Although the primary focus of all clinicians involved in hearing rehabilitation is to ensure the highest quality of patient care, it is important to recognize that this care is delivered through an organization that must ultimately be sustainable. From a business perspective, sustainability revolves around delivering care that meets the wants and needs of clients in a way that ensures the organization's ability to continuously provide services to future clients.
Clinical research in several fields has demonstrated that a person-centered care (PCC) approach to delivering services can provide improved client satisfaction and health outcomes while benefiting the organization financially and improving staff satisfaction.1,2 Researchers have described PCC in hearing rehabilitation as “quality care in which each patient is seen as an individual who experiences his/her health independently and has needs relating to being informed and involved in health decisions.”3 However, several observational studies of clinician-client interactions have revealed that clinicians may miss opportunities to address clients’ psychosocial needs and to build rapport, involve clients and their family members in shared decisions, or provide options for hearing rehabilitation,4-7 indicating that PCC is not delivered as defined.
Irrespective of what happens in the clinic, clinicians self-report that they prefer a PCC approach.8-10 Instead of trying to change clinician behaviors directly, we chose to focus our research on the organizational context for clinical practice. Hearing rehabilitation organizations (HROs) employ hearing care practitioners and provide the necessary conditions for clinical practice. Hence, we expect that HRO senior managers’ definition of organizational success and understanding of PCC can affect their clinicians’ practice of PCC.
There is little evidence to date that organizations evaluate their delivery of PCC and its outcomes in meeting client needs. Understanding how PCC is clinically evaluated is necessary for two reasons. First, using evaluation tools can drive clinical practices as clinicians respond to what is evaluated. For example, if clinicians are held accountable for targets focused on hearing device revenue or units sold, then it is reasonable to expect that the HRO will achieve targeted values ahead of other non-measured outcomes. Therefore, senior management's understanding of PCC and subsequent choice of evaluation tool(s) can indirectly affect the practice of PCC. Secondly, PCC outcomes are not as well established in hearing rehabilitation compared with those in other fields. Evaluating PCC will allow us to better understand PCC outcomes within those in hearing rehabilitation, which may further encourage—or discourage—clinical uptake of PCC by organizations and clinicians. In this research, we asked:
- How do senior managers define success?
- How do senior managers define PCC?
- How do senior managers evaluate PCC?
- What do senior managers need to evaluate PCC more effectively?
We interviewed senior managers who were ultimately responsible for clinical decisions and practices within their organizations. Sixteen senior managers from 12 HROs participated in individual semi-structured interviews. Managers were drawn from across Australia and from small and large organizations, including independent providers, as well as manufacturer-aligned, ENT-owned, not-for-profit, university-based or government-funded HROs. On average, participants had 8.42 (range: 1.5-20) years of experience as senior managers within their organization. As a group, participants were responsible for over 20 percent of Australia's clinicians (audiologists and audiometrists) delivering hearing rehabilitation services. Most participants had a clinical background (14) and several also held business qualifications (6). More than half were female.
How do senior managers define success? Participants defined organizational success as including:
- client happiness as the key element;
- financial viability of the business and the importance of being paid; and,
- staff happiness, including staff feeling valued.
How do senior managers define PCC? As a group, participants defined PCC consistently with the literature.3 When asked to define PCC, participants collectively reported that:
- care should be individualized to meet the client's goals and needs;
- clients can make informed decisions if provided with accessible information and options; and
- clients and their families should be involved in a shared decision-making process with their clinician in a setting of respect, trust, and without sales pressures.
PCC was viewed as going beyond technical expertise, involving a focus on service quality, and delivering value for the client. With this approach, participants believed that their organization could meet client expectations and rehabilitation outcomes, obtain financial success, and promote employee professional satisfaction.
How do senior managers evaluate PCC? Participants reported that they did not evaluate PCC as defined. They did not evaluate PCC directly, but reported using alternative methods to determine if PCC was provided. Their organization's methods for evaluating their delivery of PCC included one or more of the following elements:
- Key Performance Indicators (KPIs):
- Consistent hearing device uptake and use;
- Low hearing aid returns; or
- Meeting financial KPIs.
- Clients referral of others to the organization;
- Client retention determined by their return for review appointments; or
- A full appointment diary.
Observations of Client-Clinician Interactions:
- Meeting client goals (e.g., COSI) as recorded in clinical notes; or
- Clients interviewed as part of the audit process.
