Patient centeredness is increasingly referenced as a core value in the provision of care and the concept of patient-centered care is moving from innovation to expectation and in some cases, even regulation. But what exactly does it mean to be providing patient-centered care, and how does one achieve this, at either the individual or institutional level? This chapter explores the term patient centered, and current thinking about how to strengthen the partnership between patients and providers in the delivery of care. Throughout, emphasis is given to those innovations most relevant to the hospitalized patient.

While the term patient centeredness now appears commonly in both medical literature and lay media, one may encounter a variety of definitions for this phrase. Perhaps the most “official” definition is the one proposed by the Institute of Medicine (IOM) in the landmark 2001 document Crossing the Quality Chasm, which describes patient centeredness as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”1 The IOM goes on to describe patient centeredness as one of the six key “aims for improvement” for quality of care. As such it is presented as an intrinsic value, fundamental and irrefutable, as opposed to a system property with a known association with better outcomes. The concept has been advanced in the form of slogans such as “Nothing about me without me” or “Every patient is the only patient.” Overlapping terms appear in both lay literature and medical literature, including patient partnering and family-centered care. In this chapter the term “patient centered” will be used to encompass the general concept of making care delivery more responsive to the needs and wishes of the individual patient and his or her family.

The construct presumes that care delivery under current models is not adequately patient centered. The IOM “Chasm” report conceptualizes the health care delivery system as in evolution from a clinician-centric, poorly coordinated and nonevidence-based model to a patient-centric, integrated system that consistently applies scientifically supported interventions. In early stage clinician-centric models, the patient plays a passive role as decisions regarding choice, timing, and settings of care delivery are the exclusive domain of the providers, and those same providers decide what information reaches the patient. Stories abound in lay and medical literature of patients feeling at the mercy of the medical system, unable to exert control over their own care. However, it is hard to find a quantitative assessment of the current state of patient centeredness (or lack thereof) in the U.S. health care system. Some insights can be gleaned from national results of the CAHPS inpatient survey distributed by the Centers for Medicare and Medicaid Services (CMS), in which more than a quarter of patients report “never” receiving communication about new medications and their side effects, and more than 15% give the lowest possible score to questions about the responsiveness of hospital staff (composite scores, 2007 data).

The IOM describes the fully evolved stage of organizational development as the patient and family being part of the health care team with full access to information and the ability to exercise as much control over care as desired. What specific actions can an institution take to advance toward this model? These will be discussed below, divided into three key system properties: (1) free flow of information, (2) responsiveness to individual patient needs, and (3) patient participation in system design.

Free Flow of Information

Patients are not truly partners in their own care if information, either about themselves or the care they are receiving, is only selectively available. The need for full transparency is represented as two “rules for redesign” as stated by the IOM:

• Knowledge is shared and information flows freely.
  
• Transparency is necessary.

The first rule recognizes that patients should have the ability to receive complete and understandable information about their condition, in real time. The second rule establishes that patients are entitled to information about the care itself, including the performance of the health care system and its providers, as well as the approach to care and its justification. While these concepts may seem self-evident, the health care system traditionally has not been configured in alignment with these rules. Prior to passage of The Health Insurance Privacy and Portability act (HIPPA), exchange of medical documentation required that a patient obtain a subpoena. Today, care still remains far from transparent: published reports suggest the majority of hospitalized patients cannot even identify the physician in charge of their care, let alone the details of the care plan.

In the interest of better information exchange with patients, innovations are appearing. Some of these innovations change longstanding traditions of care delivery as currently practiced.

Open Communication of the Plan of Care

For the typical hospital inpatient, the formal mechanisms for discussing, developing, and implementing the plan occur without patient involvement. Communication of the plan of care is a separate responsibility of the physician, occurring most often as an unstructured verbal communication. Thus there is no system that guarantees that the patient understands the plan, or has had the chance to ask questions. However, new approaches that provide structure to these exchanges, and thus more reliable sharing of information, are appearing in the interest of both patient centeredness and patient safety. For example, the Veterans Health Administration has introduced “The Daily Plan,” a structured document containing information such as medications, scheduled procedures, and diet, reviewed with the patient each day of his or her hospitalization. The expectation is that The Daily Plan will improve provider-patient information exchange in both directions, provide an opportunity for patients to ask questions and share concerns, and identify problems that might cause risks to safety. Early reported experience shows that the large majority of patients receiving such a plan perceive a better understanding of their hospitalization, a better ability to ask questions, and a higher level of comfort with their hospital stay. Similar positive findings have been seen by introducing structured patient involvement with hospital discharge planning. A key element of these new models is some mechanism for “closed-loop communication,” meaning there is verification that the communication has been received, understood, and any remaining questions have been answered.