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Patient-centred care

Research Report Patient-centred care

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Executive Summary

An evolving process

The Scottish governments Quality Strategy (2010) puts people at the heart of everything NHSScotland does. Central to the quality strategy are three Quality ambitions, safe, effective and patient centred.

Patient-Centred Care is a modern healthcare trend based upon the establishment of a partnership between patients, their families and healthcare providers. By virtue of changes in facility design and functional procedures, a patient-centred care environment provides patients and families with fast access to reliable health advice, effective treatment by trusted professionals, clear information, assistance in self-care and emotional support and empathy. In addition, patients and families are considered as partners of healthcare staff and are involved in treatment decisions and the caring process. Patient-centred care is not dictated by a prescribed methodology and the approach is constantly evolving.

Underlying aspirations

This report provides an introduction to patient-centred care with particular emphasis on significant contributions within the available literature. It initially explains the underlying aspirations:

a welcoming environment;

respect for patients’ values and needs;

patient empowerment;

account taken of patients’ backgrounds;

the coordination and integration of care;

comfort and support, shorter waiting times;

convenient hours; and

community outreach initiatives.

A brief summary is given of the levels at which patient-centred care can be induced. The issue of the healthcare facility environment is then investigated and it is suggested that the concept of evidence-based design (EBD) has a pivotal role in the development of patient-centred care.

Management strategies – success and inhibition

Patient-centred care is interpreted in widely varying forms, from Planetree hospitals to the Picker approach of patient surveys, and a section is devoted to this topic. Although widely accepted in paediatric and maternity units, the report pays particular attention to the management strategies at organisational- and system-level required to instill a change in the outlooks of healthcare organisations in relation to other areas. Subsequently, the

Version 1: August 2012 of 33 Health Facilities Scotland, a Division of NHS National Services Scotland


primary reasons influencing the success of patient-centred care are highlighted before inhibiting factors are discussed. In addition to those mentioned above, the former category cites executive level leadership, a strategic vision, the involvement of patients and families at all levels (including committees), support and training for healthcare staff and appropriate monitoring of patient feedback. The barriers to the extension of patient-centred care include financial constraints and attitudinal opposition.

The case studies examined in the report led to the following observations:

effective, supportive and visionary senior leadership is a vital component of any patient-centred care approach;

when implementing patient-centred care, organisations must have an integrated and detailed plan and should pilot their ideas in one department or area before expanding;

to promote a patient-centred care environment fully, organisations must ensure the design of their facilities corresponds to their vision, values and principles;

organisations must not only focus on the patients but should also ensure they meet staff needs and provide a satisfying work environment.

Recommendations

In light of the information reviewed, the following recommendations are suggested for those utilising a patient centred care approach.

Recommendation 1: Before implementing a patient-centred care approach to the built environment, the needs and preferences of patients and their families should be determined through a variety of research methods including surveys and focus groups. The monitoring of feedback should continue after a patient-centred care strategy is in place, thus affording an opportunity for patients and families to influence healthcare designs, processes and operations and encourage them to envisage how an ideal healthcare environment looks and operates.

Recommendation 2: Based on input from patients, families and staff, a model through which a patient-centred strategy can be delivered should be developed. A resultant action plan will consider all areas of activity that may be affected by patient-centred care and indicate how it will be implemented at each level within the organisation and within defined timelines.

Recommendation 3: When implementing a patient centred care approach, consideration should be given to the needs and preferences of staff as well as provision of consistent support. A specific change programme therefore should be developed through which training can be provided for all staff in order to inculcate the goals, principles and requirements of a patient-centred care environment.

Recommendation 4: In planning a patient-centred care approach, the design of facilities should be paramount in the process. This can be followed through by implementing an audit process. Subsequently, to determine whether designs in use comply with the goals and objectives established to provide patient centred care or whether changes are necessary.



Background

There is an increasing focus on delivering patient-centred care within healthcare systems. In order to assist Estates & Facilities Managers and Directors it was recognised that there is a need to accumulate information on the topic. Patient-centred care represents a transformation in outlook among healthcare professionals in relation to the benefits of forming a partnership between themselves and patients and their families. This report serves as an introduction to the concept and summarises current practice. A series of recommendations arising from information accumulated through the study are made.

Research Question/Title of work

1. What is patient-centred care?

2. What are the barriers associated with the successful implementation of this healthcare philosophy?

3. How have other organisations approached the patient-centred care ethos within their health environments?

Abstract

Having a Patient centred care approach to healthcare delivering plays a central role in achieving the aims outlined in the Scottish Governments Quality Strategy.

Patient-centred care is a modern healthcare trend based upon the establishment of a partnership between patients, their families and healthcare providers. By virtue of changes in facility design and functional procedures, a patient-centred care environment provides patients and families with fast access to reliable health advice, effective treatment by trusted professionals, clear information, supported self-care and emotional support and empathy. In addition, patients and families are considered as partners of healthcare staff and are involved in treatment decisions and the caring process. Patient-centred care is not dictated by a prescribed methodology; factors such as nationality, demographics, socio-economic considerations and culture influence how organisations view patients and the approach is constantly evolving.

This report provides an introduction to patient-centred care with particular emphasis on significant contributions within the literature. It examines the underlying principles and the ways in which patient-centred care can be achieved through organisational structure, facility design, models and strategies and other factors contributing to its successful realisation. The report subsequently discusses the main barriers to patient-centred care and investigates ten case studies, from which a series of conclusions and recommendations are derived.

Method

The information contained in this report was obtained from a variety of sources: books, journals and online material. The report serves as a literature review and a summary of representative case studies.



Inclusion and Exclusion criteria

Inclusion criteria Exclusion criteria

Comprehensive, yet user-friendly information from high-standing organisations.

Information from unknown organisations or websites.

Government studies. Case studies with insufficient details.

Peer reviewed studies.

Well-developed case studies (including international sources).

Search terms included:

patient centred care;

patient centred care models;

patient centred care + Scotland;

patient centred care + UK;

patient centred care + case studies.



Introduction

In recent years hospitals have begun to re-examine their practices and policies in an attempt to improve patient safety. A new consensus has consequently developed that patients are at the centre of care, have the greatest stake in their care and should be respected as equal partners in their care (The Joint Commission, 2008). In parallel with this change in outlook, patients have developed higher expectations; they want to be listened to, respected, supported emotionally and told the truth at all times. They also expect to receive high quality care from a well-coordinated, communicating team (Conway et al., 2006).

Unfortunately, there remains a gap between current patient expectations and the service generally provided by healthcare organisations (Shaller, 2007). Although patients usually rate hospitals and healthcare professionals highly, ratings are low in some areas, with key problems being reported in gaining access to important information, being given clear explanations of treatment options and receiving responsive and considerate service (Shaller, 2007).

This general dissatisfaction combined with a less deferential attitude among patients (Conway et al., 2006) has led to demands for healthcare environments that focus strongly on individual patient needs and preferences. Patient-centred care has been shown to improve overall patient satisfaction and clinical outcomes and reduce the underuse and overuse of medical services (Shaller, 2007; Agency for Healthcare Research and Quality as cited in Shaller, 2007). It also promotes improved allocation of resources and engenders greater patient and family satisfaction (Pettoello-Mantovani et al., 2009).

