Picker Perspectives

Each month, Picker Perspectives will highlight someone who has been active in advancing

Picker Institute’s principles of patient-centered care.

This month's Picker Perspective is an interview with Stephen C. Schoenbaum, M.D., M.P.H.,

vice president of the board of directors of Picker Institute.

An Interview with Dr. Stephen Schoenbaum

In early 2008, Dr. Steve Schoenbaum, executive vice president for programs at The Commonwealth Fund, talked to Asian Hospital & Healthcare Management magazine about patient-centered care.

Healthcare processes are mostly disease-centered. How big a shift is it for hospitals to create processes that are patient-centered?

I don’t believe that the main issue is shifting from disease-centered to patient-centered care. Rather, it is shifting from physician-centered, or provider-centered, to patient-centered—and that is a very big shift. It is such a big change because in order to accomplish it one has to re-think every aspect of the patient’s journey through an episode of care from the patient’s perspective.

We think about patients having a disease or condition and about services we need to provide for them, and we think that if we have the ability to do a CT scan or perform a particular type of procedure that we are meeting the patient’s needs. But a patient’s needs are much more complex. Patients want to understand what they need medically and how what they need will affect them immediately and over the long term. They want to know what is happening next and how long it will be before that happens. Patients, particularly in hospitals, often have pain, and they need their pain to be controlled adequately. Physicians cannot easily measure pain. Historically, they have done a very poor job at managing pain from the patient’s perspective. Patients and their families get anxious. They need their anxieties to be anticipated and their fears to be allayed to the degree possible.

In the early 1990s, Picker Institute, an organization that exists to promote patient-centered care and on whose board I serve, convened focus groups of patients in order to define the attributes of care that patients felt were essential. This process led to a set of eight dimensions of “patient-centered care” including

fast access to reliable health advice
effective treatment delivered by staff you can trust
involvement in decisions and respect for patients’ preferences
clear, comprehensible information and support for self-care
physical comfort and a clean, safe environment
empathy and emotional support
involvement of family and friends and support for careers
continuity of care and smooth transitions

I would add that simplicity is a very important attribute of patient-centered journeys. Patients should receive only what is necessary, and the care they receive must be explained to them in terms they understand. The fewer steps involved in getting a patient journey accomplished successfully, the better.

I also cannot overstress the importance of coordination of care and smooth transitions between providers and care settings. Think of a patient journey as being like a complex relay race, with the patient, and information about the patient, as the baton. The baton must be passed securely from each provider to the next. If the baton is dropped, there is waste and a poorer outcome. Unfortunately, we know from surveys that too often—about one-third of the time—patients think that their care has been poorly coordinated and the transitions poorly managed.

What systems need to be put in place in order to provide care that best suits the patient’s needs (i.e., patient-centered care)?

The most important system is the one used to obtain and assess patient experiences. You don’t know if you are or are not providing patient-centered care unless you have gotten feedback from patients. It’s that simple. Once you have the feedback and the commitment to be as patient-centered as possible, then it doesn’t take many more systems to become more patient-centered.

Some aspects of patient-centered care can be facilitated by “systems.” For example, engaging the patient in the process of shared decisionmaking is an important aspect of patient-centered care. There are information tools, such as DVDs, that can help patients learn about common procedures or situations—the choice of treatment for breast cancer or prostate cancer or back pain—and make it easier to engage the patient in shared decisionmaking.

How important a role does technology play in this scenario? Is there enough technology available to push for a patient-centered care model?

Electronic medical records that are available to all of the patient’s providers and include complete, accurate laboratory results, information on allergies, medications, etc., make it easier to “pass the baton” and eliminate waste and duplication.

What role does the leadership play in bringing about a patient-centered approach throughout the organization?

The leadership is absolutely essential. Think about it. Patient-centered care can occur in a single clinical encounter, but it is most important across an entire patient journey or episode of care. Unless the leadership insists on and helps all the providers who are likely to be involved in the care of a patient to pass the baton effectively, it isn’t going to happen.

When one looks at patient-centered healthcare organizations, one of the first things one discovers is that the leadership highly values patient-centered care and has worked hard to establish that value within the organization.1 Interestingly, when one looks at hospitals that have excellent outcomes on quality measures, one also finds that the leadership highly values patient-centered care and has worked hard to establish that value and the value of continuous improvement of care outcomes within the organization.2

Let me close with a couple of comments:

Measurement of patient-experience is just beginning to become standard in hospitals in the United States. In March 2008, for the first time, results for almost all hospitals, using the standardized H-CAHPS instrument, were made public. They showed tremendous variation in performance and large opportunities for most hospitals to improve some aspect of the patient-centeredness of the care they deliver.
Do not think about patient-centered care as an “add-on” or a “frill.” It is absolutely essential to excellent care. Patient-centered care is one of the six aims of high-quality care that the U.S. Institute of Medicine delineated in its report Crossing the Quality Chasm. It is intimately related to the other five: safety, effectiveness, efficiency, timeliness and equity.

1Shaller, D., Patient-centered care: What does it take? The Commonwealth Fund, October 2007. Available at http://www.commonwealthfund.org/usr_doc/Shaller_patient-centeredcarewhatdoesittake_1067.pdf?section=4039

2Kerouac, M.A., Youngberg, B.J., Cerese, J.L., Krsek, C., Prellwitz, L.W., Trevelyan, E.W. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007 Dec;82(12):1178-86.