My most important job as a night-shift nurse is to make my patients feel safe so they can sleep.
This was the motto of my good friend Laura Gilpin who'd worked on the pediatrics unit at Memorial Sloan-Kettering Cancer Center in New York City and then on a medical–surgical unit caring for AIDS patients in San Francisco in the 1980s. She took a holistic, patient-centered approach to hospital care and remained a staunch advocate of patients and families until her untimely death in February 2007.
Laura was also a nurse on the first Planetree model unit in the United States. This experimental, patient-centered unit debuted in the mid-1980s in a San Francisco medical center. It represented the vision of a determined patient named Angelica Thieriot. Several years earlier, she'd had a life-threatening illness and was admitted to a typical hospital of that era. Although she felt she'd received sound medical care, the hospital was institutional, impersonal, and alienating, with bare white walls, excessive noise, nightly disturbances, and limitations on visitation; and she'd had inadequate access to information about her condition and treatment. She decided to do whatever she could to change the system that perpetuated that kind of environment; soon thereafter, she established the Planetree organization.
Thieriot still credits two nurses for her eventual healing. Midway through her hospitalization they came into her room and called her by name. It was the first time any staff member had addressed her directly, and it encoured her to work with them and help with her own healing.
ACTING ON A VISION
Thieriot dreamed of what a hospital could be: a place where the whole person—body, mind, and spirit—is supported; where caring, kindness, and respect are as crucial to clinical outcomes as technical skill is. She gathered a group of visionary professionals from inside and outside health care, including physicians, hospital administrators, patients, writers, and architects. Among them were Stewart Brand, publisher of the 1960s counterculture work, the Whole Earth Catalog; David Sobel, MD, director of patient education and health promotion for Kaiser Permanente's Northern California region; and Roslyn Lindheim, a professor of architecture at the University of California at Berkeley. Together they established the Planetree organization; its goal was to help hospitals move from an environment of provider-centricity—that is, designed for the convenience of practitioners—to one centered around the patient, with a more personalized, humanized approach. These early volunteers developed a philosophy and model of care from the patient's perspective. They chose the name Planetree—the type of tree under which Hippocrates, the father of modern medicine, sat and taught—to emphasize their goal of reconnecting with his holistic approach that addresses the patient's body, mind, and spirit.
With funding provided by several foundations, they began to work with patients, families, and healers to create better care experiences for patients hospitalized at San Francisco's Pacific Presbyterian Medical Center (now called California Pacific Medical Center). This early work led to the establishment at this facility of a patient library and the first Planetree model site—a 13-bed medical–surgical unit that opened in 1985. The success of this unit and its impact on patient and staff satisfaction and patient involvement and adherence to treatment regimens were documented in a University of Washington study1 and led to the development of model sites in New York, Oregon, and California during the late 1980s and early 1990s. No longer were patients passive recipients of care in an institutional setting. They had become active partners in a welcoming, engaging environment.
The model unit put into practice a policy in which medical records were shared with hospitalized patients, who were invited to read their charts and discuss the data with staff. A small patient resource room was established, and patients and family were encouraged to use the resources in order to be informed participants in their own care. The walls were painted with bright colors, and the unit was hung with cheerful artwork. The formerly staff-only kitchenette was opened up to everyone and became a hub for patients, family members, and staff.
Executives and architects from health care facilities worldwide took notice. Teams of health care professionals came to study hospitals with Planetree model units (many facilities now host tours every month). The interest eventually led Planetree to establish a membership program that offered members more flexibility in implementing the Planetree ideals than was offered to the original model sites. For example, the original model sites had to implement all 10 components of the model simultaneously and in a way prescribed by Planetree (see The 10 Components of the Planetree Model), whereas member organizations can now choose whether they want to implement all 10 components and the time frame in which they'll do so.
