By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“We are guests in our patients’ lives.”
-Don Berwick, MD
April 26-30, 2021 is National Patient Experience Week, a time for health care organizations to celebrate and reflect upon their efforts to improve the way their consumers perceive the care they receive, a time for health care organizations to proclaim that they are “Patient-Centered.”
What does it mean to be patient-centered? The answer depends on who you ask.
The root of the term “patient-centered” goes back to the 1940s with a school of psychological thought that promoted counseling that was centered on the needs of the client: client-centered counseling. In the 1950s and 1960s, Hungarian-British psychologists Michael Balint, Enid Balint, and Paul Ornstein brought a basic psychodynamic approach to primary care clinicians –the “Balint Group” approach now used in primary care medical education around the world. The Balints coined the term patient-centered medicine, which “should include everything the doctor knows and understands about his patient . . . understood as a unique human being,” as distinct from illness-oriented medicine that focuses more narrowly on diagnosis and treatment of localizable pathology.
In 2001, the Institute of Medicine identified being “Patient-Centered” as one of the six aims of health care quality (the others being safe, effective, timely, efficient, and equitable). They defined Patient-Centered as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring their values help guide all clinical-decisions. This idea of customizing the care to the patient seems consistent with the Balints’ ideas.
Starting in 2007, some larger institutions have appropriated the term patient-centered to have different definitions.
In 2007, all the American organizations representing primary care clinicians (AAFP, AOA, ACP, and AAP) combined the concept of a primary care Medical Home (the 1967 AAP idea of a PCP who coordinates the care provided by specialists), with the idea of patient-centeredness to create the Joint Principles of the Patient-Centered Medical Home. While the goal of this structure is to serve the needs of the patient, this initial conceptualization focused on putting the primary care physician at the center of this care—more of a primary care physician-centered medical home.
Sensing an opportunity, in 2008 the major accreditation agencies (NCQA, URAC, Joint Commission, and AAAHC) launched Patient-Centered Medical Home (PCMH) accreditation and recognition programs. Their focus is on elements of operational and quality infrastructure thought to be good for patients and their outcomes. Moving beyond a narrow physician-centered focus, meeting these elements helps move primary care organizations in the direction of higher quality care, using a compliance with standards approach.
In the meantime, organizations and scholars that were focused on primary care moved in two different directions.
The first of these focuses on relationships between the patient and their clinician who is able to communicate with empathy. This emphasis on relationships is epitomized by the Nuka Model of Care at the Southcentral Foundation in Anchorage, the only health center in the U.S. to win the Baldrige National Quality Award. Health care in the Nuka model is relationship-based and customer-owned. Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change. Note the additional element of community empowerment included in this approach.
The second direction was a focus on more actively seeking input of patients on how to improve the provision of health care, called Patient and Family Centered Care (PFCC). The four fundamental principles of PFCC are treating patients and families with respect and dignity, sharing information, encouraging their participation in care and decision making, and fostering collaboration in care delivery and program design, implementation, and evaluation. The new element here is the idea of moving beyond gathering survey feedback from patients, to partnering with patients to identify service problems and co-design the solutions. “Nothing about us, without us” is their catchphrase.
Both the Nuka model and the PFCC move beyond the individual clinician-patient interaction to look at what the organizations that hire these clinicians must do to be patient-centered, in ways that are challenging for standards organizations like NCQA to fully capture.
Jumping up another level above the organizations that provide care, how can health plans like PHC (as well as suppliers and state regulators like DHCS) promote patient-centered care?
- Make patient-centeredness a guiding principle—a frame-of-mind—that guides decisions and prioritization.
- Ensure consumers of health care have a voice. This includes a process that uses grievances to drive improvement, including consumers in governance and policy-making, and ideally with some joint design activities.
- Support providers, especially your primary care organizations, with financial incentives, comparative data, and sharing of best practices around optimizing the patient experience of care.
Becoming truly patient centered, meeting all the different definitions of this term, requires sustained attention from all of us. Thanks for taking a moment on National Health Experience Week to reflect on what you can do meet this ideal.