Patient-centred care is essentially a holistic concept; to work effectively, it must become embedded in all hospital processes and functions from leadership strategies to staff development. It should also incorporate the purposeful involvement of patients and their families in the treatment plan. Facility design is an especially important component of patient-centred care and factors such as private patient rooms with family accommodation, decentralised nursing stations and better way-finding can all assist in directly or indirectly improving patients’ experiences.

In 2010 The Scottish Government launched the NHSScotland Quality Strategy, the strategy aims to ensure the highest quality healthcare is delivered to the Scottish People. The Quality Strategy is underpinned by three Quality Ambitions, Safe, Effective and Patient Centred. Adopting a Patient Centred Care approach could help take forward the Quality Ambitions.

The aim of this report is to assess patient-centred care with a particular focus on its implications for facility design. It examines the underlying principles, the perceived benefits and alternative models. The experiences of healthcare organisations which have adopted a patient-centred ethos, either through design or process interventions, are investigated. The information accumulated will help identify the challenges and potential successes that may result from the implementation of a patient-centred approach within NHSScotland.



Review findings

What is Patient-centred care?

Patient-centred care is defined by the Institute of Medicine (IOM) as “healthcare that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients’ wants, needs and preferences and that patients have the education and support they need to make decisions and participate in their own care” (IOM, 2001). Responding to the full needs of patients and their families, patient-centred care not only redefines the relationships in healthcare and shapes policies, programmes, the design of facilities and staff interactions, but also requires a complete transformation in how providers regard patients and their families (IPFCC, n.d.; Planetree, 2009a).

Although patients and families may not understand the complex technical aspects of healthcare, ‘the patient experience’ warrants a highly involved role for them in patient-centred healthcare operations, not merely as advisors but partners too. Ideally, patients and families can participate in open and honest dialogue with healthcare professionals in a relationship built upon sharing and considering ideas and providing explanations when these ideas cannot be acted upon. An organisation that is truly patient-centred would consider “direct input from patients and families about what is most important to them about their care and how best a healthcare provider can satisfy those needs, preferences and expectations” (Planetree, 2009a).

In a patient-centred care environment, patients and families not only provide input but can also participate in changes and efforts aimed at improvement. Involvement can occur through a variety of modes such as focus groups, satisfaction surveys, advisory councils, ombudsman programmes, project launches, reviewing facility plans, providing testimony to government agencies and educating staff, families and community members about changes (Planetree, 2009a; IPFCC, n.d.). Having meaningful roles such as these motivates patients and families to continue being involved in healthcare operations and healthcare organisations have a key responsibility to ensure that patient and family feedback is considered seriously and acted upon promptly (Planetree, 2009a). In an organisation that follows these recommendations, the following attributes would generally be in place (Picker Institute, 2009):

fast access to reliable health advice;

effective treatment delivered by trusted professionals;

involvement in decisions and respect for preferences;

clear, comprehensible information and support for self-care;

attention to physical and environmental needs;

emotional support, empathy and respect;

involvement of, and support for, family and carers;

continuity of care and smooth transitions.



Patient-centred care: the basic principles

Organisations which are involved with patient-centred care tend to have individual philosophies about what it should entail.

Silow-Carroll et al. (2006), who conducted a study on behalf of the Economic and Social Research Institute on patient-centred care for underserved populations, summarised the doctrines of a number of different organisations and expert individuals in the following eight principles:

Welcoming environment: provide a physical space and an initial personal interaction that is ‘welcoming’, familiar and not intimidating;

Respect for patients’ values and expressed needs: obtain information about patients’ care preferences and priorities; inform and involve patient and family/caregivers in decision-making; tailor care to the individual; promote a mutually-respectful, consistent patient-provider relationship;

Patient empowerment or ‘activation’: educate and encourage patients to expand their role in decision-making, health-related behaviour and self-management;

Socio-cultural competence: understand and consider culture, economic and educational status, health literacy level, family patterns/situation and traditions (including alternative/folk remedies); communicate in a language and at a level that the patient understands;

Coordination and integration of care: assess need for formal and informal services that will have an impact on health or treatment, provide team-based care and care management, advocate for the patient and family, make appropriate referrals and ensure smooth transitions between different providers and phases of care;

Comfort and support: emphasise physical comfort, privacy, emotional support and involvement of family and friends;

Access and navigation skills: provide what patient can consider a ‘medical home’, keep waiting times to a minimum, provide convenient service hours, promote access and patient flow; help patient attain skills to navigate the health care system;

Community outreach: make demonstrable, proactive efforts to understand and reach out to the local community.

Another researcher, Shaller (2007), who completed a review of nine different patient-centred care models and frameworks, found general agreement that the main characteristics of patient-centred care are:

education and shared knowledge;

involvement of family and friends;

collaboration and team management;

sensitivity to nonmedical and spiritual dimensions of care;

respect for patient needs and preferences;

free flow and accessibility of information.



The implementation of Patient-centred care

The four levels of Patient-centred care

The realisation of a genuinely patient-centred care environment requires the integration of its ethos into every facet and activity of an organisation. According to the Institute of Medicine (as cited in Conway et al., 2006), patient-centred care should be implemented at four different levels alongside patient and family collaboration and patient participation. The four levels are as follows:

At the experience level: Care should be provided in a respectful manner that ensures the ongoing candid sharing of useful information and the contribution and participation of patients and families;

At the clinical microsystem level: Patients and families should participate fully in quality improvement and redesign teams. Care should be designed to respect the patient and family, enable access and participation and encourage the achievement of clinical goals;

At the organisational level: Patients and families should participate fully in healthcare committees and their advisory councils should report to senior leadership. Patient- and family-care should be integrated into schools and clinical programmes in a way that helps academic institutions to achieve their missions;

At the environment level: Patient and family perspectives can inform local, regional, national and international agency policy and programme development. The decisions of these agencies can affect patient and family engagement and influence school programmes. As such, they can assist in building the collaborative skills of patients, families and healthcare professionals.

The role of facility design

Facility design warrants special attention in terms of effectuating patient-centred care since, as the Institute for Patient & Family Centred Care (PFCC) (2010) states, “patient- and family-centred principles, processes and approaches are both supported by and expressed in health care environments”. In previous studies it has been established that healthcare facility design can have a direct impact on patient and family experiences and perceptions by helping or hindering effective communication between patients, their families and healthcare professionals and by shaping the attitudes and behaviour of staff (IPFCC, n.d.). Facility design also has a direct relationship with the safety and quality of patient care, as a well designed facility can help to reduce preventable accidents such as patient falls or hospital-acquired infections (Sadler et al., 2009) and can therefore assist in improving the patient experience and a patient’s satisfaction.

Unlike establishment which are described by PFCC as traditional and bland healthcare environments, organisations with a patient-centred care focus have facilities that are designed to incorporate appealing colours and textures, children’s play areas, comfortable seating, room for family and friends, friendly signage and inviting décor (IPFCC, n.d.). These changes facilitate patient-centred care by encouraging family presence and participation, enhancing access to information, supporting staff in collaborating with patients and families and increasing staff efficiency (IPFCC, n.d.).