The result is a network of member sites throughout the United States, Canada, and Europe that use the Planetree model to guide the delivery of care. This network comprises more than 150 hospitals, clinics, and nursing homes, most of which have adopted the Planetree model throughout their organization because experience has shown that single-unit implementation is unsuccessful over time. This network of affiliate members has been growing, on average, by about 15% a year over the past eight years.
DEVELOPING BEST PRACTICES
Increasingly, traditional hospitals have moved nursing staff away from the bedside into centralized areas where they can work undisturbed by patients and their families. With advances in the technologic aspects of care have come challenges to our ability to provide information to patients that they understand and can use. The roles of the family and community in patient care and support have been minimized, and this is reflected in the limits most hospitals place on visitation—both in the visiting hours they set and the amount of space they make available.
Much of the work Planetree members are doing challenges these approaches to care. We emphasize more patient-centered approaches, which include2
- keeping staff close to patients and enhancing communication by, for example, decentralizing nursing stations and providing computer access in patients' rooms.
- using medical records as a teaching tool, encouraging patients to read their own records and make notes in them during hospitalization.
- encouraging families to participate in care by establishing "care partner programs," in which interested families provide bed baths, tube feedings, back rubs, or dressing changes.
- designing care spaces to include family lounges and kitchen access as well as "family zones"—areas in the patient's room that are designated for the family, such as a window seat that can be used as a bed, a small table and chairs, or a desk or counter on which to place a laptop.
- encouraging patient involvement in decisions about care and in the development and review of hospital policies and procedures.
One of the remaining challenges to creating patient-centered care is to define it. Though we talk a great deal about focusing on patients' needs, few hospitals actually do it. Consequently, in August 2005 Planetree initiated a project whose purpose was to identify what practices were common to our most successful member hospitals. We chose to assess facilities that had achieved the highest levels of patient and staff satisfaction—as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (see The HCAHPS Survey) and employee satisfaction survey scores—after implementing the Planetree model.
Six hospitals were selected to participate in the pilot project, which aimed to identify, monitor, and evaluate more than 40 patient-centered practices. Following a thorough self-evaluation process, the facilities submitted applications documenting the various ways in which they met the criteria. A team composed of a Planetree staff member and a representative from another member hospital then traveled to each of the pilot sites and conducted focus groups with patients, family members, employees, and members of the medical staff to validate the practices and their impact on patients. A physical review of the facility was also performed to evaluate the ways in which it supports patients, family members, and staff. The team then analyzed the facility's quality outcomes, as determined according to the HCAHPS survey and the core measures of the Centers for Medicare and Medicaid Services (CMS), which evaluate the quality of care given to Medicare patients with heart failure, heart attack, or pneumonia or who are at risk for surgical infection. The results of these assessments were then evaluated by a designation advisory committee, convened by Planetree, comprising patients and representatives from nursing, medicine, hospital administration, the American Hospital Association, and the Institute for Healthcare Improvement. The process is blinded, and the committee, which confers Planetree designation, operates independently.
Results of the pilot study have been encouraging. Preliminary results of a comparison of the scores of these six pilot hospitals with national data reveal a positive relationship between adoption of these practices and better performance in the CMS's core measures and on the HCAHPS survey.3 Moreover, Planetree's Patient-Centered Hospital Designation Program, an outgrowth of the pilot study, has gained national recognition from the Joint Commission, which includes the program (as simply the Patient-Centered Designation Program) among the Special Quality Awards it recognizes for facilities that meet the criteria. Ultimately, the best practices examined in that project became a set of criteria that any facility (not just a Planetree member) must meet in order to be formally designated a patient-centered facility by the Joint Commission. Achieving this designation indicates that the facility provides comprehensive, patient-centered care and earns it national recognition through the Joint Commission's Quality Check Web site (see www.qualitycheck.org). The Planetree Patient-Centered Hospital Designation Program is now operational in the United States and is being tested abroad. As of January 2009, seven U.S. and one Canadian hospital have been designated patient-centered hospitals.
