How to prioritize patient-centeredness: Q&A with Planetree's Susan Frampton
Patient-centered care isn't just a trendy buzzword for nonprofit advocacy and membership organization Planetree; it's the organization's entire philosophy.
Founded in 1978, Planetree collaborates with providers across the continuum of care — from physician practices to acute care hospitals and from psychiatric facilities to nursing homes — to transform culture and deliver care that prioritizes the needs of the patients.
Planetree President Susan Frampton, PhD, discussed her philosophy of patient-centeredness, how far the healthcare industry has progressed regarding that mission and how it can progress even further.
Note: Interview has been edited for length and clarity.
Question: What does patient-centered care look like to you?
Dr. Susan Frampton: In a nutshell, there are three words that characterize what patient-centered care is all about. The first is personalize, how do we personalize the care experience of each patient so that they don't feel like a number or a disease or a part of the body, but a whole person? The second is humanize, how do we make sure in a very high-tech world and industry that we put the human being first and ensure we aren't doing things to people that dehumanizes them? We hear a lot of concerns from patients regarding the negative impacts technology has on the human experience, where more attention is being paid to the computer screen than to the patient. And finally, demystify is the third characteristic. We need as a professional industry to demystify the experience for patients so that they understand, in their own language, what is going on and how they can help themselves. As an industry, we've not done a good job of that; we have our own 'medical-ese' language that even educated people have a hard time understanding. Demystifying care means making it more transparent, not only in the way that things are described, but becoming more transparent in what we are willing to share with patients. Those to me are the foundational pieces of patient centeredness.
Q: Why does it matter?
SF: I think it has become very clear over the last decade as new research has emerged that being kind to patients, open with information, involving them more in decision-making and being respectful of their input is simply better medicine. We can improve clinical outcomes when patients are a part of their own care experience and when we do things with them instead of doing things to them.
There has been some pushback for many years about the softer side of medicine. For example, people question the importance of things like empathy, compassion and kindness because they feel as though they have surgeries and quality measures and other matters to attend to so the human relationship gets relegated to the back seat. What's fascinating now is the emerging literature demonstrating a very powerful connection between empathetic physicians, who have good relationships with their patients and better clinical outcomes. Literally, people who have kind, empathic physicians heal more quickly, have better management of their diabetes or chronic condition and their course of contagious diseases like the flu are shorter.
This fascinating literature supports the power of the relationship between healthcare provider and patient. Care is not just about the technology and the things we do to people; it's how we relate to them and engage in a human relationship with them. My understanding is that healthcare is all about improving medical outcomes so being patient-centered and being kind and respectful should be as important as other quality and safety efforts.
Q: Planetree clearly prides itself on humanizing healthcare. Can you give me some examples about how the organization's work does that?
SF: At Planetree, we always begin with conducting focus groups with the patients, the patients' families and the frontline staff of the organizations that we are working with, be it a hospital, psychiatric facility, physician's office or nursing home. We ask those individuals to describe to us what is working in the healing experience in that organization and what can be improved upon to make the experience better. We always start this way, listening to the voices of the people closest to the care experience. Interestingly, there is oftentimes a lot of coherence between what patients and families identify as being most important to what frontline staff do. Then, we use that information to develop transformation plans.
We also do something that is unique with the training and education for the staff — we use a retreat process that is either a full-day experience or a two-day overnight. During the retreat, we take the staff and put them in the shoes of the patients by having them participate in very interactive and engaging exercises. That way, they don't only think about the patient's experience, they get to actually feel it themselves. Planetree sees the retreat process as appealing to people's hearts as opposed to their heads. I'd say that many people working in healthcare have felt the meaning and the purpose and the mission of why they went into healthcare get drummed out of them over time. We try to help people reconnect and remember how profound their work is by giving them a little bit of the experience of walking in the shoes of the patient.
One exercise in particular that we do seems very simple but can actually be very profound for the staff involved; it's a feeding exercise. In the middle of the retreat day, people are paired up as a patient and a care provider and we have them feed each other over a silent lunch. It sounds really simplistic but most of us have never been fed as adults and it is a very uncomfortable experience. One of the things that we first learn to do for ourselves as children is feed ourselves; it's part of being autonomous and it's part of being an adult. After the participants engage in that activity, we come together and debrief it and draw the parallels with what happens to the patients when they are in a hospital or nursing home and their autonomy is taken away. Exercises like that help the staff realize how the patients feel disempowered and help us brainstorm ways that care providers can minimize that feeling as much as possible for patients. Many of the solutions created at Planetree over the decades have come out of those retreat exercises.