A number of different design interventions and configurations can be used to develop a patient-centred care environment; however, all will ultimately have the common goal of reducing patient stress and providing patients with an increased feeling of control (Lumsdon, 1993). According to Whitehead et al. (n.d.), design interventions can be either dominant in economic terms since they produce additional benefits at zero or reduced costs or they can produce additional benefits at an added cost, thereby requiring a comparison of cost-effectiveness. Some facilities may opt for radical changes in design, possibly through clustering certain departments, while others may focus more on internal aspects such as décor. In particular, hospitals have been recommended to provide universal single-patient rooms in the construction of all new facilities, which are “designed to be versatile and change with the needs of the patient” (Bader, as cited in Woodard, 2006). Other common facility design changes currently being made in healthcare environments to promote patient-centred care include:

Size, setup and décor of patient rooms: Rooms are larger to accommodate family and friends and intimidating equipment is hidden. Décor and lighting is home-like and sensitive to patient conditions and moods. A patient server with a bedside computer terminal keeps needed supplies in each room, enables caregivers to respond more quickly and eliminates the need for a central storage area. Hallways are quieter and uncluttered, enabling patients to gain more rest and heal faster;

Refining the central nursing station: By moving supplies, caregivers and records closer to patients, centralised nursing stations can be downsized. Work areas for staff are decentralised and located in pods while a central reception area handles admissions. Relaxing areas are provided for caregivers to take breaks and confer with colleagues;

Movement of services, not patients: Where nursing stations have been decentralised, the extra space available could serve as satellite stations for frequent services such as physical therapy or radiology or be devoted to a pharmacy. Other available space can be transformed into patient libraries, activity rooms and dining areas.

Additional examples of design interventions for existing and new healthcare facilities and a checklist for providing an optimal healing environment, are described in the Appendix Section.

In determining which changes will best facilitate patient-centred care, it is suggested that evidence-based design (EBD) principles be taken into account to ensure that interventions can be supported through scientific literature and past experience, rather than simply being driven by the opinions of a design team. The process of EBD involves the reorganisation of thinking, the in-depth investigation and accrual of research, the development of scientific questions and hypotheses and the testing of creative and innovative design solutions (Cama, 2009). Since patient-centred care is a relatively new concept affording considerable leeway for innovation, EBD is readily compatible and should enable a planning team to establish a built environment that meets family, patient and healthcare professionals’ needs. As a step-by-step process the efficacy of which is demonstrated by the previous experience of other organisations, EBD can not only guide the design of facilities but also act as a framework for developing efficient, effective and supported practices within a new area such as patient-centred care.



In formulating facility designs that enable and encourage patient-centred care, the evidence-based process involves four steps that will ensure research is gathered and used in a practical manner and solutions are well considered (Cama, 2009). These are:

Gather Qualitative and Quantitative Intelligence – involves the gathering of past research to inform project goals and guidelines. An interdisciplinary team learns the organisation’s culture, objectives, and principles and determines whether current research can provide the best solution or whether innovation is required. Possible solutions are further researched to determine the lessons other organisations have learned while implementing them and how they can be improved;

Map Strategic, Cultural and Research Goals – to analyse the body of knowledge, a graphic map can be used to simplify information, illustrate goals and develop a vision. A research agenda should be discussed and developed around the project guidelines, strategic initiatives and desired organisation transformations and innovations;

Hypothesise Outcomes, Innovate and Implement Translational Design – research project is activated by a clear hypothesis that provides direction, specificity and focus and that ties outcomes to new and different problem-solving approaches. Design approaches are tested at the bedside for safety and effectiveness and revised where necessary to conform to the organisation’s culture and operational model;

Measure and share outcomes – hypothesised outcomes are evaluated and results are reported at conferences or through peer review to enable other academic partners to construct an argument for or against the design intervention.

In addition to adopting EBD methods, there are a number of general principles that should be adhered to in designing a facility that best encourages patient-centred care. For instance, the Joint Commission (2008) states that the following should be taken into consideration:

incorporating EBD principles that improve patient safety, including single-patient rooms, decentralised nursing stations and noise-reducing materials in hospital construction;

addressing high-level priorities, such as infection control and emergency preparedness in hospital design and construction;

including clinicians, other staff, patients and families in the design process to maximise opportunities to improve staff workflow and patient safety and to create patient-centred environments;

designing flexibility into the building to allow for better adaptation to the rapid cycle of innovation in medicine and technology;

incorporating ‘green’ (environmentally conscious) principles in hospital design and construction.

Lumsdon (1993) states that hospital planners should also adhere to the following guidelines when designing a healthcare facility:

aggregating patients by common resource requirements and characteristics;

structuring services to best meet patient and physician needs;

decentralising services where practical and financially feasible;

job flexibility and multi-skilling to be responsive to patient and physician needs;



eliminating or simplifying process and reporting structures to the greatest extent possible;

empowering employees to make decisions based on their skill and responsibility levels;

maintaining continuity of care.

Due to the important relationship between facility design and patient-centred care, multidisciplinary teams should strive to produce plans that contribute to better clinical outcomes, greater safety, increased patient and family satisfaction and improved cost efficiencies (IPFCC, n.d.). Patient- and family-centred care principles should also be incorporated into organisation and building missions, visions and philosophies and should have a central role during construction and renovation projects (IPFCC, n.d.).

When considering facility design in the context of patient-centred care, it must be noted that although design interventions can initially prove expensive, the operating cost savings that result from lower infection rates, fewer patient transfers and falls, decreased drug costs and employee turnover rates and improved market shares can make the changes or additional innovations a sound long-term investment (Sadler et al., 2009).

Patient-centred care in practice

In the quest to establish a regime that best fulfils the objective of genuine patient-centred care, organisations can benefit from adopting a specific framework to guide their approach. The literature currently describes several initiatives which may assist planners, designers and decision-makers. These approaches are thoroughly distinct and each embraces its own set of principles or objectives upon which decisions are based and good practice is gauged.

1. The Planetree Model

Planetree is an affiliation of hospitals and healthcare facilities of widely varying sizes committed to patient-centred care (Planetree, 2009a). It originated as the result of disillusionment at the depersonalising treatment experienced in a conventional hospital by Angelica Thieriot, who was suffering from an acute viral infection. The Planetree approach attempted to change radically how healthcare was delivered to patients and their families. Based on a philosophy of patient education and participation, family involvement and increased access to health and medical information for patients and their families, Planetree encourages a “patient-centred, holistic approach to healthcare, promoting mental, emotional, spiritual, social and physical healing” (Planetree, 2009a).

Planetree’s ethos is perhaps best explained by the late Dr. Tom Ferguson when a patient in the Pacific Presbyterian Hospital in San Francisco (Healthy (n.d.)):

“I am spending the day in a 21st century hospital. Classical music plays softly in the background. The numbers on the rooms are handpainted, with flowered borders. I am surrounded by subtle colors and indirect, full-spectrum lighting.

There are no long, echoing corridors. No hectic, fluorescent-lit nurse's stations. No empty gurneys standing in the hall. Everything has the feel of a well-kept residence. The hospital of the future looks a lot like home.



Patients wear their own clothes, their own robes, and their own pajamas, just as they would at home. They lie on flowered sheets and are encouraged to sleep in.

Patients and family members can cook meals in a private kitchen or watch video movies in a cozy private lounge. There is no nurse's station. Medical charts are prominently displayed, and patients are encouraged to read and write in them.

