Organizational dimensions of relationship-centered care. Theory, evidence, and practice.
Current health care reform initiatives are being driven by multiple pressures, Organizations that have reorganized care delivery to be patient-centered (ie, the central dimension of patient-centered care (or relationship-centered care) is a . Eight health care organizations across the USA with a reputation for successfully .. Exchange: Patient- and family-centered care initiative is associated with . Organizational dimensions of relationship centered care: theory. Beach MC, Inui T, and the Relationship-Centered Care Research Network. Organizational dimensions of relationship-centered care. J Gen. Intern Med ; S9-S . initiative to improve civility at diverse clinical sites. Also describes .
Soon after, patient-centered interviewing 9 was adopted as the standard for effective patient—physician communication, and remains so to this day. Rhetoric aside, many social scientists had long been observing that the balance of power and discretion in medical care was precisely that—care centered on the preferences and values of the doctor.
Noting patients' and clinicians' discontent with, and even alienation from, prevailing systems of care, the Task Force sought to develop a values foundation for the work of the health professions.
In the current era just as in the pastthe social role and privileges of the healer seemed to be founded upon meaningful relationships in health care, not just on technically appropriate transactions within these relationships. Principles of Relationship-Centered Care Relationships provide the context for many important functions and activities in health care.
Within relationships, we exchange information, allocate resources, arrive at diagnoses, choose treatments, and assess the outcomes of care. None of these is carried out solely by 1 party; all are mediated by the qualities of the manifold relationships that link patient, clinician, team, organizations, and community.
Organizational Dimensions of Relationship-centered Care
Relationship-centered care RCC is built upon 4 related principles that are described below. Relationships in Health Care Ought to Include Dimensions of Personhood as Well as Roles In the clinical encounter, RCC makes explicit that both the patient and the clinician are unique individuals with their own sets of experiences, values, and perspectives.
In RCC, clinicians remain aware of their own emotions, reactions, and biases, and monitor their own behavior in light of this awareness. In addition to the explicit recognition that clinicians bring their personhood into the encounter, RCC emphasizes the importance of authenticity, in the sense that clinicians should not, for example, simply act as if they have respect for someone; they must also aim actually to have internally the respect that they display externally.
Affect and Emotion Are Important Components of Relationships in Health Care Relationship-centered care recognizes the central importance of affect and emotion in developing, maintaining, and terminating relationships. In RCC, emotional support is given to patients through the emotional presence of the clinician. Relationship-centered care therefore challenges the notion of detached concern, in which stepping back to maintain affective neutrality breaks the bond that holds people together.
Rather than remaining detached or neutral, clinicians ought to be encouraged to empathize with patients, because empathy has the potential to help patients experience and express their emotions, 1213 to help the clinician understand and serve the patient's needs, 14 and to improve patients' experience of care. All Health Care Relationships Occur in the Context of Reciprocal Influence Health and health-related actions do not occur in isolation but are related to one another in time, space, and content.
As such, the smallest unit of measure in RCC is an interactional exchange. Furthermore, clinicians are undoubtedly benefited by the opportunity to know their patients, and RCC encourages clinicians to grow as a result.
While achievement of the patient's goals and the maintenance of health are the more obvious focus of any encounter, allowing a patient to have an impact on the clinician is a way to honor that patient and his or her experience. RCC Has a Moral Foundation The formation and maintenance of relationships in health care is morally valuable for several reasons.
First, unlike customer relations in which individual and organizational gain are paramount, genuine relationships are morally desirable because it is through these relationships that clinicians are capable of generating the interest and investment that one must possess in order to serve others, and to be renewed from that serving. Although one could argue that physicians have fiduciary duties to patients that arise through some sort of contract rather than through the formation of a genuine relationshipit tends to be true that, humans are more morally committed to those with whom they are in a personal relationship.
Furthermore, rather than considering this partiality to be a moral weakness, some have argued that such enhanced commitment to those with whom we have a personal relationship with is morally desirable. This sort of honesty is morally desirable as an end in itself, and it allows the patient to assess her impact on the clinician accurately, rather than being misled by a particularly good role performance.
Dimensions of RCC In suggesting that an explicit focus of care ought to be on relationships, we embrace and expand the principles of patient-centeredness within the patient-clinician relationship, and we also consider the relationships of clinician-clinician, clinician-community, and clinician-self as foundational and intrinsic to health care. Below, we provide a general description of these dimensions of RCC.
In the table, we have highlighted the areas of RCC that we also consider to be part of patient-centered care.
Monitor the state of the relationship Acknowledge the importance of the relationship to one's own well-being Outcomes Patient feels honored, respected, attended to, etc.
The elements listed in Table 1 are those that we consider to be integral to RCC.
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There are many other variables attitudes, behaviors, personal characteristics, outcomes that might be correlated with RCC, but are not central to their definition. For example, future research might explore the question of what kinds of life experiences and educational approaches lead to the adoption of an RCC outlook, or under what circumstances RCC-related behaviors have the best impact race- or gender-concordant dyads, or routine vs emergent care, for example.
Whatever those experiences or circumstances are, they are correlates of RCC and not part of the definition. Similarly, the anticipated outcomes of RCC are not included among its defining elements. Whether, and under what circumstances, RCC leads to favorable outcomes is an important empirical question for future investigation, but the achievement of favorable outcomes is not its defining feature.
The elements described in Table 1 are also intended to be illustrative rather than comprehensive, in that there are many more attitudes and behaviors that could be added. Some omitted variables may be nested under the more general elements listed, meaning that they are not so much left out as simply embedded in the higher-order concepts listed.
Patient representative Action plans for improvement are collaboratively developed with the patient advisors. VP Patient Care Interviewees in five out of eight organizations cited the engagement of patients, families and carers as a critical strategy for promoting patient-centered care.
