MORE THAN 2 DECADES AGO, primary care clinicians began to measure not only “patient satisfaction” with care but also the physical, social, and emotional factors that affect patients' health and well-being, that is, “what matters to the patient” (Nelson et al., 1983). More than a decade ago, a critical review of the literature identified collaborative interaction between a clinician or clinical team and the patient as the final common pathway for the improvement of patient function (Wagner et al., 1996). The term “patient-centered” care affirms the power of knowing and acting on what matters to the patient and the proven benefits from collaborative interaction. Moreover, “patient-centered” care rejects the notion of paternalistic “doctor-centered” healthcare services (Davis et al., 2005; Wagner et al., 2005). Regardless of the origins of the term, there is a growing recognition that the provision of care centered on patients' needs and expectations is a key attribute of quality care (Bergeson & Dean, 2006).
In 1999, as the “patient-centered” concept was starting to take hold, the Institute for Healthcare Improvement (IHI) began its program for the Idealized Design of Clinical Office Practice (IDCOP). Within the IDCOP model, the patient-provider interaction was placed at the “heart of care” (Kilo & Endsley, 2000). However, there was also a recognition that ideal practice required much more than a focus on the collaborative interaction and effective care alone. It required attention to ensuring that patients have easily available access to that care, evidence-based care that is delivered consistently over time, and a vital workforce for delivering the care. Donald M. Berwick, MD, the President and CEO of IHI, asserted that when these attributes of ideal practice were optimally combined, patients would be able to strongly agree that “I receive exactly the care I want and need exactly when and how I want and need it!”
Since that time, IHI and others have continued to explore how best to put the patient experience at the heart and center of redesign efforts in ambulatory care. In this introduction to the series, we provide an overview of both the experiences and the practical steps practices and health systems can take so that their patients attain “exactly the care they want and need.” This series has been written in the spirit of sharing what we and others have learned so that all ambulatory care-based practices can adapt the ideas described here and make the delivery of patient-centered care a reality for millions of patients.
LESSONS LEARNED FROM 10 YEARS OF EXPERIENCE
With the advantage of hindsight and 10 years of experiences from many participating practices and health systems, we have identified 5 helpful principles for making high-quality, patient-centered care a reality.
It is important to understand and influence the culture
- At the policy level, current payment priorities and methods favor interventions for acute, episodic-based care. For example, although most payment systems provide coverage for office visits, they do not pay for follow-up contact by the care team with patients needing ongoing support for managing their medications and creating healthy diets or exercise programs. In addition, care is fragmented with little coordination of care across providers because payment systems reimburse providers for specific episodes of care (Fisher et al., 2003). More subtly, even the clinical decisions of physicians within the office will reflect the intensity of medical resources of the environment in which they find themselves (Sirovich et al., 2006).
- Leadership matters! At the organizational level, progress toward improvement is greatly impacted by the way in which the “owner” of a clinical practice sets policies and reinforces the importance of improvement. When leadership and staff priorities are not aligned, poor quality is likely (Tucker, 2008). For example, if financial incentives for physicians are tied to the number of patients seen rather than the overall care and/or quality of the care provided, the focus is then on volume and not care. On the other hand, when leadership is aligned with staff and vice versa, exemplary care can happen.
Make wise use of preexisting models and methods
- The IHI has developed and utilized a number of models such as the IDCOP model discussed above to help practices improve care processes and patient outcomes. It is important not to see a model as a rigid roadmap without regard to resource requirements or inherent limitations for spread to other conditions and patient populations.
- Some methods and models seem to work better when their components are “sequenced.” For example, among small, independent practices, a specific sequence derived from the Chronic Care Model (Wagner et al., 1996) and microsystem (Wasson et al., 2008) principles is being delivered at almost no cost to many smaller practices cross the United States (http://www.IdealMedicalPractices.org).
