Putting Patients First: Patient-Centered Care: More than the Sum of Its Parts

The Symphony of Consumer Partnering and Clinical Governance: An Organizational Review Using the RE-AIM Framework

INTRODUCTION

Partnering with Consumers in healthcare systems is now widely accepted and mandated in many countries. Despite this acceptance, there is minimal information regarding the best practice of how to successfully establish systems to embed this practice into healthcare systems.

METHODS

This evaluation used the RE-AIM implementation framework to retrospectively analyse data from a 3-year timeline to review the events relating to the transition of Consumer Partnering into a Clinical Governance Unit. Data was sourced via Phase 1 - a focus group to establish a 3-year timeline of events, enablers and barriers, and Phase 2 - a quantitative and qualitative semi-structured interview to review systems that had been developed to support embedding partnering with consumers into Clinical Governance.

RESULTS

Five primary enablers and five barriers to successfully embedding a Consumer Partnering Team into a Clinical Governance Unit were identified. Enablers included Executive sponsorship and ownership of the value of partnering with consumers, Executive leadership influence on local area uptake, an organization-wide network, valuing via remuneration, and a centralized orientation and onboarding programme for Consumer Partners. Barriers included skills and attitudes of committee chairs, the size of the Directorate (smaller local areas can be easier to influence change), patient feedback data requires interpretation to be useful, staff turnover can reduce the relationships with Consumer Partners, and financial insecurity is a barrier to implementation and maintenance.

CONCLUSIONS

This article described how an Australian Health Service embedded a Consumer Partnering Team into a Clinical Governance Unit to ensure that partnering became business as usual practice. Enablers, barriers, and unintended consequences can be used as learnings for other organizations to develop a similar approach.

PATIENT OR PUBLIC CONTRIBUTION

Two Consumer Partners with lived experience of the health service, and members of the organizations committee structures are part of the evaluation team. As team members, the consumers participated as equal contributors in evaluation design, analysis of the focus group and interview data, and contribution to the writing and review of the manuscript. Two Consumer Partners with lived experience of the health service, and members of the committee structures participated in the focus groups and the interviews.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers

PURPOSE

Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage.

MATERIALS AND METHODS

Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews.

RESULTS

Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality.

CONCLUSIONS

Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

Patient and family engagement in patient care and research in Canadian intensive care units: a national survey

PURPOSE

While patient and family engagement may improve clinical care and research, current practices for engagement in Canadian intensive care units (ICUs) are unknown.

METHODS

We developed and administered a cross-sectional questionnaire to ICU leaders of current engagement practices, facilitators, and barriers to engagement, and whether engagement was a priority, using to an ordinal Likert scale from 1 to 10.

RESULTS

The response rate was 53.4% (124/232). Respondents were from 11 provinces and territories, mainly from medical surgical ICUs (76%) and community hospitals (70%). Engagement in patient care included bedside care (84%) and bedside rounds (66%), presence during procedures/crises (65%), and survey completion (77%). Research engagement included ethics committees (36%), protocol review (31%), and knowledge translation (30%). Facilitators of engagement in patient care included family meetings (87%), open visitation policies (81%), and engagement as an institutional priority (74%). Support from departmental (43%) and hospital (33%) leadership was facilitator of research engagement. Time was the main barrier to engagement in any capacity. Engagement was a higher priority in patient care vs research (median [interquartile range], 8 [7-9] vs 3 [1-7]; P < 0.001) and in pediatric vs adult ICUs (10 [9-10] vs 8 [7-9]; P = 0.003). Research engagement was significantly higher in academic vs other ICUs (7 [5-8] vs 2 [1-4]; P < 0.001), and pediatric vs adult ICUs (7 [5-8] vs 3 [1-6]; P = 0.01).

CONCLUSIONS

Organizational strategies and institutional support were key facilitators of engagement. Engagement in patient care was a higher priority than engagement in research.

From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Background

Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016–January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%–100%).

Objective

To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family ‘key card’ education.

Methods

We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families.

Results

In the postintervention period (February 2017–December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%–100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments.

Conclusion

Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.

Patient and Family Engagement in the ICU. Untapped Opportunities and Underrecognized Challenges

The call for meaningful patient and family engagement in health care and research is gaining impetus. Healthcare institutions and research funding agencies increasingly encourage clinicians and researchers to work actively with patients and their families to advance clinical care and research. Engagement is increasingly mandated by healthcare organizations and is becoming a prerequisite for research funding. In this article, we review the rationale and the current state of patient and family engagement in patient care and research in the ICU. We identify opportunities to strengthen engagement in patient care by promoting greater patient and family involvement in care delivery and supporting their participation in shared decision-making. We also identify challenges related to patient willingness to engage, barriers to participation, participant risks, and participant expectations. To advance engagement, clinicians and researchers can develop the science behind engagement in the ICU context and demonstrate its impact on patient- and process-related outcomes. In addition, we provide practical guidance on how to engage, highlight features of successful engagement strategies, and identify areas for future research. At present, enormous opportunities remain to enhance engagement across the continuum of ICU care and research.