Q: During your time working in healthcare, would you say the industry's attitude has changed toward patient-centeredness? How so?
SF: I think we're in a time of great transition around patient-centered care in particular and I think there is a lot of great work being done to address some of the challenges. I think many, many organizations are finally beginning to get it but there is still a lot of work to do.
I do believe the issue has now risen to a national level thanks in part to the Patient Protection and Affordable Care Act. Threaded through that document are requirements for transparency and engagement as partners with patients and families, therefore it's talked about nationally.
There is a whole research arm now that the government funds called Patient-Centered Outcomes Research Institute that asks patients to help them define what a good medical outcome from the patient perspective is and then they fund research around that. So I think this is a fantastic time for patient-centered care. The issue is really being looked at differently and taken seriously and there is a lot of energy being directed toward improvement.
Q: What can the industry — specifically, individual organizations — do to improve upon patient-centered care and make it more of a priority?
SF: What I would suggest at the organizational level — be it for a hospital or a nursing home or a physician practice — is that they use a framework to guide their patient-centered improvement work. I say this because there are a zillion things going on in patient-centered care and everyone is saying that everything they do is patient-centered. It has gotten to the point where it's easy to get lost in the weeds. I've also seen many shotgun approaches to different patient-centered projects that don't have any sustainability.
One of the things Planetree is focused on in the work that we've done for decades is identifying which practices correlate with excellence and then we've organized those into a framework that organizations can use to guide their work. Some organizations also want to formally recognize their progress so there is a designation process in patient-centered excellence for which they can apply. Another possibility is to use the criteria as the framework to help guide them since it is very comprehensive and it was essentially developed by patients. I think it's very important that organizations don't approach waste time and resources in a scattered fashion given everything we know about what works in implementing patient-centered culture changes and sustaining them.
In terms of important specific suggestions, I would encourage establishment of an active patient-family partnership counsel so that every organization reaches out to the people it serves — the patients and their families — and invites them to be part of an involved group that works with organization. For example, members can review patient safety initiatives, sit on the quality committee and review sentinel events, or they might be involved in interviewing and hiring decisions. Giving the patients that are served a seat at the table in terms of how the organization is run can be incredibly transformational.
Another tactic could be to focus on addressing the needs of clinical staff for more skills training around communication. Many physicians and nurses and caregivers get little to no formal communications training in medical school despite the fact that they are in the communication business. They are communicating with patients and their families every day, hundreds of times of day. Many errors and compliance issues — a great challenge for our system — comes down to communication. So we really need to refocus on providing quick, practical communication tips and training for clinicians.
Quality, safety and patient centeredness — looking at issues through the human perspective of the individual patient — is the third leg of the stool when we talk about improving our healthcare system.
Q: What are the benefits of taking a patient-centered approach to care, besides happier patients?
SF: There are real financial benefits today to improving the patient experience because hospitals, in particular, are at the forefront of the public reporting movement. Hospitals have to survey patients after discharge and ask them, how did we do? How was your experience? Were you listened to? Was our staff responsive? Did you get your questions answered? These questionnaires are being sent out by a majority of our hospitals today and the data that comes back is publicly reported on the internet. Reimbursement from Medicare and Medicaid are linked to those survey results. Hospitals now have to hit certain levels of competence on the patient experience measures in order to get their full Medicare and Medicaid reimbursement. These financial incentives have encouraged many more efforts to address patient-centeredness but, and while we've seen some movement, so far, we're not seeing huge improvements. I think part of the challenge is we're not seeing widespread consistent, coherent, coordinated efforts to improve the experience.
Patient experience scores and a dashboard that captures performance on patient-centered practices should be shared with the leadership and board of healthcare organizations, just like financials are. Unfortunately, that is not common at this point.
That said, I'm still very optimistic about the trajectory of patient-centered care. I think that people will continue to experiment with different practices and approaches and as we do a better job at integrating patients and families into design of improvement initiatives, we'll continue to learn as we go and get better and better.
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