- Start with the full scale in mind. Although a number of practices have had initial dramatic results from collaborative and other learning methods that focused on improving care for particular subpopulations of patients such as those with diabetes or asthma (Chin et al., 2004; Schonlau et al., 2005), they have not always been able to apply the changes to all patients in their practice. Asking the question of how specific changes can be planned and sequenced to be more easily applied to all populations of patients has emerged as a promising approach to total system redesign.
Place what matters to the patient in the center
- Healthcare professionals are well trained to assess, diagnose, and prescribe for what, bioclinically, is the matter with the patient. Healthcare professionals are less comfortable assessing and helping manage issues that matter to the patient (such as their functional limits or their information needs). In addition, many practices do not have processes in place to support the provider in being able to respond to complex psychosocial and behavioral health issues. The issues that matter to the patient are at the heart of patient-centered care (Moore & Wasson, 2006a).
- Patient-centered care will not occur unless patients help set the agenda for practice redesign. Practice may have patients serve in an advisory capacity either as part of a patient council or as a member of the care team or having patients comment on care using surveys. Practices are less accustomed to placing what matters to a particular patient on the agenda of the clinical staff. For assessing and helping manage issues that matter to the patient, different approaches, tools, and techniques are necessary. “CARE vital signs,” described in an article by that name, illustrates how patient-centered care can be implemented in any setting with any patient population.
- At all levels—policy, organizational, and especially at the front line—the greater the number of “handoffs,” the greater the opportunity for misunderstanding, mistakes, waste, and errors (Fisher et al., 2003; Wasson, 2008; Wasson et al., 2007). Paradoxically, the inclusion of many complementary roles within a team can sometimes undercut its efficient and effective function. Reliability of service is a useful byproduct of reduced complexity.
Use the lowest cost, most adaptable technology
- The last decade has witnessed tremendous advances in healthcare technology and promotion of its virtues. Many office practices are using electronic medical records, automated registries, e-mail, and even e-prescribing. However, few of these technologies begin with the patient and follow him or her seamlessly through the care processes. A previous issue of the Journal of Ambulatory Care Management was devoted to “Technology for patient-centered collaborative care” (Moore & Wasson, 2006b). Relevant examples are reintroduced in this issue of the journal.
THIS SERIES OF ARTICLES
The series of articles that follow report on a decade of experience building on the foundation of IHI's IDCOP. Table 1 provides an overview of the “take-home” messages from these articles. The intent of all the authors is to make sure that the “take-home” is practical and replicable for most primary and many specialty care settings.
Even if usual care is not yet particularly patient-centered, one would hope that it would at least be reliable and safe care. Unfortunately, this is not the case. For example, depending on their burden of illness, from 1% to 7% typical adult patients report a personal harm in the past year (Wasson, 2008). Unreliable service and design of practice undercut any effort to improve care. One key learning from IHI's work has been that reliability strategies associated with higher levels of success include consideration of human factors in design of work processes. In “Making patient-centered care reliable,” the authors emphasize the factors, both human and system, that have to be changed if high reliability is to become an intrinsic property of care.
Without a patient's involvement, the outcomes of patient-centered care will be inadequate. “Activation of patients for successful self-management” describes how to effectively activate patients for successful self-management even when the clinical circumstances are less than ideal.
When physicians, nurses, medical assistants, receptionists, and others who help support patient care focus on the needs of their patients and the vitality of their function as a team, it is more likely to identify, implement, and sustain necessary improvements than is possible in an environment where there is little recognition or support for the development of a care team. In “Optimizing the care team,” the authors describe some useful methods for making a care team as patient-centered and reliable as possible.
Since beginning its office practice improvement work, advanced access has been a central focus of IHI activities. Yet many patients still experience long waits for routine appointments with their primary care physicians or for a referral to a specialist. The article titled “Accessing patient-centered care using the advanced access model” describes the methods and benefits of improving access to care and emphasizes 6 high-leverage changes for making it work in any clinical setting.
