What does it really mean to be “Patient-Centered”?

What does it really mean to be “Patient-Centered”? Finding the heart of transformed healthcare

“I fear the inevitable day on which I will become a patient. What chills my bones is indignity. It is the loss of influence on what happens to me. It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself. That’s what scares me: to be made helpless before my time.” Don Berwick MD

“What is wrong is that the system exerts its power over reason, respect, and even logic in order to serve its own needs, not the patient’s. What is wrong is the exercise of a form of violence and tolerance for untruth, and—worse for a profession dedicated to healing—needless harm” Don Berwick MD

Have you or a family member had a patient experience? What was it like?

Patient-centeredness: Bridging the chasm between two extremes Radical consumerism Classic professionalism “Patients make decisions that are not in their best interests.” Professions reserve to themselves the authority to judge the quality of their own work because of: Altruism Expertise Self-regulation • “The customer is always right” • Consumers have the “authority”, exercised by marketplace choices, to judge quality. • Excellence is in the eye of the customer.

IOM Quality Aims draw from both camps Professionalism Consumerism “Patient-centeredness”—partnership, respect Timeliness Efficiency Equity • Safety—”avoiding misuse”; not doing harm from care. • Effectiveness—”avoiding overuse and underuse”; grounding care in evidence

Consumers independently assess the safety, comfort, reliability, gas mileage, beauty, and driving fun as separate characteristics of the quality of an automobile---We don’t need to be engineers Why then are patients judged incapable of assessing safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity of our healthcare?

“They give me exactly the help I need and want exactly when I need and want it” Mantra for the Idealized Design of the Clinical Office Practice Project, IHI

“We would all be better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives”. Don Berwick MD

A fundamental shift of perspective Host—Patients are visitors to our world Guest—We are guests in their lives “The needs of the patient come first”. Mayo Clinic “Nothing about me without me” “Every patient is the only patient”—Harvard Community Health Plan • Habits and rules of doctors and nurses come first. • Many things happen without the patient’s input or consent. • Becoming a “patient” means becoming an anonymous member of a class

“Patient-centeredness is that property of care that welcomes me to assert my humanity and my individuality. If we be healers, then I suggest that it is not a route to the point; it IS the point.” Don Berwick MD

What does patient-centered care look like? How patient-centered do you think your practice is?

Transforming your practice—Example of South Central Foundation When Customers Drive the System it Changes Everything—For the Better

The customer drives everything Multiple strategies to listen to customer-owners: • Surveys • Focus Groups • Mystery shoppers • Project teams • Advisory councils Language, Patient Engagement

All customers have a health care team they know and trust: • Customer-owners choose their own doctor. • If they are dissatisfied, they can choose another. • Each doctor works in a team—1-2 MAs, full-time nurse, administrative assistant. • All care occurs in exam rooms • All team members work at the top of their license. Relationship

SCF Team function • Panel size about 1200 • Teams see only their panel • When care is needed outside the medical home, the handoff is immediate and the customer is returned promptly. • Specialists are assigned to primary care teams. Relationship

Customers should face no barriers to care: • Same day access—70-80% of slots open on any given day when that day starts. • 2/3 of teams give out direct phone lines. • Teams handle what they can over the phone, scheduled today with the team-member who can provide the needed care. • Specialty care also same day in most cases. • Physical space reflects values Service

SCF Clinical Outcomes • Utilization—40% drop in urgent/ED care; 50% reduction specialist care; 30% reduction inpatient days. • Quality—”perfect asthma care” increased from 35% to 85%; asthma admissions dropped from 10% to 3%; childhood immunizations from 85 to 94% • Customer satisfaction—91% favorable ratings Reliability, transparency

“I fear the inevitable day on which I will become a patient. What chills my bones is indignity. “ Don Berwick MD We will all be patients someday

What does it really mean to be “Patient-Centered”?