American College of Physicians: Internal Medicine — Doctors for Adults ®

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Patient-centered care: Not just a catchphrase

How to focus hospital care where it belongs

From the August ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Charlotte Huff

Six years ago, patient rounds at The Christ Hospital in Cincinnati often involved residents and attending physicians huddled around conference tables talking, with only occasional forays to visit patients.

The patient's voice and perspective were sometimes obscured as a result of the intense educational focus, said Jeff Schlaudecker, MD, a geriatric hospitalist and assistant director of the inpatient family medicine service. When the teaching team did gather at the bedside, “it definitely was not in a collaborative way. It was, ‘Let's go look at this rash.’ Or, ‘I want everybody to get a chance to listen to this [heart] murmur.’”

Photo by Thinkstock.

Photo by Thinkstock.



These days, rounds with the family medicine residency service at The Christ Hospital are nearly always conducted at the bedside. The doctors introduce themselves, speaking directly to the patient and family as they review and update the patient's medical condition. Typically the bedside nurse also is present, Dr. Schlaudecker said.

The goal is to develop better rapport, key to getting patients well and keeping them that way, he said. This patient-centered care philosophy, first tried in the hospital's geriatric unit and soon expanded to all other adult inpatient units, also reminds physicians in training to pay attention to more than the diagnostic minutiae.

“We're not just talking about a conglomeration of labs and tests and ejection fractions,” Dr. Schlaudecker said. “We're talking about a real person here.”

Shifting focus

The Institute for Patient- and Family-Centered Care, a non-profit organization based in Bethesda, Md. and founded in 1992, initially focused on children and their families in discussing the concepts of patient-centered care. But administrators and clinicians who treated adults expressed interest in incorporating patient-centered care into their practices, and started attending the Institute's seminars as well, said William Schwab, MD, a board member at the Institute (see sidebar, next page). “So the Institute expanded its focus to all aspects of the health care system,” Dr. Schwab said.

By 2001, the Institute of Medicine was emphasizing the benefits of patient-centered care, listing it as one of the six central treatment aims in its high-profile report, Crossing the Quality Chasm. Since then, an increasing number of health care organizations have focused more attention on patient perspectives. Last year, The Joint Commission began to evaluate hospitals against a set of patient-centered standards, such as communicating at the patient's comprehension level. The standards will be included in accreditation decisions starting this July.

Some of the core concepts of patient-centered care, such as sharing all medical details and collaborating on care with the patient, might seem obvious. But as hospitals and their clinicians scrutinize the way they treat patients, they can run smack into an uncomfortable reality, Dr. Schwab said.

From the scheduling of blood work to the logistics of patient rounds, “we have to acknowledge that a lot of the reason we do what we do, the way we do it, is because it works for us, the doctors or the health system as a whole,” he said.

Take the practice at some hospitals of waking up patients at dawn to draw their blood, he added. “When I come in at 7 a.m., I want to know what their labs are. That works for me, but how about the patient?”

To address such issues, hospital administrators are increasingly giving patients and family members an advisory role, in order to get a better sense of how hospital care—from routine procedures to the layout of the hospital itself—is perceived by the patient.

At Georgia Health Sciences Medical Center in Augusta, previously called Medical College of Georgia, more than 250 former patients and family members provide regular input through a handful of patient-focused advisory councils. Patients don't tend to fixate on high-tech bells and whistles when they assess a hospital's care, said Bernard Roberson, administrative director for patient- and family-centered care.

“Our patients tell us that if you communicate well with [them], and educate [them] about what's going on and help to manage [their] emotional needs, that's how they determine whether or not they got quality care,” Mr. Roberson said.

Measuring results

A September 2011 study in the Journal of General Internal Medicine found that patients reported greater satisfaction with their physicians' care when they were treated under a patient-centered approach rather than a more traditional model. The analysis, which focused on the internal medicine residency program at Johns Hopkins Bayview Medical Center in Baltimore, looked at patient satisfaction for a variety of indicators, from food to clinical care.

While those treated by the patient-centered team didn't give the food or nursing care any higher marks, they reported higher satisfaction with physician care, including time spent with the doctor and the doctor's courtesy and skill in keeping them informed, said Janet Record, MD, a hospitalist and study author, as well as an assistant professor of medicine at Johns Hopkins University School of Medicine.

Training physicians in these skills was more time-consuming on the front end, she acknowledged. The patient-centered team, part of a teaching curriculum called the Aliki Initiative, was only assigned half the number of patients as the traditional teams, she said. But it's unknown the degree to which residents continue using patient-centered communication skills in busier settings after they leave the Aliki rotation, or how much time it takes to implement these skills once honed, she said.

It's possible that some of the upfront costs in additional training time are offset by later savings to the health care system, Dr. Record said, citing a May 2011 Archives of Internal Medicine study she worked on. It determined that the 30-day heart failure readmission rate was lower in the Aliki patient-centered team—4% compared with 14% on three standard teaching teams.

