patients, families, communities, businesses, and government.20 In the Institute of Medicine’s 2001 report, Crossing the Quality Chasm,12 PCC is listed as one of the prominent 6 aims for the future quality of healthcare.
Even in the infancy of implementation of the RBC model, the present inquiry supports a relationship between the model and reduced readmission rates within 24 hours, representing a positive effect to potential reimbursement. The Fetzer Institute and the Pew Health Professions Commission task force have identified RBC model as the key to delivery of quality healthcare.20 Healthcare at its best is provided through relationships, and as a function of healthcare reform, reimbursement will be influenced by the quality of the relationships created through pay-for-performance, patient satisfaction reporting, and quality indicators. The RBC model has been shown in the literature and in this study to support a patient-centered, collaborative care environment, maximizing satisfaction and potential reimbursement. Broadening the definition and application of PCC to small rural settings is in the best benefit of the patient. This study provides important data about the influence of this approach and the impact on patient satisfaction and quality.
The author thanks Jayne Felgen, MPH, and Dr Carol Boswell for their caring, support and guidance throughout this project.
1. Bournes DA, Ferguson-Paré M. Human becoming and 80/20: an innovative professional development model for nurses. Nurs Sci Q. 2007; 20: 237–255.
2. Caress AL, Beaver K, Luker K, Campbell M, Woodcock A. Involvement in treatment decisions: what do adults with asthma want and what do they get? Results of a cross-sectional survey. Thorax J. 2005; 60: 199–205.
3. Coyle J, Williams B. Valuing people as individuals: development of an instrument through a survey of patient-centeredness in secondary care. J Adv Nurs. 2001; 36 (3): 450–459.
4. Grillo-Peck AM, Risner PB. The effect of a partnership model on quality and length of stay. Nurs Econ. 1995; 13 (6): 367–374.
5. Lindhardt T, Nyberg P, Hallberg HR. Collaboration between relatives of elderly patients and nurses and its relation to satisfaction with the hospital care trajectory. Scand J Caring Sci. 2008; 22: 507–519.
6. Olsson LE, Hansson E, Ekman I, Karlsson J. A cost-effectiveness study of patient-centered integrated care pathway. J Adv Nurs. 2009; 65 (8): 1626–1635.
7. Sidani S. Effects of patient-centered care on patient outcomes: an evaluation. Res Theory Nurs Pract. 2008; 22 (1): 24–37.
8. Suhonen R, Valimaki M, Leino-Kilpi H. Individualized care, quality of life and satisfaction with nursing care. J Adv Nurs. 2005; 50 (3): 283–292.
9. Upeneiks VV, Akhavan J, Kotlerman J. Value added care: a paradigm shift in patient care delivery. Nurs Econ. 2008; 26 (5): 294–300.
10. Wolf D, Lehman L, Quinlan R, et al.. Can nurses impact patient outcomes using a patient-centered care model? J Nurs Adm. 2008; 38 (12): 532–540.
11. Watson J. Assessing and Measuring Caring in Nursing and Health Science. New York, NY: Springer; 2002.
12. The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century
. Washington, DC: The National Academies Press; 2001.
16. Koloroutis M. Relationship Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2004.
17. Felgen J. I2
: Leading lasting Change. Minneapolis, MN: Creative Health Care Management; 2007.
18. Senge P. The Fifth Discipline Fieldbook. New York, NY: Doubleday/Currency; 1994.
19. Porter-O’Grady T. Shared governance and new organizational models. Nurs Econ. 1987; 5 (6): 281–287.
20. Tressolini C. Pew-Fetzer Task Force. Health Professions Education and Relationship-Based Care. San Francisco, CA: Pew Health Professions Commission; 1994.
© 2012 Lippincott Williams & Wilkins, Inc.