Hundreds of true believers were in Boston last month to discuss healthcare through the patient's eyes. Picker Institute's conference on patient-centered care focused on motivating healthcare workers to embrace dignity and humanity in medical treatment.
To Marie Ray Knight, chief operating officer of Regional Medical Center at Memphis (Tenn.), it's important that staff members have an unquestionable code of conduct to follow. In a bluntly worded presentation, Knight recalled that as a young girl she received some grandmotherly advice on a sensitive subject.
When young Knight asked why she should follow the advice, the reply was: "because Grandma says." After the third or fourth time Knight asked and got the same answer, she realized it was the smart thing to do. The advice, in other words, was clear and wasn't to be questioned.
Knight has taken that theory to employees by asking them to adhere to straight, simple rules "that become integral parts of the caregiver's performance with patients and families." For the nursing department, it's little things such as keeping ID cards visible at all times, answering the telephone within three rings and identifying yourself and your purpose when entering a patient's room. The 28 "behavioral standards" are part of a customer responsiveness program that Knight contends "will be here longer than I am. Even the union and those who oppose change understand that."
In these times of rightsizing, re-engineering and cost-cutting, it's comforting to know there are patient-centered crusaders among us. Picker Institute, a not-for-profit affiliate of Beth Israel Hospital Boston with support from the Commonwealth Fund, says seven dimensions of care dominate patients' experiences. They are:
access to care
respect for patients' values, preferences and expressed needs
communication between the patient and providers
physical care, comfort and alleviation of pain
involvement of family and friends
transition and continuity
Surveys are used to rate the success of patient-care services. But, according to Knight, you don't need a survey to discover that "patients should be treated like customers, and customers want control over their lives." The Regional Medical Center credo outlines 12 basic needs of customers, which include knowledge of what's going on, honesty from caregivers and preservation of self-esteem.
Sounds simple, although Thomas L. Delbanco, M.D., Beth Israel Hospital's director of general medicine and primary care, believes that few hospitals are equipped to support patient-centered care. Furthermore, the "institutional setting and mind-set of healthcare resists involving patients in planning, designing or evaluating care."
In fact, the patient-centered-care movement has been stymied by the re-engineering craze, which uses terms like patient-centered and patient-focused to boost work redesign initiatives.
"As enterprising consultants have developed, marketed and disseminated new models for reducing costs, much of the original thinking has been lost," said Margaret Gerteis, Picker Institute's director of education. "Few healthcare workers now equate patient-centered models of care with the concerns and perceptions of patients."
That's not to say the true believers aren't interested in efficiency. But, Gerteis contends that "if we don't meet patients' needs, what does efficiency accomplish?"
Frank J. Puglisi Jr., executive director of Merrithew Memorial Hospital in Martinez, Calif., believes that healthcare reform must address the pressures of public dissatisfaction with the medical system as well as the economic implications of managed care.
"Future financial success, as well as survival, will depend on the partnerships between patients and providers to promote individual and community wellness," he said.
Furthermore, the rapid diffusion of medical technology is making it more difficult for any hospital to establish a technological edge that is perceptible to patients. Puglisi says the patient's experience of illness and treatment by providers ultimately will dominate the quality debate.
Susan Edgman-Levitan, Picker Institute's executive director, is hopeful that managed care will achieve its promise of organizing medical services around the customer in a seamless continuum of care.
"Carefully managing a patient through the continuum of care is not only humane, it also can have a positive financial impact on providers," she said. "In the past, we've seen far too many problems when a patient with a chronic illness moves through the various channels of the ambulatory-care system. Better coordination saves money and helps prevent errors."
On the hospital side, the institutional barriers must come down. Ralph Muller, president of the University of Chicago Hospitals and Health System, says "people who work in hospitals think that they are patient-centered. In fact, they tend to define the patient's wants through their own professional biases."
Accepting the patient's views on quality care offers hope that organizational reshuffling does not. If you do not change, "then other corporate maneuvering does not add value or reduce cost," Muller said. "Long-term commitment to changing internal operations, guided by a patient-centered philosophy and management, will do this."