There is no restricted zone. Patients are welcome anywhere on the ward. There are no visiting hours. Friends and family are welcome at all times. Many choose to be here around the clock. In addition to providing companionship, interested family members are trained to give routine and advanced nursing care – changing dressings, caring for permanent intravenous lines, flushing out IVs and suctioning family members who are on respirators. Family members who learn these techniques can continue them at home after the patient is discharged.

All the comforts of home – yet this is all part of a top modern medical center. The CAT scanners, the MRI machines, the kidney transplant unit are just down the hall. Welcome to the Planetree Unit at Pacific Presbyterian Hospital in San Francisco. Welcome to a revolution in the way hospitals care for, and think about, the people they serve.”

2. The Picker Institute Approach

The Picker Institute is a non-profit organisation dedicated to promoting patients’ views on healthcare issues. Unlike Planetree, it focuses not on directly changing the patients’ immediate environment but on enhancing care by scrutinising feedback and ensuring it is acted on. Specifically, using focus groups and phone interviews, Picker measures patients’ experiences of care across eight areas in order to determine where improvements can be made within healthcare organisations (Shaller, 2007). These can be broadly summarised as: respect for patients, co-ordination of care, communication, physical comfort, emotional support, involvement of family, help in making the transition from hospital to home and access to care (as reflected by waiting time). Picker co-operates with the NHS in patient and staff surveys of different kinds.

3. Institute for Patient and Family – Centred care

The Institute for Patient-and Family-Centered Care (IPFCC) was established in 1992 to provide essential leadership in advancing the understanding and practice of patient- and family-centred care. By promoting collaborative, empowering relationships among patients, families and healthcare professionals, the Institute assists patient- and family-centred change in all settings where individuals and families receive care and support. The IPFCC may be thought of as an advocacy and support body for the promotion of patient-centred care and seeks to provide assistance to designers, planners and managers.

4. Hearthstone Model – care for Alzheimer patients

Hearthstone Alzheimer Care was founded in 1992 to provide innovative treatment and assisted living settings for people with dementia. Based upon a mission of “creating residential treatment environments where residents and families can truly flourish” (Hearthstone, 2010), Hearthstone focuses its research and activities on the design of the physical environment, the development of meaningful activities and social roles for



residents and clients, the management of complex medication regimes and the measurement of treatment outcomes to improve quality of life (Hearthstone, 2010).

5. Patient-centred medical home

The most serious problem facing hospital staff is the large number who experience back injuries attributable to patient handling. Ceiling lifts have been identified most consistently as the solution, although it is important that their physical implementation is accompanied by a programme to educate staff.

It is thought that staff suffering from stress might benefit from views on nature, bright daylight and reduced noise in much the same way as patients.

A summary of the relationships between design factors and healthcare outcomes as defined by Ulrich et al. (2008) are described as follows.

Researchers believe that adopting an EBD approach within healthcare can provide an organisation with benefits other than patient-related outcomes and staff satisfaction. From a budgetary and organisational standpoint, Hamilton and Watkins (2009) argue that EBD can induce improvements in efficiency and financial performance through:

Confidence in research grounded concepts: defensible designs and budgets, improved document quality, credible evidence of project performance and strength of client recommendations.

Improved profitability/efficiency: useful feedback data on completed projects, better quality documents, improved project management and efficient internal design process.

Acquisition of new work: data on performance of completed projects, credible claims during business development, visibility in the marketplace (speaking, writing), expertise in the field and strength of reputation.

Management Strategies

Unlike the initiatives outlined above which apply on a broad level, this sub-section focuses on how patient-centred care can be achieved within an organisation and with respect to which the word ‘strategy’ will apply. This part of the report accordingly contains information on the strategies that can be used to implement and maintain patient-centred care. Shaller (2007) states that two specific strategies can be used to implement and maintain patient-centred care within a healthcare facility. What are referred to as ‘organisation-level’ strategies are designed to help achieve patient-centred care by focusing on leadership, training, rewards, quality improvement and evidence-based work, while ‘system-level’ strategies focus on patient education, public reporting and accreditation. Unlike organisation-level strategies, system-level strategies are aimed at changing external healthcare system incentives and influencing and rewarding organisations that are attempting to implement patient-centred care within their facilities.

Organisation-level strategies

Leadership Development and Training: Senior leadership at Director level is essential for realising patient-centred care and requires sufficient resources to develop educated,



committed individuals to take on these roles. Leadership education and development should include all healthcare professionals from graduate students to senior level and should encompass all disciplines (nursing, administration, medicine etc) and sectors (healthcare delivery, suppliers, insurers, etc.).

Internal Rewards and Incentives: In conjunction with the leadership strategy, guidelines should be developed to help retain leaders and reward them for good performance. Compensation and incentives for all levels of staff should include measurements of patient-centred care rather than only quarterly figures. This process will require new levels of engagement and support by those at director level.

Training in Quality Improvement: Staff members at all levels require training in quality-improvement concepts and methods to enable them to make, measure and manage change. Team-based work is particularly important since patient-centred care concepts are built upon the development of partnerships and relationships.

Practical Tools Derived from an Expanded Evidence Base: Methods that serve to improve patient-centred care must be recorded and made available to managers and those leading the process of transformation. Improvement guides are currently being developed by certain organisations (the Picker Institute already has some available for review).

System-level strategies

Public Education and Patient Engagement: Patients are the most important drivers of change in healthcare organisations and formulating strategies to educate and engage them in their own care will complement other patient-centred care achievements and satisfy their need to become active partners in their treatment. Tools to support patients in embracing this expanded decision-making role are becoming more widely available, although further work is needed to help patients become aware of these opportunities.

Public Reporting of Standardised Measures: Measures for determining progress towards patient-centred care are useful for monitoring and guiding improvement within organisations and increasing an organisation’s accountability. Measuring and reporting should be based upon the best available scientific evidence and should enable comparisons within and across organisations and practitioners. It is generally agreed that public reporting of patient-centred care measurements will help to stimulate organisational change.

Accreditation and Certification Requirements: In the past, accreditation and certification programmes have provided significant external incentives to health care organisations to improve their practices. Measurements of patient-centred care are being increasingly included in these evaluation processes.

Factors that Contribute to the Achievement of Patient-Centred Care

In addition to the four levels of implementation, the strategies and models described above and the important role of facility design, Shaller (2007) believes several additional factors need to be in place in order to establish an environment that best facilitates and ensures the success of a patient-centred care approach. These are:



leadership, at the level of the Chief Executive Officer (CEO) and director level, sufficiently committed and engaged to unify and sustain the organisation in a common mission;

a strategic vision clearly and constantly communicated to every member of the organisation;

involvement of patients and families at multiple levels, not only in the care process but as full participants in key committees throughout the organisation;

care for the caregivers through a supportive work environment that engages employees in all aspects of process design and treats them with the same dignity and respect that they are expected to show patients and families;

systematic measurement and feedback to monitor continuously the impact of specific interventions and change strategies;

quality of the built environment that provides a supportive and nurturing physical space and design for patients, families and employees alike;

supportive technology that engages patients and families directly in the process of care by facilitating information access and communication with their caregivers.