Our Sunshine place: A collective narrative and reflection on the experiences of a mental health crisis leading to an admission to a psychiatric inpatient unit

Acute mental health inpatient units are complex environments where tensions between clinical and personal recovery can be amplified. The focus for mental health staff is often centred on providing clinical care, whereas from the patient perspective, the admission can represent a profound existential crisis. There are very few user-led accounts of their experiences of psychiatric inpatient unit. This project was developed in the traditions of Analytic Auto-Ethnography, a research methodology which provides a systematic process to reflect on our own experience while still producing trustworthy findings. Through this process, a collective narrative and critical reflection of a group of over 20 individuals with experiences of either providing or receiving care in an acute psychiatric inpatient unit was developed. The narrative developed shows that for some the hospital admission was a time of healing; for others, the inpatient unit represented an alien and unsafe environment, which accentuated the strangeness of the experiences of mental ill health. Common themes among the group were that of an overarching need to make sense of what happened leading up to the admissions and to come to terms with the potential impact of the illness on identity and future. This journey can be best described as a process of healing and moving towards 'wholeness'. Safety, connection, autonomy and control were identified as factors which either facilitated or hindered the process of successfully integrating the various experiences.

Stakeholder Engagement in Trial Design: Survey of Visitors to Critically Ill Patients Regarding Preferences for Outcomes and Treatment Options during Weaning from Mechanical Ventilation

RATIONALE

Stakeholder engagement in research is expected to provide unique insights, make research investments more accountable and transparent, and ensure that future research is applicable to patients and family members.

OBJECTIVES

To inform the design of a trial of strategies for weaning from mechanical ventilation, we sought to identify preferences of patient visitors regarding outcome and treatment measures.

METHODS

We conducted an interviewer-administered questionnaire of visitors of critically ill patients in two family waiting rooms serving three intensive care units (ICUs) in Toronto, Canada. Respondents rated the importance of general and ventilation-related outcomes in two hypothetical scenarios (before a first spontaneous breathing trial, and after a failed spontaneous breathing trial) and selected a preferred technique for the breathing trials. With regard to the patient they were visiting, respondents identified the most important outcome to them at ICU admission, during the ICU stay, and at ICU discharge.

MEASUREMENTS AND MAIN RESULTS

We analyzed 322 questionnaires (95.5% response rate). All outcomes were highly rated (average range: 7.82-9.74). Across scenarios, outcomes rated as most important were ICU and hospital survival (9.72, 9.70), avoiding complications (9.45), quality of life (9.394), patient comfort (9.393), and returning to previous living arrangements (9.31). Overall, the most important ventilation-related outcomes were being ventilator-free (8.95), avoiding reintubation (8.905), and passing a spontaneous breathing trial (8.903). Passing a spontaneous breathing trial assumed greater importance after an initial failed attempt. "Time to event" outcomes were less important to visitors. We did not identify a preferred spontaneous breathing trial technique. Although ICU survival was the most important outcome at ICU admission and during the ICU stay, visitors rated quality of life higher than hospital survival at ICU discharge.

CONCLUSIONS

Visitors to critically ill patients prioritized two general outcomes (ICU and hospital survival) and three ventilation-related outcomes (being ventilator free, avoiding reintubation, passing a spontaneous breathing trial), and valued avoiding complications, maintaining quality of life, comfort, and returning to previous living arrangements. The outcomes preferences of the survey respondents evolved temporally during the ICU stay.

Characterizing Citizens' Preferences for Engagement in Patient Care and Research in Adult and Pediatric Intensive Care Units

RATIONALE

Engagement promotes and supports the active participation of patients and families in health care and research to strengthen their influence on decision-making. We sought to characterize how citizens wish to be engaged in care and research in the intensive care unit (ICU).

METHODS

Interviewers administered questionnaires to visitors in 3 adult ICUs and 1 pediatric ICU.

RESULTS

We surveyed 202 (adult [n = 130] and pediatric [n = 72]) visitors. Adults and pediatric visitors prioritized 3 patient care topics (family involvement in rounds, improving communication between family members and health-care providers, and information transmission between health-care practitioners during patient transfers) and 2 research topics (evaluating prevention and recovery from critical illness). Preferred engagement activities included sharing personal experiences, identifying important topics and outcomes, and finding ways to make changes that respected their needs. Both respondent groups preferred to participate by completing electronic surveys or comment cards and answering questions on a website. Few respondents (<5%) wanted to participate in committees that met regularly. Although adult and pediatric respondents identified common facilitators and barriers to participation, they ranked them differently. Although both groups perceived engagement to be highly important, adult respondents were significantly less confident that their participation would impact care (7.6 ± 2.2 vs 8.3 ± 1.8; P = .01) and research (7.3 ± 2.4 vs 8.2 ± 2.0; P = .01) and were significantly less willing to participate in care (5.6 ± 2.9 vs 6.7 ± 3.0; P = .007) and research (4.7 ± 3.0 vs ± 5.8 ± 3.0; P = .02).