- Exploring if clients were given enough choice or information.
- To optimize the client journey primarily for marketing purposes (large organizations only)
- Evaluating high client/device satisfaction, device benefit, or a reduction in communication difficulties (e.g., via a hearing aid user's questionnaire);
- Informal comments or gifts to clinicians and reception staff; or
- Clients express their desires in questions and it was important to listen and respond to these requests.
Most participants reported that their organization did not routinely evaluate clients who did not take up hearing devices. Those who did not formally evaluate PCC reported that trust in their clinical staff and organizational processes ensured the delivery of PCC. For example, one manager said that they “would argue that a lot of [their] clinicians were doing (PCC) maybe on an unconscious level anyway.” Another manager reported that their organizational processes encouraged family member attendance at hearing rehabilitation appointments.
What do senior managers need to evaluate PCC more effectively? Participants noted that a PCC evaluation tool suitable for clinical practice would have the following attributes:
- Short, with few questions, and easy for the client to complete within existing frameworks of appointments;
- Affordable and cost-effective to implement and ideally adapted into existing channels;
- Easy to interpret for clinicians and organizations, and easily identify areas that need improvement to inform training needs;
- Linked with strong outcomes and evidence-based (the tool would need to be valid, with a clear purpose and measures what it intends to); and
- Piloted and refined within each organization. Staff input is seen as necessary for its uptake.
DISCUSSION AND IMPLICATIONS
The study results showed that PCC was not directly evaluated in current clinical practices, which may in part explain why PCC is not widely observed in audiology practice. Managers described PCC as individualizing client care, helping clients arrive at informed choices, and involving clients and their family members, yet none of the HROs surveyed evaluated PCC as described. Managers relied on alternative methods to infer the practice of PCC based on the anticipated outcomes of PCC. However, managers recognized the importance of evaluating PCC and were able to clearly identify their requirements for a clinically viable evaluation tool.
These results identify opportunities to better evaluate PCC clinically within HROs. Research in other health care areas suggests that PCC outcomes are strongly associated with how HROs define success in this study—client happiness, financial viability, and staff happiness—which underscore the importance of evaluating PCC in routine clinical practice. This will allow organizations to infer the cause-and-effect relationship of current practices and their clinical processes on valued outcomes. Our research is building on these outcomes by exploring the facilitators and barriers to the evaluation of a PCC approach to hearing rehabilitation.
Acknowledgments.The authors would like to thank all study participants, and acknowledge the financial support of HEARing CRC, established under the Australian Government's CRC Program, which supports industry-led collaborations between industry, researchers, and the community.
1. McMillan SS, Kendall E, Sav A, King MA Whitty, JA, Kelly F, Wheeler AJ. Patient-centered approaches to health care: A systematic review of randomized control trials. Medical Care Research and Review.
2. Charmel PA, Frampton SB Building the business case for patient-centered care. Healthcare Financial Management.
3. Grenness C, Hickson L, Laplante-Lévesque A, Davidson B Patient-centred care: A review for rehabilitative audiologists. International Journal of Audiology.
4. Ekberg K, Grenness C, Hickson L Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology
. 2014;23(September):337–351. doi:10.1044/2014_AJA-14-0011.
5. Ekberg K, Barr C, Hickson L Difficult conversations: Talking about cost in audiology consultations with older adults. International Journal of Audiology.
6. Grenness C, Hickson L, Laplante‐Lévesque A, Meyer C, Davidson B The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of the American Academy of Audiology.
7. Grenness C, Hickson L, Laplante‐Lévesque A, Meyer C, Davidson B Communication patterns in audiologic rehabilitation history‐taking: Audiologists, patients and their companions. Ear & Hearing
. 2015b;36(2):191‐204. doi:0196/0202/2015/362-0191/0.
8. Laplante-Lévesque A, Hickson L, Grenness C An Australian survey of audiologists’ preferences for patient-centredness. International Journal of Audiology.
9. Manchaiah V Gomersall, PA, Tomé D, Ahmadi T, Krishna R. Audiologists’ preferences for patient-centredness: a cross-sectional questionnaire study of cross-cultural differences and similarities among professionals in Portugal, India and Iran. BMJ Open.
10. Manchaiah V, Dockens AL, Bellon-Harn M, Burns ES Noncongruence between Audiologist and Patient preferences for Patient-Centredness. J Am Acad Audiol.