Many of these contributory elements are echoed by Silow-Carroll et al. (2006), who carried out work on behalf of the Economic and Social Research Institute. This paper stated that organisations looking to implement patient-centred care should ensure that the following essential components are established beforehand:

feedback and measurement: seek and respond to suggestions and complaints from patients and families; develop, collect and evaluate data on measures of patient-centred care and feed back the results into further improvements; incorporate accountability for addressing deficiencies and continually improving indicators;

patient/family involvement: include patients and family members in the planning, design and ongoing functioning of the organisation; consider the patient a member of his/her care team;

workforce development: employ, train, and support a workforce that reflects, appreciates and celebrates the diversity of the communities and cultures that the organisation serves; reward and recognise staff exhibiting patient-centred principles; develop communication skills among all levels of staff; empower staff to be part of patient-centred teams;

leadership: top management, Board, and department heads make a clear, explicit commitment to patient-centredness and act as role models;

involvement in collaboratives and pilots: seek out and join pilot research projects and collaborative relationships with other organisations that attempt to ‘push the envelope’ in developing new methods to operationalise patient-centred principles;

technology and structural support: use electronic systems/user-friendly software programmes that promote patient/family education and compliance and minimise medical errors; structure the physical environment to optimise patient flow and safety;

integration into institution: tie patient-centred care to other priorities such as patient safety, quality improvement, etc. and incorporate patient-centred practices into daily operations and culture.



Barriers to Patient-Centred Care

Although it is self-evident that the patient’s perspective should be paramount in patient-centred environments, many healthcare facilities still find it difficult to incorporate patient and family feedback into their operations and transform it into meaningful programmes. Conway et al. (2006) state that most patient-centred care efforts have taken place within paediatric and maternity units in acute-care hospitals, with modest advances in other areas and departments. In some cases, patient-centred care may be limited due to concerns about confidentiality, transparency, a challenging of healthcare expertise and the issues that may arise if hospitals cannot provide what patients and their families want (Planetree, 2009a). Silow-Carroll et al. (2006) believe that there are seven specific barriers that affect the implementation of patient-centred care, namely:

difficulty recruiting and retaining underrepresented minority physicians;

lack of defined ‘boundaries’ for outreach staff who may be overwhelmed dealing with interrelated health, social, cultural and economic issues of patients;

strict hiring requirements that pose obstacles to hiring neighborhood residents;

lack of tools to gauge and reward Patient Centred Care (PCC) performance;

financial constraints;

traditional attitudes among staff unwilling to change the ‘old school’ provider/patient relationship or acknowledge and address cultural and socio-economic issues;

fatigue and competing priorities.

However, Conway et al. (2006) take a more comprehensive approach stating that the barriers to patient-centred care implementation relate specifically to attitudes, education and organisations as follows:

Attitudinal barriers

fear that patients’ and families’ suggestions will be unreasonable and that confidentiality will be compromised;

belief that a customer service programme is sufficient for patient satisfaction and involvement and patient- and family-centred care is not necessary;

perception that there is a lack of evidence for patient-centred practices;

belief that patient-centred care is time-consuming and costly;

belief that their patients are too poor, too violent, too uneducated, too humble to be engaged or to engage.

Educational Barriers

lack of understanding and skills for collaboration on the part of health care professionals and administrators as well as of patients and families;

leaders’ lack of understanding of patient-centred care and its benefits;

organisations unprepared to provide patients and family members with the training and support needed to participate in collaborative endeavours.



Organisational Barriers

lack of guiding vision and organisational culture and leadership;

tendency to implement either a top-down approach to initiating partnerships with insufficient effort put in to building staff commitment or the tendency to implement a grass-roots effort that lacks leadership, commitment and support;

scarce fiscal resources and competing priorities.

Lastly, as mentioned above, there is an important relationship between a facility’s design and an organisation’s ability to provide patient-centred care. For instance, the poor design of hospital units can result in increased noise levels, which affect sleep, communication and healing, while multi-bed patient rooms, poor air quality and a lack of hand-washing facilities can cause a rise in hospital-acquired infection rates (Harris et al., 2008). Facility design can also affect healthcare staff since poor design and layout and badly placed communication technologies can prevent staff from properly assessing and caring for their patients (Page, as cited in The Centre for Health Design, 2008). Furthermore, as stated by Hendrich et al. (as cited in Hendrich and Chow, 2008), “elements of the current hospital work environment, including inefficient work processes and physical designs, gaps in technology infrastructure and unsupportive organisational cultures, contribute to inefficiencies and stress for hospital nurses, limiting the time they can spend in direct patient care”. Poor design is therefore a major barrier to the development of patient-centred care and both factors should be considered in unison when developing a patient-centred care environment.

Lessons from the case studies

The key points arising from the examination of the ten case studies detailed in The Appendix Section are discussed below.

Key Point 1: Effective, supportive and visionary senior leadership is a vital component of any patient-centred care approach.

The case studies indicate that strong, progressive leadership is an important component for organisations looking to implement patient-centred care. In some of the case studies, guidance and direction with regard to patient-centred care stemmed from the organisations’ leaders or board of executives in a top-down approach, exemplified by Clarian West Medical Centre. In other case studies, however, such as the University of Pittsburgh Medical Center, leaders took a more passive stance and supported the efforts of grass roots patient-centred care initiatives that were suggested and piloted by empowered front-line staff. In these cases, leaders supported a bottom-up approach and simply helped staff to expand the programmes into other areas of the organisations. Regardless of the approach, the case studies indicate that supportive leaders who will act as a voice for patient-centred care initiatives are an important component for organisations implementing patient-centred care.

Key Point 2: When implementing patient-centred care, organisations must have an integrated and detailed plan and should pilot their ideas in one department or area before expanding.



As was the case with MCG Health System, many of the organisations initiated their patient-centred care initiatives in one area, department or hospital, in order to test approaches, determine benefits and revise strategies before expanding further. This was found to be beneficial in all cases, preventing staff from being overwhelmed with changes and enabling organisations to pilot their ideas without disrupting all staff, patients and families until the strategy was perfected and able to be expanded efficiently.

Having a plan, such as the Polytechnic’s Nordstrom customer service model or Vanderbilt’s Elevate programme, has also been found to be a vital component. These plans not only provide guidance and direction but also act as a framework for decision-making.

Key Point 3: To promote a patient-centred care environment fully, organisations must align the design of their facilities with their vision, values and principles.

As noted in the literature review, the realisation of patient-centred care can be largely dependent on the design on an organisation’s facilities. This belief was echoed in the case studies, where many organisations made changes to their facilities in order that their patient-centred values and vision were borne out by the design of their buildings. Typified by Bronson Methodist Hospital and the Polyclinic Family Practice, this was more common within organisations that were completing new buildings or major renovations and therefore had the opportunity to plan new designs based on staff, patient and family input. These new designs not only promoted patient-centred care values, but also enabled staff to complete tasks more efficiently and often resulted in increased patient and staff satisfaction.

Key Point 4: Since staff can influence the success of a patient-centred care initiative, organisations must not only focus on the patients but should also ensure they take care of their staff, meet their needs and provide a satisfying work environment.

In several of the case studies, it was noted that the planning of patient-centred care not only focused on the well-being and satisfaction of patients and families but also on the staff. Employee input appears to be a particularly important component and several organisations, such as Advocate Lutheran General Hospital and Vanderbilt Medical Centre, ensured that during the planning stages, nurse, physician and ancillary staff input was taken into consideration in conjunction with that from patients and families.

