OPINION
Relationship-centred care: toward real health system reform
Johny Van Aerde,
MD, MA, PhD, FRCPC
The health care system and its professionals are criticized, at times even politicized and moralized, for the way they conduct their business.
Some discussions on reforming the system are about ideology, some are about effectiveness and efficiency, while others focus on private and public resources or the financial sustainability of provincial and federal health care systems. Because viewpoints are often driven by politics and self-interest, conversations evolve into debates rather than dialogue. Top
These debates about “health care reform” are often not really about that at all. If they were, they would include the socio-economic aspects of the Canadian health system.1 If they were, they would focus more on the essence of care, on the way caregivers partner with patients and with each other to reduce human suffering. Many of these debates are also divorced from meaningful action.
Many of us are longing for a cultural transformation that returns some of the “caring” to the system; we also want to own that change, rather than have more structural changes imposed on us. The feeling of helplessness permeating the system is, in part, a result of the fact that we continue to apply old frameworks to what have become complex, adaptive systems. Clinical interaction, the basic element of any health care system, is a complex, adaptive process. Top
The traditional view of clinical interaction is based on a form of Cartesianism, where the body is a machine and medical professionals are technicians whose job it is to repair that machine. In this mechanistic model of doctor-centred care, medical decision-making is viewed as an exclusively professional prerogative where physicians have the greatest authority.2,3 In the 1960s and 70s, authority and expert knowledge were challenged in all sectors of society, but it wasn’t until the late 80s and early 90s that resentment arose against the unilateral authority of doctors and the tendency to depersonalize care. New integrative disciplines were encouraged to counteract the scientific fragmentation that encouraged physicians to divide their care into disease- and organ-oriented specialties.2,3 The time had arrived to reintroduce “health” and “care” into the health care system. Patient-centred care was born.
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One initiative to reduce patient-driven care, Choosing Wisely Canada,8 helps to engage physicians and patients in conversations about unnecessary tests and treatments. However, this may not yield the intended results unless the conversations take place within the context of relationship-centred care (RCC), where neither the clinician nor the patient but the relationship as a whole is the focus.9
What is the genesis of RCC? The Pew-Fetzer Interprofessional Task Force saw clinical interaction as a complex adaptive system.2,3,9 It recognized that, while the purpose of health care is to respond to the needs of the patient, the process can be understood neither from a doctor- nor patient-centred perspective, but requires an explicit focus on the relationship between the partners.9 The patient–clinician relationship is an entity different from either of its parts, and it has all the characteristics of a complex, adaptive system.2 Twelve years after the Task Force’s initial monograph, Beach and Inui10 articulated four principles of RCC: Top
- relationships in health care ought to include the personhood of participants (the patient’s and clinician’s unique experiences, values, and perspectives)
- affect, empathy, and emotion are important components of these relationships
- all health care relationships occur in the context of reciprocal influence (although the patient’s goals take priority, both clinician and patient influence each other and benefit from the relationship)
- RCC has a moral foundation, allowing clinicians to develop the interest and investment needed to serve others and to be morally renewed by those they serve
More than anything, RCC is about partnership at every level and the respect, mutual understanding, and shared decision-making of which each partnership is comprised.3
In his new book, Service Fanatics, James Merlino,11 a keynote speaker at the 2014 Canadian Conference on Physician Leadership and chief experience officer at the Cleveland Clinic, describes the theory around RCC and evidence of how it can be practised successfully. The Cleveland Clinic has been a world leader in medical outcomes for decades, but it had lost some of its caring. In 2008, although ranked among the top four for outcomes in all but one specialty, the Cleveland Clinic was mediocre in terms of overall patient experience: in the 16th and 14th percentile for nurses’ and physicians’ communication, respectively, and in the 4th percentile for room cleanliness.