CONCLUSIONS

Adult and pediatric visitors expressed comparable engagement preferences, identified similar facilitators and barriers, and rated engagement highly. Adult visitors were significantly less confident that their participation would be impactful and were significantly less willing to engage in care and research.

Compassion as the foundation of patient-centered care: the importance of compassion in action

The Institute of Medicine defines patient-centered care 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." What is missing in this definition is an explicit emphasis on compassion. This perspective article draws on the experience of Planetree (CT, USA), a not-for-profit organization that partners with healthcare establishments to drive adoption of patient-centered care principles and practices by connecting healthcare professionals with the voices and perspectives of the patients and family members who utilize their services. Across hundreds of focus groups facilitated by Planetree, patients and their loved ones emphasize that paramount among their needs, preferences and values are compassionate human interactions. For care to be truly patient-centered, a foundation of compassion is essential. Reports from patients and the media, and research from healthcare systems around the world demonstrate the fallacy of assuming that compassion is a current or prevalent feature of the care experience. Concurrently, a growing evidence base highlights the supreme importance of compassion in driving high-quality, high-value care. However, good intentions are not sufficient for delivering compassionate care. Drawing on the experiences of exemplary patient-centered hospitals (recognized as such following a rigorous culture audit to determine fulfillment of the criteria for formal recognition as a Designated® Patient-Centered Hospital [Planetree]), this paper explores practical approaches for embedding compassion in healthcare delivery and organizational culture to meet patients' expressed desires for empathic and respectful human interactions.

Ayurveda: between religion, spirituality, and medicine

Ayurveda is playing a growing part in Europe. Questions regarding the role of religion and spirituality within Ayurveda are discussed widely. Yet, there is little data on the influence of religious and spiritual aspects on its European diffusion. Methods. A survey was conducted with a new questionnaire. It was analysed by calculating frequency variables and testing differences in distributions with the χ (2)-Test. Principal Component Analyses with Varimax Rotation were performed. Results. 140 questionnaires were analysed. Researchers found that individual religious and spiritual backgrounds influence attitudes and expectations towards Ayurveda. Statistical relationships were found between religious/spiritual backgrounds and decisions to offer/access Ayurveda. Accessing Ayurveda did not exclude the simultaneous use of modern medicine and CAM. From the majority's perspective Ayurveda is simultaneously a science, medicine, and a spiritual approach. Conclusion. Ayurveda seems to be able to satisfy the individual needs of therapists and patients, despite worldview differences. Ayurvedic concepts are based on anthropologic assumptions including different levels of existence in healing approaches. Thereby, Ayurveda can be seen in accordance with the prerequisites for a Whole Medical System. As a result of this, intimate and individual therapist-patient relationships can emerge. Larger surveys involving bigger participant numbers with fully validated questionnaires are warranted to support these results.

A concept analysis of patient-centered care

BACKGROUND

Patient-centered care (PCC) has moved to the forefront of health care over the last decade as a healthcare improvement recommended by the Institute of Medicine. Yet the term lacks clear definition among healthcare professionals.

PURPOSE

The purpose of this article is to describe a concept analysis using Walker and Avant's method as an organizing framework. In this review, nursing and interprofessional literature, including psychology, medicine, social science, physical therapy, and occupational therapy, are examined. Using research articles to delineate variables, multiple terms inherent to PCC are explored.

FINDINGS

Findings suggest that PCC is integral to the provision of quality care, promoting positive outcomes for patients, organizations, and healthcare professionals. An operational definition of PCC, including attributes, antecedents, and consequences, is developed, and this definition correlates with Jean Watson's caring theory in nursing practice today. Model and contrary cases illustrate the concept.

PRACTICE IMPLICATIONS

Defining measurable variables can link associated nursing care with improved patient outcomes. The need for further inquiry is discussed.

Values-based medicine and modest foundationalism

Philosophically, values refer to the basic commitments that justify judgements, beliefs and practices, both at the community and personal levels. The study of these kinds of values is axiology. We suggest that all people subscribe to three foundational values - survival, security and flourishing - and that these foundational values are expressed by way of concepts, systems, principles and practices that may differ substantially from culture to culture. Values can stand on their own as foundational justifications for health care and medicine. Many ethical quandaries can be better understood, even though they may remain unsolved, by reference to the foundational values that people can agree upon. This version of values-based health care has strong claims to prior logical status as a justification for the whole enterprise of health care, and values-based medicine is a part of this larger domain.