Other case study organisations focused on their staff through developing recruitment, retention and diversity plans, providing training opportunities and consistently measuring outcomes such as staff turnover and doctor-to-staff ratios. Providing rewards and recognition for high staff performance is an especially important component, as is the provision of resources (particularly, time, empowerment and the appropriate facilities) to develop strong relationships with their patients and families. Analysis of the case studies confirms that these procedures contribute to the development of high staff satisfaction and therefore can positively influence the success of a patient-centred care programme.

Key Point 5: Patients and families must be encouraged to participate in a variety of involvement opportunities and organisations must be prepared to handle their input efficiently and effectively.



The case study organisations indicate that for the successful introduction of patient-centred care requires that patients and families must be encouraged to participate and have a variety of opportunities available in which they can become involved and through which they can provide their input. In these cases, involvement opportunities ranged from Advisory Councils, task forces and committees, to joining in with rounds, conducting walk-throughs and reviewing patient information with hospital staff. The variety enabled patients and families to become involved in an area that was of interest to them and at a level at which they felt comfortable. Through providing these varied opportunities and incorporating the resulting input into their patient-centred care programmes, the case study organisations all scored well for patient satisfaction.



Conclusions and recommendations

Based on the literature reviewed the following conclusions and recommendations are made:-

Conclusion 1: In order to engender a patient-centred care environment, healthcare organisations must continually seek and, where possible, incorporate feedback from patients and families. This process requires an organisation to accept criticism in a constructive manner and determine where improvements can be made. Decisions regarding the organisation’s operations, design and processes should be based to the greatest extent possible upon patient and family needs and preferences.

Recommendation 1: When implementing a patient-centred care approach, NHSScotland should determine the needs and preferences of patients and their families through a variety of research methods including surveys and focus groups. This course of action would afford an opportunity for patients and families to influence healthcare designs, processes and operations and encourage them to envision how an ideal healthcare environment looks and operates.

To ensure organisations are continually aware of patient and family needs and preferences, continual monitoring of feedback is necessary after a patient-centred care strategy is in place. A range of vehicles, such as working groups, advisory committees, project reviews or education programmes, are ways of making this available to patients and families to enable them to participate in the development of a patient-centred care approach.

Conclusion 2: The successful implementation of patient-centred care requires the adoption of a framework and strategy that best reflects patient and family needs and preferences and the organisation’s values, vision and objectives. Before implementation, each significant change should be well-researched, pilot-tested and presented for patient, family and staff feedback.

Recommendation 2: To take this forward a model, based on patient, family and staff input, should be developed which a patient-centred care strategy can be delivered. The model should include the principles, goals and objectives under which NHSScotland plans to operate and should act as a framework upon which all decisions will be based.

This framework should be linked with an action plan that outlines how those utilising the approach intend to implement a patient-centred care environment and achieve its goals and vision. The action plan should consider all areas that will be impacted by patient-centred care, such as customer service, staff training, evidence-based facility design and policies and procedures. It should also indicate how patient-centred care will be implemented at each level within the organisation and within defined timelines.

Those undertaking a patient centred care approach should ensure that patient-centred care interventions can be supported in the literature and are pilot-tested and revised as necessary before implementation. Furthermore, to ensure future decisions take patient and family input into account, the patient-centred care strategy and framework should be incorporated into all strategic and operational plans.



Conclusion 3: Implementing patient-centred care requires a complete transformation in how healthcare organisations regard patients and their families (Planetree, 2009a), since they must be prepared to seek input, face criticism in a constructive manner and incorporate suggested changes where possible. This new approach can be a difficult and disruptive transition and, as a result, much support is needed to ensure staff are well-equipped to handle the changes.

Recommendation 3: When implementing a patient-centred care approach, NHSScotland should consider the needs and preferences of its staff and provide them with consistent support. A specific change programme therefore should be developed through which training can be provided for all staff in order to inculcate the goals, principles and requirements of a patient-centred care environment. An exemplar would be the ‘Elevate’ programme at Vanderbilt Medical Centre. A focus on developing ‘change’ leaders within senior management teams who will guide the patient-centred care process and provide staff, patients and families with the support they need during the changes, is one way of achieving this.

Staff input from all levels should be represented on various committees, planning and working groups. Additionally staff should be provided with the required resources to provide patient-centred care to customers.

Conclusion 4: Facility design is an integral component of a patient-centred care environment. A poorly designed environment can be a major barrier to the achievement of patient-centred care, while a well-designed facility can actually facilitate this process.

Recommendation 4: In planning a patient-centred care approach, facility design remains a priority throughout the process. This can be achieved through auditing the relevant facilities to determine whether its designs comply with the goals and objectives of their anticipated patient-centred care approach or whether changes need to be made. The Appendix Section provides information on common design interventions that can assist in facilitating patient-centred care.



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Appendix

1. Case Studies

In addition to examining patient-centred care from a general perspective, this report reviewed ten case studies to determine how different organisations approached the concept and which benefits were gained in each instance.

MCG Health System

Source: Conway et al. (2006)

The MCG Health System (MCG) in Augusta, Georgia has collaborated with patients, families, clinicians and administrative leaders since 1993 when it began planning for the construction of a new Children’s Medical Center, which now ranks among the highest in patient/family satisfaction. With the commitment of MCG’s senior leaders, MCG is working to extend their patient and family-centred care principles beyond pediatrics.

MCG has clearly defined patient- and family-centred values and included them within the organisation’s strategic plan, recruitment strategy, position descriptions and performance-review system. Currently, over 125 patient and family advisors are involved in collaborative endeavours at MCG, serving on the Health Partners advisory council, the Family Advisory Council, the Children’s Advisory Council, the MS Patient and Family Advisory Council or the Patient and Family Safety and Medicine Reconciliation Committees.

Since implementing a patient- and family-centred approach, MCG has achieved the following objectives:

patient satisfaction scores rose from the 10th to the 95th percentile;

length of stay in the neurosurgical unit decreased by 50%;

medical error rate fell by 62%;

discharges (volume) increased 15.5%;

the nursing staff vacancy rate fell from 7.5% to 0%, with a waiting list of five RNs;

positive change in perceptions of the unit by faculty, staff, and house staff.

Cincinnati Children’s Hospital Medical Center

Source: Conway, et al. (2006)

The Cincinnati Children’s Hospital Medical Centre (CCHMC) has partnered with the Pursuing Perfection programme, which has been developed to help implement the recommendations of the IMO’s Crossing the Quality Chasm Report. The CCHMC is committed to advancing the practice of patient-and family-centred care and to improving the experience of care for patients and families. Through a proactive Senior Leadership Team, support for this effort has been garnered at the organisational level and within clinical microsystems. In addition, the hospital has partnered with families on multiple



levels, including through the Family Advisory Committee, on quality-improvement and hospital-wide teams, unit-based committees and task forces.

CCHMC no longer views family members as patients and, as such, they are allowed access to patient units at any time. The families are encouraged to be present and involved during rounds, are able to review patient information with the doctors and nurses to ensure accuracy and can be involved in the patient’s discharge goals and treatment plans.

Through implementing a patient- and family-centred care approach, CCHMC has achieved the following objectives:

patients are being discharged sooner;

medical order entry error rates have been reduced from 7%-9% to 1%;

faculty report that patient- and family-centred rounds are a more effective way to teach;

families are involved in decision-making.