As the CEO, Dr. Toby Cosgrove said, “Patients were coming to us for the clinical excellence, but they did not like us.”12 Because medical excellence could not be improved much and because most people form their opinion based on the perception of experiences rather than clinical outcomes alone, the Cleveland Clinic made patient experience an enterprise-wide priority and named it Patients First. The organization also faced a penalty: the federal government would soon start to withhold 2% of Medicare payments from facilities ranking low based on the Hospital Consumer Assessment of Healthcare Providers and Systems.13 Within 5–6 years, the Cleveland Clinic became a frontrunner in the study of patient experience and soared from below average to high scores for patient experience.11,12 Top
Because one cannot provide what has not been defined, the Cleveland Clinic first had to come up with a definition of patient experience. If defined too narrowly as patient satisfaction, patient safety may be marginalized.4-7 Therefore, the definition had to include outcomes and safety. Following the four principles of RCC,10 a definition also had to include the patient’s understanding of his or her experience, while also adjusting the caregiver’s beliefs, assumptions, and presumed knowledge of what patient experience should be. Taking all this into consideration, the clinic’s current aim is to provide safe care, of high quality, in an environment of exceptional patient satisfaction, in a values-conscious environment. All 43 000 members of the Cleveland Clinic enterprise were defined as caregivers, as each one could affect the patient experience, directly or indirectly.
Although institutions talk a lot about the importance of empathy in delivering good care, there was actually little knowledge of what a patient experiences as he or she navigates the health care system. For that reason, the Cleveland Clinic collected and continues to collect data from patients, using surveys and interviews. For example, patients said that they wanted the reassurance that the people taking care of them really understood what it was like to be a patient. Anything patients and families saw and heard was processed against what they believed was important according to their values and assumptions; this affected how they viewed their care and the organization.11 The studies also revealed that patients often used proxies in their ratings: for example, they might see a dirty room as a sign that the hospital delivered poor care. Another striking finding was that satisfaction was higher if the caregivers had a happy demeanor: patients believed that unhappiness meant they were doing something that made the health care provider unhappy or that something was going on with the patient that the caregivers did not want to reveal. Top
As in any cultural change, both the brain (facts) and heart (empathy) of all caregivers and employees had to be engaged to align with the organization’s vision of Patients First. To accomplish this, several points of action were needed: support from the top of the organization, a chief experience officer who reported directly to the CEO, resources to support the initiative, a sense of urgency created by the poor performance data and pending financial implications, and the development of tools for the change “by us, for us.”11
Although everyone from physician to janitor co-owned the initiative, the development and delivery of the tools was adjusted for different groups. Everyone in the organization, without exception, participated in half-day exercises. After working interactively in groups of 10 with a facilitator, participants were offered follow-up mentoring to maintain the new skills. Despite physicians expressing fears that the new initiative would conflict with efforts to maintain high standards of quality, safety, and cost reduction, the clinic rose in rankings for quality and safety, and efficiency in delivery of care improved too. People were, and still are, involved — including patients on whom the institution relies heavily to identify problems and improve processes.11 Top
Although involvement was not easy for any group of caregivers at the clinic, engaging physicians was most challenging. Without physician engagement, patient experience (or almost anything else) is difficult to improve. In “Turning doctors into leaders,” Dr. Thomas Lee writes, “The problem with healthcare is people like me — the doctors.”14 Most physicians want to help, particularly for a noble cause, but they are often not asked or engaged in a meaningful way. An invitation from senior leaders is a start. At the Cleveland Clinic, other motivational tools included articulating a common purpose that reflected physicians’ values, satisfying self-interest by rewarding the achievement of targets, and earning respect from the physicians to be engaged.15 Making the invisible visible by sharing data and educating physicians about how they were going to be judged in a new values-based rather than volume-based world helped them understand what the scores on patient experience meant and how those ratings could affect the organization’s and their own finances.11 Top
