The Health Care Manager Volume 00, Number 0, pp. 1–5 Copyright # 2017 Wolters Kluwer Health, Inc. All rights reserved.

Patient-Centered Organizational Statements Merely Rhetoric? A Survey of Health Care Leaders William A. Nelson, PhD; Rachel C. Forcino, MSc; Glyn Elwyn, MD, PhD, MSc, FRCGP Health care organizations have embraced the concept of patient-centered care, but there is concern that the mere inclusion of those words in mission and value statements does not equate to implementation at the health care delivery level. Despite initiatives to align the patient-clinician encounter with broader patient-centered values, there have been mixed results, often creating a gap between practice and the organization’s stated position. This preliminary study aims to assess the extent to which patient-centered values are reflected in actual patient care. The survey was sent electronically to Dartmouth’s Masters in Health Care Delivery Science alumni, leaders in health care management. A majority of 49 survey respondents acknowledged the importance of patient-centered values to their organizations. However, 90% of respondents identified a gap between patient-centered values and day-to-day patient care. Thematic analysis of respondent comments showed a misalignment of organizational incentives with patient-centered care, a lack of leadership priority given to patient-centered values, and a failure to clearly define patientcentered values. Quantitative and qualitative data indicated that patient-centered statements represented rhetoric rather than the reality of patient care. Consistently achieving patient-centered care will require leaders to adopt a systematic approach to move beyond rhetoric. Key words: leadership, management ethics, organizational ethics, patient-centered care

ODAY’S HEALTH CARE organizations have embraced the concept of patient-centered care. This emphasis has become particularly prominent since the 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm described patient-centered care as one of six interrelated aims that are essential to high-


Author Affiliations: Department of Medical Education (Dr Nelson), The Dartmouth Institute for Health Policy and Clinical Practice (Ms Forcino), Geisel School of Medicine at Dartmouth (Dr Nelson and Dr Elwyn), Dartmouth College, Lebanon, NH. The authors have no conflicts of interest to disclose. Correspondence: William A. Nelson, PhD, Department of Medical Education, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Box 8, Suite 200, 37 Dewey Field Rd, Hanover, NH 03755 (wi[email protected]). DOI: 10.1097/HCM.0000000000000186

quality health care delivery.1 Adding further weight to the IOM’s interrelated aims is their linkage to the basic ethical concepts underpinning the delivery of health care: respect of patients and acting in the patient’s best interests.2 The patient-centered aim seeks to ensure that clinical care is respectful and responsive to individual patient preferences, needs, and values and that patient values guide all clinical decisions. Patient-centered care is epitomized by shared decision-making between patients and clinical care teams.3 The fulfillment of the quality aim of patient-centered care and its companion ethical principles serve as foundational for clinician-patient encounters.4 For health care organizations, consistently pursuing the patient-centered aim is central to fulfilling their missions.5 As a result of the IOM report, many leaders have turned their attention toward improving patient-centeredness so that improved 1

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communication with patients is included in their organizations’ overall mission. Despite these initiatives by health care leadership, there have been mixed results.6,7 An observational report describes only moderate success in improving patient-centered care.8 Furthermore, ‘‘despite expanding initiatives, many organizations have faced barriers when attempting to transform their organizational culture from provider focused to patient focused.9 For example, changing ‘‘the mind-set of employees from a provider focus to a patient focus’’ has been cited as the primary barrier to patient-centered care.6 However, Luxford and colleagues’6 qualitative study suggests that those who have been successful in fostering patient-centeredness ‘‘have gone beyond mainstream frameworks . . . and have adopted a strategic organizational approach to patient focus.’’6(p1) The study reinforces the importance of recognizing, then systematically addressing barriers through a ‘‘comprehensive organizationwide approach, fundamentally linked to an organizational strategy’’6(p2) for achieving patient-centered care. To attain success in aligning patient-centered care with actual practices requires a clear awareness of what is actually occurring in the clinical setting. Therefore, we sought to assess the extent of alignment between the commonly espoused patient-centered organizational values of patient-centered care and current clinical practice, as reported by health care administrators and clinicians. METHODS To assess perceptions of alignment of patientcentered health care and actual clinical practices, we administered a brief survey, which was pilot tested and reviewed by several professional groups of health science researchers, clinicians, and administrators before administration. The study was reviewed and approved by Dartmouth’s Institutional Review Board. The survey, hosted online by Qualtrics, LLC, was sent electronically to three cohorts of Dartmouth’s Master’s in Health Care Delivery Science program alumni. These cohorts average 23 years of professional experience