Clarian West Medical Centre

Source: Litch (2007)

When tasked with building a new hospital facility, the leaders at Clarian West Medical Centre focused on integrating three key ideas: a healing physical environment, the work of healthcare and the technology needed and the critical relationships between families, patients and staff. The team worked closely with architects to integrate natural light, colours, materials and elements of nature to balance hospital form with healthcare function.

The result was a 76-bed suburban facility set within 70 acres and designed to take care of not only patients, but also their families and caregivers. The new, top-ranked facility has met all financial targets, embraced new technology and designs and received positive survey responses from stakeholders. Specific achievements include:

medical error rate of only 1 per 125,000 doses;

high employee satisfaction;

93% of employees believes the hospital invests in their future;

95% of staff believe Clarian is a great place to work.

Advocate Lutheran General Hospital

Source: Litch (2007)

With the addition of an 8 story-building housing 192 private rooms, Advocate Lutheran General Hospital (ALGH) is undergoing major renovations to transform its 617 bed facility into one that will meet the needs of the community for another 50 years. ALGH started with a vision to “create a facility that expands and enhances Advocate Lutheran General



Hospital, and Lutheran General Children’s Hospital’s leadership in providing quality healthcare to patients on a regional basis” (Litch, 2007). During the planning phase, the organisation developed a set of guidelines to help them achieve their vision. These were: patient safety goals, enhanced patient/family centred care operations and enhanced operational and effectiveness efficiencies.

ALGH conducted a number of focus groups with stakeholders, including physicians, nurses, patients and families, to determine best how to achieve these objectives. After 300 meetings with 162 people consistently involved in the design process, ALGH discovered several common themes, namely: privacy, comfort, security, safety, family-centred care and convenience.

The hospital is now in the next planning stage, having created full-size mock rooms and a mock ICU unit for all staff and former patients and families to evaluate through surveys. ALGH continues to receive many positive responses as it proceeds with its planning process.

Stanford University Hospital

Source: Hollander et al. (1994)

After implementing a number of uncoordinated quality improvement programmes, Stanford University Hospital decided to consolidate these efforts into a full patient-centred care approach. Initially limiting changes to just those that directly involved in-patient care, the patient-centred care team conducted walk-throughs of the hospital, supplemented their meetings with readings and information gathered from patient focus groups and analysed hospital design and processes through the eyes of the patient. The team developed seven main topics to be addressed during the first phase and worked to improve a number of specific areas such as nurses’ reactions to call button and medication requests, patient transport, the clarification of physician’s orders, the decentralisation of support services and the consolidation of housekeeping and transportation personnel. Specific achievements that arose through this work include:

decreased budget by £50 million over 4 years;

highest patient satisfaction ratings ever;

high employee satisfaction;

substantially decreased reaction times to patient requests;

staff appreciation for the interdependencies between departments;

more personalised service for patients;

elimination of unneeded management levels.



Bronson Methodist Hospital

Source: Shaller (2007)

Bronson Methodist Hospital (BMH) has received numerous awards for its commitment to patient-centred care. With a strong leader who continually promotes the vision that patients are the central focus of the organisation, the hospital has a knowledgeable and collaborative management team that meets three times each year for planning and strategy development. Nursing and medical leaders also encourage collaboration through goal-sharing and the alignment of strategic objectives.

BMH continually promotes its three strategic goals: Clinical Excellence, Corporate Effectiveness and Customer and Service Excellence, upon which individual performance is evaluated. In addition, the hospital’s Workforce Development Plan has developed strategies to develop and retain staff, as well as address future recruitment, retention, development and diversity.

The hospital has also developed a state-of-the-art, private room facility that is designed on 28 acres, with outpatient and inpatient pavilions and a central garden atrium. In addition, they are in the process of developing a new birthing centre and neonatal intensive care unit using evidence-based design techniques. BMH continually measures employee turnover, outcomes, length of stay, cost per unit of service, waiting times, patient satisfaction levels, infection rates and organisational behaviour, in addition to patient feedback through focus groups, rounds, telephone calls and surveys.

As a result of their efforts, the organisation is consistently rated by Fortune Magazine as one of the ‘100 Best Companies to Work For’ and patient satisfaction has risen from 95% in 2002 to 97% in 2004.

The Polyclinic Family Medicine Practice

Source: Shaller & Edgman-Levitan (2008)

The Polyclinic is a multi-specialty group practice, employing 107 primary-care and specialist physicians and serves approximately 78,000 patients. The staff group includes three hospitalists who coordinate inpatient care at Swedish Medical Centre and act as the liaison between the patients’ primary care physicians and the hospital. On-site facilities include a laboratory, X-ray services and outpatient surgery, while off-site, it supports smaller satellite locations such as the Family Practice site. The Polyclinic mission is “to promote the health of patients by providing high-quality, comprehensive, personalised healthcare”.

As a ‘high-end service provider’, the clinic follows the Nordstrom model of customer service and maintains a high doctor-to-ancillary staff ratio to ensure physician access and promote a ‘one-stop’ approach to medical care. The clinic has a strong team culture due to a shared set of values and commitment to patient-centred care among physicians and an ‘open access’ strategy that enables same-day scheduling and convenient timing for



appointments. A successful marketing strategy attracts and retains a regular patient base of downtown residents and workers.

The Polyclinic is lead by a board of physician directors. After two years of service and a performance review, physicians are eligible for nomination to shareholder status through which they have an equal say in the running of the organisation.

Facility design is an important component of this clinic, with décor taking the form of natural colours, a polished, high-end look and feel and large windows. Children have their own age-appropriate waiting room and signs are provided throughout for easy way-finding. A consultation ‘pod’ station encourages communication, efficiency and interaction among staff and physicians and enables 5-minute informal meetings between physicians and staff to review events and identify strategies for addressing problems.

The following key systems are integral components of the Polyclinic’s approach to patient-centred care:

Open-Access Scheduling – encourages teamwork among doctors, a culture of ‘meeting today’s demand today’ and a daily huddle to review processes;

The Built Environment – facility design is based upon staff input, patient flow and the observation of other processes;

Patient Input and Feedback – a patient survey indicated the need for a dermatology practice, endocrinologist and allergy specialist on site. Patient feedback postcards are located throughout the clinic;

Information Management System – enables electronic patient scheduling, order management and the receiving of results locally and remotely. A pilot programme is currently testing email messaging between patients and reception;

Human Resource Policies – only team players with communication skills are hired and provided with a 2-day trial period. Management meets regularly with staff and physicians and assesses continually for employee satisfaction. In addition to regular training, all staff attend an annual all-day training event focusing on a particular theme. Staff are recognised and rewarded through gift cards, monthly employee or team-of-the-month nominations and employee activity evenings;

Physician Compensation – based mainly upon productivity with 5% attributed to performance levels. Bonuses are provided according to productivity, patient satisfaction and tenure.

As a result of their work and focus, the clinic has scored in the 95th percentile for doctor-patient communication and the upper quartile for access and interaction with office staff.

University of Pittsburgh Medical Center

Source: Shaller & Darby (2009a)

The University of Pittsburgh Medical Centre (UPMC) is an integrated global health enterprise of 20 hospitals and 400 ambulatory sites in Western Pennsylvania. The Centre employs 50,000 people, has a budget of $7 billion and as the region’s largest employer has a significant economic influence in the area.