The data from the clinic’s interviews and surveys helped the physicians understand patient experience scores and what needed to be changed. Initially, there was a significant disconnect between how physicians thought they communicated with patients and how patients rated their actual ability to communicate: 75% of the negative comments about physicians pertained to communication.11,12
Once the physicians were aware of the data and their meaning, the clinic had to figure out how to help doctors acquire, practise, and maintain the necessary skills to improve their communication. The delivery format and timing of courses and workshops were adjusted to accommodate physicians’ learning style and schedules. Merlino11 found that level of engagement was as difficult for salaried as for fee-for-service physicians. Learning in highly interactive small-group sessions, led by credible peers who had taken specific training, followed by peer-based coaching to maintain the learned skills proved to be the most successful way to address communication issues. The physician facilitator was often one of the physician leaders, who make up 10% of all doctors in this physician-led organization, and this too may have contributed to the successful implementation of Patients First. As a consequence, the patient experience score for physician communication rose to the 67th percentile in 2014 — up from 14th in 6 years.11 All patient experience scores and outcomes are listed on the Internet.16 Top
In Canada, do we know what the patient experience (not patient satisfaction) is in our organizations? How is each of us perceived by our patients? How can we make the invisible visible for RCC? How can physicians become more engaged in these types of organizational changes and system transformation? Although governments should be engaged in dealing with the socio-economic aspects of health, we, physicians, together with other caregivers and patients, have to lead transformational changes like relationship-centred care at the front line. The Cleveland Clinic provided the evidence that successful cultural changes around RCC affect all performance indicators and move us toward a sustainable health care system.
Investing in RCC is long overdue. It keeps empathy central in clinical interactions and it also serves self-interest. Someday, a loved one or you will be a patient. When that day comes, what do you want your patient experience to be? Top
References
1. Meili R. A healthy society. Saskatoon: Purich; 2012.
2 .Scott J. Complexities of consultation. In: Sturmberg J, Martin C, editors. Handbook of systems complexity in health. New York: Springer Sciences; 2013:257-77.
3. Suchman A. Relationship-centered care and administration. In: Suchman A, Sluyter D, Williamson P, editors. Leading change in healthcare: transforming organizations using complexity, positive psychology and relationship-centered care. London: Radcliffe; 2011:35-42.
4. Detsky J, Shaul R. Incentives to increase patient satisfaction: are we doing more harm than good? CMAJ 2013;185:1199-200.
5. Fenton J, Jerant A, Bertakis K, et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures and mortality. Arch Intern Med 2012;172:405-11.
6. Lee D, Tu J, Chong A, et al. Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction. Circulation 2008;118:1938-45.
7. Manary M, Boulding W, Staelin R, et al. The patient experience and health outcomes. N Engl J Med 2013;368:201-3.
8. Choosing Wisely Canada. Canadian Medical Association and University of Toronto. http://www.choosingwiselycanada.org/
9. Tresolini C, Pew-Fetzer Task Force. Health professions education and relationship centered care. San Francisco: Pew Health Professions Commission; 1994.
10. Beach MC, Inui T, Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med 2006;21(suppl 1):S3-8.
11. Merlino J. Service fanatics: how to build superior patient experience the Cleveland Clinic way. New York: McGraw-Hill; 2015.
12. Merlino J, Raman A. Health care’s service fanatics. Harv Bus Rev 2013;91(5):108-16.
13. Hospital Consumer Assessment of Healthcare Providers and Systems. http://www.hcahpsonline.org/home.aspx
14. Lee T. Turning doctors into leaders. Harv Bus Rev 2010;88(4):50-8.
15. Lee T, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev 2014;92(6):3-6.
16. Cleveland Clinic: patient satisfaction. U.S. News and World Report; 2013. http://health.usnews.com/best-hospitals/area/oh/cleveland-clinic-6410670/patient-satisfaction
Author
Johny Van Aerde is president of the Canadian Society of Physician Executives. He is clinical professor of pediatrics at the University of British Columbia and the University of Alberta, he is an associate faculty member at the School for Leadership Studies at Royal Roads University in Victoria, and he is on the faculty of the CMA’s PMI Physician Leadership Program.
Correspondence to: johny.vanaerde@gmail.com