In “Balanced measures for patient-centered care,” the authors make the case that patient and staff ratings of care should be considered to be just as valuable as bioclinical or process measures. Moreover, patient measures are inherently actionable and likely to result in better care. The authors demonstrate how practices that build patient-reported measures into everyday work have twice as many patients reporting that they receive exactly the care they want and need.
Finally, in an article titled “CARE vital signs,” we emphasize the value of a simple tool designed for 2 purposes: (1) to improve patient-centered care for a particular patient and (2) to stimulate the clinicians to build on that use to improve patient-centered care for all patients. For practices wanting to make patient-centered care more than jargon, this is a simple and very effective way to begin.
The series of articles represents the efforts of many participants to improve medical care during the past decade. Future scientific developments and social trends will undoubtedly bring changes in clinical care and the methods needed to improve it. Despite the inevitability of these changes, we hope that the content of these articles will be useful for years to come.
Bergeson, S. C., & Dean, J. D. (2006). A systems approach to patient-centered care
. Journal of the American Medical Association, 296
Chin, M. H., Cook, S., Drum, M. L., Jin, L., Guillen, M., Humikowski, C. A, et al. (2004). Improving diabetes care in midwest community health centers with the health disparities collaborative. Diabetes Care, 27
Davis, K., Schoenbaum, S. C., & Audet, A. (2005). A 2020 vision of patient-centered care
. Journal of General Internal Medicine, 20
Fisher, E. S., Wennberg, D. E., Stukel, T. A., Gottlieb, D. J., Lucas, F. L., & Pinder, É. L. (2003). The Implications of regional variations in Medicare spending. part 1: The content, quality, and accessibility of care. Annals of Internal Medicine, 138
Kilo, C. M., & Endsley, S. (2000). As good as it could get: Remaking the medical practice. Family Practice Management, 7
Moore, L. G., & Wasson, J. H. (2006a). An introduction to technology for patient-centered, collaborative care. Journal of Ambulatory Care Management, 29
Moore, L. G., & Wasson, J. H. (Eds.). (2006b). Technology for patient-centered collaborative care. Journal of Ambulatory Care Management, 29
Nelson, E. C., Conger, B., Douglass, R., Gephart, D., Kirk, J., Page, R., et al. (1983). Functional health status levels of primary care patients. Journal of the American Medical Association, 249
Schonlau, M., Mangione-Smith, R., Chan, K. S., Keesey, J., Rosen, M., Louis, T. A, et al. (2005). Evaluation of a quality improvement collaborative in asthma care: Does it improve processes and outcomes of care? Annals of Family Medicine, 3
Sirovich, B. E., Gottlieb, D. J., Welch, H. G., & Fisher, E. S. (2006). Regional variations in health care intensity and physician perceptions of quality of care. Annals of Internal Medicine, 144
Tucker, M. E. (2008, May 1). Adverse work conditions tied to worse patient care. Internal Medicine News
, p. 1.
Wagner, E. H., Austin, B. T., & VonKorff, M. (1996). Organizing care for patients with chronic disease. The Milbank Quarterly, 74
Wagner, E. F., Bennett, S. M., Austin, B. T., Greene, S. M., Schaefer, J. K., & VonKorff, M. (2005). Finding common ground: patient-centeredness and evidence-based chronic care. Journal of Alternative and Complementary Medicine, 11
(Suppl. 1), S7–S15.
Wasson, J. H. (2008). Who is in charge? Even affluent patients suffer consequences of fragmented care. Journal of Ambulatory Care Management, 31
Wasson, J. H., Anders, G. S., Moore, L. G., Ho, L., Nelson, E. C., Godfrey, M. M., et al. (2008). Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need. Joint Commission Journal of Quality and Patient Safety, 34
Wasson, J. H., Mackenzie, T. A., & Hall, M. (2007). Patients use an internet technology to report when things go wrong. Quality and Safety in Health Care