in health care settings. Survey questions included the following: ‘‘Thinking about your health care organization where you provide health care services, work as an administrator, or (for respondents not working at a health care facility) where you receive your own health care, to what extent would you agree or disagree that patient-centered care values are important to the overall mission of the organization?’’ ‘‘Thinking about health care organizations generally, to what extent would you agree or disagree that a gap exists between patient-centered organizational values and day-to-day patient care?’’ ‘‘Thinking about your health care organization, where you provide health care services or work as an administrator or (for respondents not working at a health care facility) where you receive your own health care, to what extent would you agree or disagree that a gap exists between patient-centered values and day-today patient care?’’ Respondents were presented with a Likert-type response scale including fully disagree, somewhat disagree, neutral, somewhat agree, and fully agree options. After each question, a text box allowed respondents to ‘‘offer any additional comments regarding their response.’’ The survey concluded with several demographic questions, including the type of employment (clinician, administrator, both, or other), size of facility, teaching or nonteaching organization, for-profit or nonprofit status, and accountable care organization status. Quantitative results were analyzed using SPSS version 21 (IBM Corp, Armonk, New York). Qualitative analysis followed a thematic framework. Two authors (W.N. and R.F.) independently coded qualitative data, after which emerging themes were discussed and consensus on main themes reached. RESULTS Of 132 surveys distributed, we collected 49 responses with a response rate of 37%. Demographic characteristics of respondents are outlined in Table 1. Most respondents work in health care facilities (36/49, 73%), as clinicians (11/49, 22%), administrators or

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Patient-Centered Organizational Statements Table 3. Identifying a Values Gap

Table 1. Demographic Profile of Respondents (N = 49) Frequency (%) Type of employment Clinician providing health care Administrator or manager in a health care facility Combination of clinical and administrative duties Health insurance company/payer Other No response provided Organization’s teaching status Teaching hospital Nonteaching hospital I do not know No response provided Organization’s ACO status ACO Planning to become an ACO Not an ACO I do not know No response provided

11 (22) 14 (29) 11 (22) 3 (6) 1 (2) 9 (18) 29 4 1 15

(59) (8) (2) (31)

16 5 10 2 16

(33) (10) (20) (4) (33)

Abbreviation: ACO, accountable care organization.

managers (14/49, 29%), or in roles that combine clinical and administrative duties (11/49, 22%). A majority works in teaching hospitals (29/49, 59%), and a third works in accountable care organizations (16/49, 33%). Forty-five percent of respondents’ health care settings (22/49) are urban or suburban and most are not-for-profit organizations (32/49, 65%). Survey responses are summarized in Tables 2 and 3. Most respondents (43/49, 88%) acknowledge the importance of patient-centered care to the overall mission of their health care organizations. However, when considering health

To What Extent Would You Agree or Disagree that a Gap Exists Between Patient-Centered Organizational Health Care Your Health Values and Organizations Care Day-to-Day Generally Organization Patient Care? (N = 49), n (%) (N = 49), n (%) Fully agree Somewhat agree Neutral Somewhat disagree Fully disagree

17 27 3 2 0

(35) (55) (6) (4) (0)

15 30 2 2 0

(31) (61) (4) (4) (0)

care organizations generally, most respondents (44/49, 90%) identify a gap between these patientcentered organizational values and day-to-day patient care. This finding also corresponds to respondents’ own health care organizations, as a similar proportion agrees that this gap exists in the organizations where they work or receive care (45/49, 92%). Many respondents offered comments elaborating on their views related to patient-centered organizational values and day-to-day patient care. Four general themes were identified and are described in Table 4. Misaligned organizational incentives and a limited focus on the part of clinicians and administrators were commonly cited among those respondents offering comments. Organizational leadership’s lack of priority given to patient-centered values or failing to clearly define patient-centered values also plays a role. Table 4. Qualitative Themes

Table 2. Organizational Mission Theme Thinking About Your Health Care Organization, to What Extent Would You Agree or Disagree That Patient-Centered Care Values Are Important to the Overall Mission of the Organization? (N = 49) n (%) Fully agree Somewhat agree Neutral Somewhat disagree Fully disagree


26 (53) 17 (35) 3 (6) 3 (6) 0 (0)

Misaligned incentives Limited focus Mismatch of priorities Uncertain concept

Description Organizational incentives and metrics are not aligned with patient-centered care. Clinicians and administrators lack a consistent patient-centered focus. Leadership shows conflicting goals. Leaders fail to clarify and define patient-centered care.

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Misaligned incentives Respondents often noted a gap between espoused values and the metrics used throughout the organization, citing ‘‘the system, process, and misaligned incentives’’ as making alignment with organizational values ‘‘challenging.’’ For example, incentives such as those implemented by the Centers for Medicare & Medicaid Services were acknowledged as ‘‘well meaning’’ but also described as ‘‘misguided,’’ ‘‘not aligned with the patient and [his or her] needs and preferences,’’ and ‘‘an insidious problem.’’ Furthermore, respondents felt these incentives ‘‘create a substantial hurdle to doing what is best for the patient [versus] what is financially attractive to the institution.’’ Limited focus Clinicians and administrators described inconsistent attention to patient-centered care. Some respondents recognized this as a personal shortcoming by the individuals involved in clinical care, with one describing it as ‘‘arrogance, innocence, naivete´, or a bit of both.’’ Another cited physicians ‘‘not fully implementing and vigorously pursuing patientcentered techniques like. . .teach-back’’ as a limitation. Others feel that, although ‘‘doctors are almost all truly dedicated to their patients,’’ they ‘‘don’t always recognize when there’s the conflict’’ between patient-centered values and the care that they deliver. Inconsistency in applying patient-centered care between providers and settings was also noted, with one respondent explaining that ‘‘we want to implement patient-centered care . . . because of patients’ needs; however [in] other areas, [such as] surgery, they still are working based on doctors’ needs.’’ Priority mismatch Respondents noted a lack of alignment when the ‘‘organizational culture espouses patient-centeredness, but this is not fully integrated within the organization.’’ The priority mismatch was described as ‘‘a large gap’’ between current day-to-day patient care and ‘‘a cultural transformation that truly puts