Institutions applying for Planetree membership are now strongly encouraged to be evaluated for this designation. Although it's still voluntary for Planetree member hospitals, the demonstrated correlation between these best practices and improved patient satisfaction makes a strong case for participation. In the early days of disseminating the Planetree model, little hard evidence existed linking this model of care to patient outcomes, and early adopters were encouraged to experiment widely using a variety of approaches to improving the patient experience. The designation project has helped to identify a set of core practices for patient-centered care in hospitals, and no doubt additional innovations will be developed.
We welcome the opportunity during the coming months to describe in more depth the best practices associated with patient-centered care. This series of articles will include detailed descriptions of these practices, including the use of open medical records, care partner programs, patient-directed visitation, patient and family involvement, the creation of quiet healing environments, the power of caring touch, and access to information about the patient's condition and treatment and patient-centered designation. Each installment will detail how these practices were developed and implemented and the evidence supporting their importance to the patient's experience.
The HCAHPS Survey
Collecting information from patients, providing data on hospitals.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients' perceptions of their hospital experience and publicly reports the results. It's the first tool to allow consumers to compare hospitals on the basis of these data. The survey poses 27 questions about a patient's recent hospital stay that reveal, among other things, the patient's experience communicating with nurses and physicians, the responsiveness of staff, the hospital's cleanliness and noise levels, and pain management.
The vast majority of acute care hospitals in the United States will adopt this survey during the coming year to measure patient satisfaction. The Centers for Medicare and Medicaid Services has designed financial incentives that reward facilities that use the instrument and report data.
Consumers can go to www.hospitalcompare.hhs.gov to review the results and compare hospitals. Additional information about the development, content, and administration of the survey can be found at www.hcahpsonline.org.
The 10 Components of the Planetree Model
The following is adapted from Planetree's Web site (www.planetree.org/ABOUT/acutecare.html):
- Human Interactions. Creating organizational cultures that support caring, kindness, and respect in all interactions between patients, families, and staff members.
- Family, Friends, and Social Support. Encouraging the involvement of family and friends as partners in the care experience, whenever possible; offering patient-directed visitation, including in the ICU and ED, family presence protocols, and care partner programs.
- Access to Information. Providing patients with information and educational resources so they can actively participate in their own care. Patients have access to their medical charts; can take part in collaborative care conferences (in which the patient, family, physician, and nurse converse at the bedside); and can visit libraries or Planetree Health Resource Centers that are open to the community and offer health and medical information.
- Healing Environments Through Architectural Design. Creating quiet, healing environments using evidence-based design principles that create homelike and welcoming settings that remove barriers between patients, families, and caregivers.
- Food and Nutrition. Providing delicious, healthful meals and making good food choices available to patients, families, and staff 24 hours a day, seven days a week.
- Arts and Entertainment. Creating an atmosphere of serenity and playfulness by displaying artwork in the patient rooms and treatment areas, having volunteers work with patients to create their own art, and inviting local artists and musicians to help lift spirits through exposing patients to the arts and entertainment.
- Spirituality. Supporting patients, families, and staff to connect with their own inner resources by providing access to clergy and places of worship, gardens, labyrinths, and meditation rooms.
- Human Touch. Using caring touch and massage to reduce anxiety, pain, and stress in patients, families, and staff members.
- Complementary Therapies. Expanding choice by offering patients access or referral to aromatherapy, Reiki, guided imagery, therapeutic touch, acupuncture, chiropractic, Tai Chi, yoga, and other integrative modalities.
- Healthy Communities. Increasing the role of hospitals and redefining health care to include the health and wellness of the community by working with schools, senior citizen centers, churches, and other community partners.
1. Martin DP, et al. Randomized trial of a patient-centered hospital unit. Patient Educ Couns
2. Frampton SB, et al., editors. Putting patients first: designing and practicing patient-centered care.
1st ed. San Francisco: Jossey-Bass; 2003.
3. Brady C. Making patient-centered care more visible: Planetree's vision. The Patient: Patient-Centered Outcomes Research