The Big Shift

Stephen C Schoenbaum

Stephen C Schoenbaum

Executive Vice President The Commonwealth Fund, USA.


Shifting to patient-centred care implies a re-think of every aspect of the patient's journey through an episode of care from the patient's perspective.


When one looks at healthcare organisations that are patient-centred, first thing one discovers is that the patient-centred care is highly valued by leadership and it has worked hard to establish those values within the organisation.

Healthcare processes are mostly disease-centred. How big a shift is it then for hospitals to create processes that are patient-centred?

I do not believe that the main issue is shifting from disease-centred to patient-centred care. It is shifting from physician-centred or provider-centred to patient-centred, and that is a very big shift. It is a big change because in order to accomplish it one has to re-think every aspect of the patient's journey from the patient's perspective. Patients wish to understand the medical treatment offered to them and how it would affect them immediately and in the longer run.

In early 1990s, Picker Institute, an organisation that promotes patient-centred care, where I am a board member, convened groups of patients in order to define the attributes of care that patients felt were essential. This process led to a set of eight dimensions of 'patient-centred care' including:

  • • Respecting the patient's values, preferences and expressed needs
  • • Informing and educating the patients about their treatment
  • • Patient's access to care
  • • Emotional support to relieve fear and anxiety
  • • Involvement of family and friends
  • • Continuous and secure transition between health care settings
  • • Physical comfort
  • • Coordination of care

I would add that simplicity is a very important attribute of patient-centred care. Patients must be told what is necessary and the care they receive must be explained to them in the terms that are comprehensible to them. The shorter the patient's stay is in the hospital, the better it is.

I cannot overstress the importance of co-ordination of care and smooth transitions in a healthcare set up.

A patient's stay in the hospital is like a complex relay race wherein the patient and information about the patient, are the baton. The baton must be passed on securely from one provider to the next. If the baton is dropped, there is waste and a poorer outcome. Unfortunately, we know from surveys that about one-third of the time, patients think that their care has been poorly coordinated, and the transitions, poorly managed.

What systems need to be put in place in order to provide care that best suits the patient's needs (i.e. patient-centred care)?

Most importantly, one needs to have a system that can obtain and assess the patient's experience. It is only through the patient's feedback you know if you are patient-centred or not. Some aspects of patient-centred care can be facilitated by 'systems'. For example, engaging the patient in the process of shared-decision making is an important aspect of patient-centred care. There are information tools such as DVDs that can help patients learn about common procedures or situations-choice of treatment for breast cancer or prostate cancer or back pain, and make it easier to engage the patient in shared decision-making.

How important a role does technology play in this scenario? Is there enough technology available to push for a patient-centred care model?

Health information technology makes it easier to coordinate care. Having the electronic medical records available to all care providers, with accurate laboratory results, information on allergies, medications etc. makes it easier to 'pass the baton' and eliminate waste and duplication.

What role does the leadership play in bringing about a patient-centred approach throughout the organisation?

Patient-centred care can occur even in a single clinical encounter. However, it is important that it happens throughout a patient's stay in the health care set up. For that, leadership is absolutely essential.

When one looks at health care organisations that are patient-centred, first thing one discovers is that the patient-centred care is highly valued by leadership and it has worked hard to establish those values within the organisation.

Any other comments that you would like to make?

Yes. I'd like to make a couple of comments:
1. Measuring of patient's experience is just beginning to become a standard in hospitals in the US. For the first time in March 2008, results for almost all hospitals using the standardised H-CAHPS instrument were made public. They showed tremendous variation in performance and large opportunities for most hospitals to improve some aspect of the patient-centred care they delivered.
2. Do not think about patient-centred care as an 'add-on' or a 'frill'. It is absolutely essential to achieve excellent care. Patient-centred care is one of the six aims of the high-quality care that the US Institute of Medicine delineated in its report 'Crossing the Quality Chasm'. It is intimately related to the other five: safety, effectiveness, efficiency, timeliness and equity.