patients first.’’ As one respondent noted, ‘‘though some efforts are being made to focus upon patient-centered organizational values, day-to-day care is still more geared toward satisfying the bottom line functions of the organization’s business.’’ Although patient-centered values are ‘‘philosophically very important,’’ they can ‘‘conflict with other goals in the actual delivery.’’ Symptoms of this conflict are especially evident through ‘‘low staffing [and] discharge support’’ as well as ‘‘opaque pricing.’’ Undefined concept Organizations’ failure to clarify and define patient-centered care was cited as another recurring cause of the gap between patientcentered values and day-to-day patient care. Some respondents feel that ‘‘patient-centered values are not explicitly articulated’’ within their organizations, potentially because ‘‘most of the senior leaders [do not] understand or pay attention to basic patient values.’’ However, another respondent feels that ‘‘on face, everyone wants to be patient-centered’’ but acknowledges that ‘‘fewer have thought about the particulars or implications of that.’’ DISCUSSION These health care leaders suggest through both quantitative and qualitative data that, although organizations, such as the ones in which they work, are willing to espouse patient-centeredness in their value and mission statements, there seems to be a gap between what is professed and what is achieved. There are reports that important organizational targets and measurements are not focused on patient-centered care, executive and clinical leaders exhibit conflicting goals and fail to define patient-centered care, focusing more on increasing hospital amenities and improving facility esthetics than on promoting approaches focused on good communication and patient involvement in care processes. Data from the survey and our analysis of the open-ended comments confirm that organizational level interest in patientcentered care does not seem, according to

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Patient-Centered Organizational Statements these respondents, to have been translated into changes in the way clinical practice is executed or managed. We were not able to achieve our intended response rate, and it is possible that nonrespondents may have different views. However, having presented the results of this study to master’s of health care delivery science students, we did not meet any contrary opinions. The respondents may well be more critical than their peers in other organizations, because they were participants in a master’s program focused on health care improvement. CONCLUSION We view these results as preliminary, because they need replication and confirmation. They do, however, point to a rhetoricpractice gap, where organizations use the term patient-centered care but fail to operationalize the most salient and important components—those that would make a direct


impact on how patients are informed, engaged, respected and included in their care. To achieve patient-centered health care, it is not enough to ask clinicians to do better. Health care leaders need to make a commitment to patient-centered care that goes beyond mission and values statements. There is a need for executive and clinical leaders to ensure the consistent implementation of patient-centered care. Such an implementation process requires a carefully planned, organizationwide, and systematic approach. Luxford and colleagues6 offer a systematic approach for hospitals to make sure patient-centeredness happens; our findings highlight the importance of adopting this type of systematic approach. ACKNOWLEDGMENTS The authors acknowledge the helpful efforts of Dr Thom Walsh and the leadership of Dartmouth’s Masters in Health Care Delivery Science in drafting the research survey instrument.

REFERENCES 1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 2. Nelson WA. Ethics: a foundation for quality. A strong ethical framework helps determine organizational success. Healthc Exec. 2011;26(6):48-49. 3. Barry MJ, Edgman-Levitan S. Shared decision making— pinnacle of patient-centered care. N Engl J Med. 2012; 366:780-781. 4. Nelson WA. The imperative of a moral compassdriven healthcare organization. Front Health Serv Manage. 2013;30(1):39-45. 5. Nelson WA, Taylor E, Walsh T. Building an ethical organizational culture. Health Care Manag (Frederick). 2014;33(2):158-164.

6. Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care. 2011;23(5):510-515. 7. Nelson WA, Walsh T. Ensuring patient-centered care. Leaders must get involved and make it a priority. Healthc Exec. 2014;29(4):40-42. 8. Katz-Navon T, Naveh E, Stern Z. The moderate success of quality of care improvement efforts: three observations on the situation. Int J Qual Health Care. 2007;19(1):4-7. 9. Rozenblum R, Lisby M, Hockey PM, et al. The patient satisfaction chasm: the gap between hospital management and frontline clinicians. BMJ Qual Saf. 2013; 22(3):242-250.

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Patient-Centered Organizational Statements: Merely Rhetoric? A Survey of Health Care Leaders.

Health care organizations have embraced the concept of patient-centered care, but there is concern that the mere inclusion of those words in mission a...
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