CHAPTER 3:MODELS AND FRAMEWORKS
D) The Out of Pocket Model
3.4 Frameworks of Quality Improvement
3.4.2 Patient Experience Frameworks of Healthcare as a QI Initiative
"Patient care is defined as an approach and philosophy to the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among providers, patients, and families" (Abraham and Moretz,2012:44).
Figure 3. 2:Paradigm shift towards Improving Patient Experience Source: Barry and Edgeman-Levitan (2012:780)
It is evident that health care is moving towards emphasising patient experience in the care approach. In highlighting the role of patient experience where patients are more engaged and health care is delivered using innovative strategies, the health care system is able to provide quality health care. By investigating the patient experience of care the health system is able to identify the different aspects of health service that needs to be improved and in this way it can direct QI initiatives.
The IOM framework and the Picker Principles place the patient at the core of the health directive. Experience of care is highlighted as important in the framework to improve quality of health care due to its associations with "improved patient satisfaction, better health
Where have we been
• Fragmented care
• Provider centered care
• Paper
• Patients as passive participants
• Facility based visits
Where are we going
• Coordinated Care
• Patient centered
• Electronic
• Patients are fully engaged
• Innovative care delivery strategies
“What's the matter with you?” “What matters to you?”
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outcomes, and cost-effective care"(Cosgrove, Fisher, Gabow, Gottlieb, Halvorson, James, Kaplan, Perlin, Petze, Steele, and Toussaint,2013:321).
Anhang-Price, Cleary, Zaslavsky and Hays (2014:10) found that positive experiences of care were associated with care practices that prioritised the patient's needs. However, changing the culture, high implementation costs and the maintenance of new practices have limited the move towards care that focuses on the patient (Luxford et al.,2012:512). The models of the experience of care are discussed further in the section that follows:
3.4.2.1 Picker Principles
The Picker Institute (Europe) pioneered the use of carefully designed survey instruments to obtain detailed reports of patient experience and identify areas for improvement in the public health system (Picker Institute Europe,2014:12). These survey instruments differ from patient satisfaction surveys which have a more subjective focus.
"Patient centred care is health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers" (ACSQHC,2013:11). Its underlying principles include the following:
• treat all stakeholders including the patient with dignity and respect;
• encourage and supporting patients, carers and families to participate in shared decision- making;
• communicating and sharing information with patients, carers and families; and
• encourage collaborations with patients, carers, families and health professionals in the development of programs and in the delivery and evaluation of health services.
The cornerstone for assessing patient centred care is to understand how patients experience their care. The link between patient experience and patient centred care is thus revealed. This work of understanding patient experience is commonly guided by the Picker framework. The Batho Pele Principles which are used in SA is closely related to the principles of patient care as depicted by the Picker Principles.
65 3.4.2.2 Institute of Medicine
The Institute of Medicine (IOM) was established in 1970 and is the health arm of the National Academy of Sciences. In 2001 the IOM published a report ‘Crossing the Quality Chasm: A New Health System for the 21st Century’ (Institute of Medicine,2001:5). The report outlined 6 major aims for all health care organisations, stating that health care should be; safe, effective, patient-centred, timely, efficient and equitable. Care was described as encompassing qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. Care properties are described in Table 3.1 and also show the relationship between how these properties can be achieved when incorporated in the health care system and in the professional patient relationship.
Table 3. 1: IOM and Picker Care Properties, by Target Area.
Care properties, by target area. Health care system Both - Professional-patient relationship and health care system
Alleviation of fear/Anxiety Collaboration between disciplines towards
goal of healing Medical terminology is standardised to improve communication
Provision of Factual information Long term Communication about care
Education/Shared knowledge Coordinated and integrated care Culture supporting positive interaction between patients & caregivers Emotional/Psycho-social support Creates new standards/evolves Equitable treatment for all Enhancing Dr/patient relationship Effective professional resources for
people who can't manage their own health Free flow/accessibility of information
Holistic Focus on expected patient outcomes vs.
departmental needs. Incorporate art (music, visual etc.) into patient care
Incorporating prevention/health promotion
Personalization Incorporate massage/human touch Involvement of family/friends Partnership among professionals, patients
and families
Infrastructure supports administration, training, information financing and quality improvement
Patients understanding &
Participation in goal of healthier society
Patient control Integrate alternative/complementary
practices Respect for patient needs/customized care
Participate in own care Patients participation in financing &
incentives for healthcare Respect for patient preferences/wants Patient responsibility for health Simplifying care at the bedside Respect for patient values
Physical comfort Team management of health professionals Quality Reaching agreement about managing
illness Transition planning Patients’ values guide clinical decisions
Adapted from ‘Putting Patients First’- Health professional-patient relationship
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Stiff et al. (2013:610) states that there are commonalities between patient centred care and patient experience. Still explains that "Patient experience is seen as a measure of patient centeredness, and can be used to ensure organizations are delivering patient centred care". Dr.
Susan Frampton, President of Planetree, also noted that patient experiences were not only a measure of the patient-centred approach used at health facilities but also provided valuable feedback on how to promote quality. Therefore patient experience not only indicates the degree of patient centeredness but also indicates how patients view the entire process of healthcare. For this reason, the study has drawn its attention to patient experience as a whole rather than patient centeredness.
3.5 Health Systems that Adopt the Patient Frameworks for Improving the Experience of