There's an added incentive to keep patients satisfied and away from the hospital after discharge now that federal officials are tracking hospital readmissions and other quality criteria, Dr. Schwab added. “This is not just about being nice,” he said. “This is about quality and safety and [improving] care by having an active and vibrant partnership.”

For example, doctors can put a higher emphasis on visiting patients when loved ones can be present. Visiting hours may no longer be rationed, even for patients in the intensive care unit; instead the option of continuous family presence can be seen as a strategy for obtaining the best outcomes. And the patient's daily treatment plan may be made easily accessible, either on paper or a nearby white board.

Bedside rounding

At Johns Hopkins Bayview, one of the major focuses of the patient-centered team has been an interactive approach to rounds, similar to the one described by Dr. Schlaudecker.

Historically, during patient rounds, “the physicians tend to speak in the hallway together using a lot of medical jargon about patients, and the patients are not privy to what the discussions are,” Dr. Record said. The patients, she added, “sit in their room and they wonder what the doctors are doing, and why they take so long to come to the bedside.”

Rather than rapidly ticking off the treatment plan to the patient, the team first gauges the patient's understanding of his or her medical diagnosis and related treatment, Dr. Record said.

The additional discussion involved doesn't appear to be any more time-consuming, she said. In fact, there may be less repetition, as doctors don't cover the same medical information twice, both in their teaching huddle and then inside the patient's room.

Typically patients don't interrupt while their case is presented, because they've been told they will be given time to ask any questions at the end, Dr. Schlaudecker said. “For the most part, with rare exceptions, [patients] say, ‘Nope, you got it.’”

Less medical jargon also tends to be used with the patient sitting right there, said Dustin Smith, MD, a hospitalist at Atlanta Veterans Affairs Medical Center. Physicians at his facility also stress that patients and their loved ones are part of the treatment team, and encourage them to add insights, he said.

Sometimes patients or family members do point out errors in the medical history as the case is being presented, Dr. Smith said. In the end, the open-window process provides patients more confidence that medical information isn't being hidden from them. “I think it builds a lot of trust,” he said.

Patients are most likely to benefit from the approach if they're interested in learning more about their disease and how to manage it, Dr. Schlaudecker said. Discussions at the bedside also are particularly helpful when the patient's thinking is somewhat impaired—due to a mental illness or developmental disability—but they have an involved caregiver who is soaking up all of the details, he said.

Shared decisions

Even if a hospitalist practices at a facility that hasn't rolled out a patient-centered initiative, she can still take steps to foster better rapport. One is to use less medical jargon and to avoid lecturing to the patient, Dr. Record said. “I think listening more (is important)—listening to the patient's perspective and understanding. We have to listen and ask the right questions.”

Hospitalists in particular may be treating patients for whom returning to full health isn't an option, due to the severity of their illness or injuries, noted David Reuben, MD, FACP, chief of the division of geriatrics at the University of California Los Angeles (UCLA).

In these cases, physicians can help patients sort through complex choices in a goal-focused manner by framing some of the medical issues involved, said Dr. Reuben, who co-authored a piece on this subject in the March 1 New England Journal of Medicine. A hospitalist might either ask a patient about his or her goals in an open-ended way, or present specific medical options to better understand what matters to a particular patient, he said.

For example, Dr. Reuben recently had an elderly patient who took medicine that helped her sleep, but left her hung over in the morning and prone to falls. She had already fallen once and cracked two ribs, making it clear that she could no longer safely get to the bathroom at night alone. So he outlined her options in the context of goals. “Is the goal for her to sleep soundly through the night, or is the goal for her to be able to live independently?” In the end, he said, “she chose [hiring] the caregiver because she wanted a sound night's sleep.”

These types of discussions encapsulate patient-centered care, because they incorporate the patient into the decision-making process, Dr. Reuben said. In short, it is a patient's right to make a poor decision if the doctor has laid out the potential downstream consequences in terms that the patient really comprehends, he said.

“I would sleep much better at night, I would be much happier if this person was not on [eszopiclone],” he said of his elderly patient. But “my sleeping at night is only part of the picture.”

This woman likely can look forward to a few years more of life at most, he added. “How that person lives that next year or two—who should be determining that?”

Charlotte Huff is a freelance writer in Fort Worth.

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Patient-centered tenets

As hospitals strive to build treatment more around the patient, the Institute for Patient- and Family-Centered Care in Bethesda, Md., recommends clinicians focus on four key tenets. They are:

Respect and dignity: Listen to and honor patient and family perspectives and choices, incorporating them into treatment.

Information sharing: Share complete and unbiased information in a timely fashion to help patients and loved ones make better decisions.

Participation: Encourage patients and families to participate in care and decision making at the level at which they choose.

Collaboration: Ensure health care leaders collaborate with patients and families in policy and program development along with related issues, including health facility design and treatment delivery.

More details on the tenets are online.

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