Engagement ranged from involvement in organizational decisions e. At an organizational level, this typically included patient and family advisory committees, along with representation on the board of trustees, quality improvement committees, employee interview panels and medical executive committees.
While engagement was mentioned as a facilitator of patient-centered care at all sites, the most extensive levels were reported by acute inpatient facilities.
Sustained focus on employee satisfaction We have a people's choice award where we recognize the medical staff that patients have selected as having met their needs in a very outstanding way. VP Quality Interviewees in seven out of eight organizations consistently reported that a focus on improving the satisfaction of employees was viewed as a facilitator for building a patient-centered organization.
Interviewees acknowledged links between employee satisfaction and patient satisfaction and noted that constantly developing and reviewing the staff culture and work environment were important processes in their organization. Employees were publicly recognized for achievements through newsletter articles and award ceremonies, and they displayed plaques on wards.
Regular measurement and feedback reporting I think consistency in focus, in measurement, in feedback to the frontline …. They all cited using feedback actively to identify areas for improving patient-centered care. Interviewees noted that their organizations had a long history of systematic measurement of patient feedback typically exceeding 10 yearsusing a variety of mechanisms such as surveys, focus groups, anonymous shoppers, real-time feedback and complaints databases.
Adequate resourcing for care delivery redesign We are listened to, and many of the things we suggest are put into practice. CEO interviewees noted that changes in care delivery, based on patient feedback, were often surprisingly simple and inexpensive.
Organizational Dimensions of Relationship-centered Care
Building staff capacity to support delivering patient-centered care If they're not fitting into what we're looking to for our vision, we don't bring them on board. Nurse Manager There comes a point where you coach and you teach, but then you also hold accountable and if you're not comfortable doing these things, maybe you should work in another place.
Workforce capacity building techniques reported included training in communication skills, patient-centered care values, customer service and leadership skills and using specific patient feedback in individual staff development.
Accountability and incentives … if you want to have better care, you have to have people accountable for it. It's not rocket science — it's just basic management.
Organizational dimensions of relationship-centered care. Theory, evidence, and practice.
Chief Executive Officer Interviewees cited the use of accountability for patient care experience as a key enabler six out of eight organizations. Interviewees reported that patient feedback ratings were incorporated with other metrics in employee performance reviews at all levels, and in some sites they were also linked to remuneration incentives.
Board scorecards and dashboards typically included patient care experience metrics for review as a key performance indicator. Culture strongly supportive of change and learning Part of our culture is that we're never happy with the status quo. In a now-familiar discouraged tone, Dr. Slade points out the downward slide in Dr. Pantrof's results and reminds him of the organization's commitment to providing patient-centered care and the pressing need to grow the practice.
Pantrof a brochure prepared by their outside consultant and he spots a bulleted list of practical recommendations like opening each visit with a personal greeting and making good eye contact with patients.
He returns to his office to prepare for his afternoon clinic. There are 16 patients scheduled and the first 2 are waiting.
Feeling quite alone and almost hopeless, Dr. Pantrof's eyes drift across the office landscape as he wonders if there is any help in sight.
Stanton Health Plan recognizes that it needs to consider carefully how to meet the employers' demands without antagonizing its clinicians. The plan's leadership is aware of litigation in which a nearby IPA has filed for an injunction against a leading health plan to prevent implementation of a similar pay-for-performance program.
The SHP leadership decides that the only way to avoid this fate—and to honor the plan's mission of ensuring the highest quality medical care at an affordable price—is to work collaboratively with the Clinton Heights IPA in developing its pay-for-performance program.
Stanton Health Plan establishes a working panel comprised of plan leadership and 7 clinicians selected by the Clinton Heights IPA to represent the network. The panel has a 5-month timeframe to develop the pay-for-performance program.
At the first meeting, Dr. Lois Murray, the SHP chief medical officer and chair of the panel, tells the assembled leaders their charge. She adds that nationally, the trend toward pay-for-performance is increasing and that refusing to participate will result in the loss of business from the entire employer coalition. She invites the leaders to work with her to create the most meaningful, fair, and forward-looking pay-for-performance program possible. The leaders spend some time expressing their anger and frustration about the unraveling of medicine.
They voice their resentment about society's failure to appreciate the complexity of clinical medicine, and the failure of the public to recognize that professionalism has always been a sufficient safeguard for ensuring high-quality care. They recount a long list of methodological problems with comparing quality across clinicians and groups whose patient mix, they say, are too different to be compared, and for which, they hold, available data are highly inaccurate. Murray listens carefully to their concerns and lists them on a flip chart.
Over the next 5 months, the panel sketches out a program that incorporates findings from other communities. On the basis of the evidence gathered, they set realistic expectations for clinician performance, develop a communication plan, and begin to inform the practitioner community, allowing time for discussion and the expression of the natural emotions to surface as part of the process of introducing significant change. Listening, responding to the expression of feelings, respecting the turbulence engendered in change, and engaging partners as respected equals result in a program that is viewed by most clinicians throughout the IPA as acceptable.
The program is implemented later that year.
Pantrof and Slade, or Clinton IPA clinicians return to their practices and begin working to change processes and behaviors? Is there a theory of relationship-centered organizations and administration that can help guide their next steps? What does the research literature suggest about relationship-centered health care organizations and the extent to which clinician-colleague relationship quality contributes to organizational outcomes? Compared with the rich literature on clinician-patient relationship quality and its impact on outcomes, the quality of clinician-colleague relationships remains relatively unstudied.
The relative paucity of measures for evaluating clinician-colleague relationships and organizational culture signifies the fact that this area has largely been a blind spot in the health care quality field until recently. This assertion was widely interpreted to mean that improved technology and enhanced information infrastructures would be the solution to medical errors and the path to improving safety in health care.