According to Shaller and Darby (2009a), “UPMC’s culture of innovation and entrepreneurial activity has provided a fertile environment for the development and spread of patient- and family-centred care at multiple levels throughout the system”. Through UPMC’s full cycle of care programme that treats patients from the doctor’s office to the hospital and back again, patients enjoy a one-stop experience in home-like facilities. UPMC believes that by putting patients first, they can achieve higher levels of safety, quality and efficiency.

Patient-centred care was initially implemented in the UPMC Orthopaedics Programme at Magee-Womens Hospital, with the focus on “organising hospital resources and processes around the needs of patients and families rather than around the various specialised departments”. This patient-centred approach is now being extended to other areas and hospitals such as the day-of-surgery and trauma units, where facilities have been designed to be more patient-friendly and inviting, and procedures, such as gaining clearance to remove a cervical collar, have been made more efficient.

Patient-centred care at UPMC is supported through the Centre for Quality Improvement and Innovation, which provides leadership, education and support infrastructure to enable the attainment of PFCC best practices. The patient and family care experience is fully documented and patients are shadowed by students or staff throughout their stay. UPMC also uses patient surveys, staff interviews and family focus groups to assess their performance continually. If problems are found, a patient-centred care working group with representatives from all service areas works to solve the issues and test possible solutions.

UPMC believes that although top leaders must be involved and supportive, for PFCC to be successful employees at the grass roots level must have the ability to be innovative in their positions and empowered to enable change to occur. UPMC consciously works to keep the design and implementation of PFCC projects decentralised.

Through their work, UPMC has made dramatic improvements in patient and family satisfaction and organisational efficiencies, such as reduced length-of-stay, decreased staff turnover and smaller wait times in the operating room.

University of Colorado Hospital

Source: Shaller & Darby (2009b)

The University of Colorado Hospital (UCH) is the Rocky Mountain region’s leader in tertiary care and its only academic medical centre, with 410 beds and cardiac, medical, neonatal and surgical intensive care units. UCH also offers primary care and outpatient services at campus and off-site clinics and emergency care at its Level II trauma facility. As a non-profit organisation, UCH prides itself on providing care for the uninsured and underinsured individual and is committed to healing its patients, discovering new treatments and cures and educating present and future generations of healthcare providers.

PFCC was initiated at UCH in 2004 and has been developed by patients and staff with the focus of forming “beneficial partnerships among patients, families and healthcare practitioners”. Communication, teamwork, respect and integrity are emphasised in these relationships through the PFCC Advisory Council, which comprises patients, family caregivers and employees. Through retreats for staff, patients and families, the council



continually seeks input on how to involve patients and families in hospital operations and decisions. Physicians at the hospital serve on key committees and have a major voice in hospital operations and management and therefore a stake in UCH’s success. Nursing leadership promotes evidence-based practice as an important process and encourages staff to further their skills through professional development certifications.

UCH continues to raise awareness of PFCC through its websites and checks all policy or system changes that could affect patients and families with the PFCC Advisory Council. The hospital is looking to expand the council’s reach by creating smaller, unit-based councils that could provide patient and family input in a more targeted manner and recruiting patient and family members onto the hospital’s key committees.

Through their work and particularly through the PFCC Advisory Council, UCH has achieved the following:

a tobacco-free campus policy;

participation of patients and families in recruitment interviews;

easier-to-read patient bills;

patient education materials;

creation of medication reconciliation wallet cards to improve patient safety;

input of patients and families in the revised patient valuables policy.

Vanderbilt Medical Center

Source: Shaller & Darby (2009c)

Vanderbuilt Medical Centre (VCM) is one of the USA’s highest performing hospitals for patient-centred care and a major teaching, research and referral centre. In 2006, the hospital served over 1 million clinic patients and 50,000 inpatients and, on average, provides US$220 million per year for patients who are unable to pay for their own care.

With a very visible and consistent senior leadership team, the Centre has undergone an entire culture transformation, enabling it to focus fully on the patient. In 2004, VCM executives launched a 5-year programme called ‘Elevate’ with the goal of embedding a shared vision within all facets of the organisation and creating clearly defined behaviour expectations. The values of this programme are now visible through the organisation from the top executives to the front line caregivers.

Vanderbilt includes patients and families in many centre operations from policy and planning to the direct provision of care and participation in medical rounds and continues to extend its network of Patient and Family Advisory Councils into all departments and services. Patients are continually engaged through an advanced information technology programme called My Health at Vanderbilt and other communication and education programmes assist in engaging, informing and empowering patients and families from admission to beyond discharge.



Individual champions have been widely responsible for the progression of patient- and family-centred care within VCM, with the support of the organisation’s top executives. The organisation hopes to further extend its reach by partnering with civic organisations, schools and businesses to continue improving health and health delivery in the larger community.

Through their work, Vanderbilt has achieved the following:

85% of its measures (based on the topics of Finance, Growth, People, Customer Service, and Quality) scored in the 90th percentile;

achieved above average ratings for patient satisfaction and experience;

New Children’s Centre tripled amount of family space available;

completed a $5-million programme to reformat and deploy vehicular and pedestrian signs.

2. Design Interventions for Existing and New Health Facilities

Existing Health Care Facilities

Source: Sadler et al. (2009)

Design Intervention Quality and Business-Case Benefits

1. Install alcohol-based hand gel dispensers at each patient bedside and at all points of patient care [1]

Reduced infections, improved hand hygiene compliance

2. Install noise-mitigation materials such as sound-absorbing ceiling tiles as part of a noise reduction plan [2]

Reduced patient and staff stress, reduced patient sleep deprivation, increased patient satisfaction

3. Utilise music and art as positive distractions during procedures [3,4]

Reduced patient stress, pain, medication use and anxiety

4. Include effective wayfinding systems [5] Reduced staff time spent giving directions, reduced patient and family stress

5. Improve task lighting in pharmacy and medication rooms [6]

Reduced medication errors

1. Randle J., Clarke M.C. and Storr J. (2006). Hand hygiene compliance in healthcare workers. Journal of Hospital Infection, 64(3): 205-209

2. Blomkvist V. and Eriksen C.A. (2005). Theorell T., Ulrich R.S., Rasmanis G. Acoustics and psychosocial environment in coronary intensive care. Occupational and Environmental Medicine, 62: 1-8.

3. Walworth D.D. (2005). Procedural-support music therapy in the healthcare setting: A cost-effectiveness analysis. Journal of Pediatric Nursing, 20(4): 276-284. 12

4. Ulrich R.S. and Gilpin L. Healing arts: Nutrition for the soul. In: Frampton S.B., Gilpin L., and Charmel, P., eds. (2003) Putting Patients First: Designing and Practicing Patient- Centred Care (pp117-146). Jossey-Bass, San Francisco.




5. Carpman J. and Grant M. (1998). Design That Cares: Planning Health Facilities for Patients and Visitors (2nd edition). American Hospital Publishing, Chicago.

6. Buchanan T.L., Barker K.N., Gibson J.T., Jiang B.C. and Pearson R.E. (1991). Illumination and errors in dispensing. American Journal of Hospital Pharmacy, 48(10): 2137-2145.

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