The document discusses strategies for improving patient-centered care. It focuses on ensuring patients feel oriented, informed, and involved in their care. This includes introducing all medical staff, explaining plans in plain language, checking for understanding, keeping patients updated on delays, allowing them to explain concerns, and setting clear expectations for next steps. The goal is for patients to understand their care and feel their needs, preferences, and questions are being addressed.
3. Patient-centered care
Understanding and responding to the needs
and preferences of our patients
Challenging
a national dilemma
an NYP issue
sometimes daunting for house staff
Requires a collaborative response
4. POTHOLEs in patient-centered care
P PAY ATTENTION
ORIENT PATIENTS
O
AND FAMILIES
TEST
T
UNDERSTANDING
HUMANISM – BE
H
KIND
O ON-TIME CARE
LET PATIENTS
L
EXPLAIN
EXPECTATIONS –
E WHAT SHOULD
PATIENTS EXPECT?
5. Is there time to do this?
Possibly
Famous study by Beckman, et al. (Ann Intern
Med 1984;101:692-696): on average,
physician interrupted patient 18 seconds into
the encounter
For the minority of patients (23%) able to
complete their initial responses to the
physician, the longest was 2.5 minutes
Small investments in time spent with patients
may have enormous value to them, may
improve clinical outcomes, and might save
time later
6. PAY ATTENTION
1. Meaningful listening
Giving the patient your full attention
Eye level, eye contact
Sit when you can
The opposite of multi-tasking
7. PAY ATTENTION
2. Discharge Time Out
Protected time with patient (and nurse if possible)
involving active verbal communication about
discharge plans, meds, follow-up
Be clear with details
Gauge patient understanding
8. ORIENT PATIENTS AND FAMILIES
1. Introductions
Include everyone: glossary of providers and who’s in
charge
Medical student: student doctors in their 3rd or 4th year of
medical school who help us to take care of patients as they
learn
Intern: a doctor taking additional training in _____
Resident: a doctor taking advanced training in _____
Attending: a senior (faculty) doctor in our department who
is in charge
Fellows, consultants
Nurses, social workers
“Ranking of physicians is very confusing - should explain
what resident does, senior resident, attending. Also where
fellow fits in. Also who is what. Also medical students.”
9. ORIENT PATIENTS AND FAMILIES
2. Rhythm of the ward/service
Who does what with patients when
e.g. the medical student and the intern will check in on
you first thing in the morning, usually about 7 am; then
we’ll come by as a team for a few moments to assess
you and your progress between 9 and 10; Dr. Xx will
stop by at other times to check on you; and we’re all
available if something comes up
10. TEST UNDERSTANDING
1. Explain without jargon
“Her crit was falling; it could be dilutional but we’re not sure, so we
want to give her 2 units of packed cells.”
Better:
“Her hematocrit value dropped; it may be from the fluids she
received, but just to be safe we want to transfuse 2 units of red
blood cells.”
Even better:
“Her red blood cell count decreased. This may be due to intravenous
fluids we gave her to maintain a safe blood pressure. I’m
making sure she’s not losing blood, but to be safe I’d like to give
a transfusion of 2 units of blood.”
11. TEST UNDERSTANDING
2. Solicit questions, understanding
Does that make sense?
What questions do you have for me?
I want to be sure I was clear and explained this to
you
Can you tell me in your own words what you
understand (or will do… or how you will…) [called a
teach back]
“They started explaining a few days before discharge to make
sure I felt ready.”
12. HUMANISM – BE KIND
1. Adult-to-adult amenities or age appropriate, for
Pediatrics
Common courtesies – knocking on door, may I
come in?, introductions/reminders
Greetings – Good morning, Mrs. Smith
Providing privacy and modesty – closing doors and
curtains, arranging bedclothes and sheets
Providing/restoring comfort and convenience – e.g.
call button, lights (on/off), bedside table, phone, TV,
food tray in reach
“Didn't love the wake up call by a group of residents. They need to
learn how to knock on a door.”
13. HUMANISM – BE KIND
2. Empathize
empathy: understanding another person’s
viewpoint, and appreciating that person’s feelings
practical steps to empathic communication:
awareness and inquiry: what is the patient feeling?
acknowledgement: you might feel…, it may be…, it
seems that…, I wonder how…
appreciation and affirmation: I know that…, I
appreciate that…, you are…
not intervention or remediation of feelings
14. ON-TIME CARE
Understandably, often challenging for house
staff who may themselves be at the mercy of
hospital staff and the processes and the
delays they cause
But, several strategies may mitigate these
effects for patients
15. ON-TIME CARE
1. Realistic timelines
don’t be vague
try to provide timely visits, interventions and care to
patients, but provide them with realistic
estimates, often involving a range of times
“Doctor said he would visit before discharge. He didn't visit and
then discharge was extended for hours without being seen.”
16. ON-TIME CARE
1. Update, empathize
keep patients informed of delays (they are reassured
if they know you know; more reassured if they know
you’re trying to expedite)
if you cannot expedite, acknowledge their
frustration, re-affirm your commitment to their care
17. ON-TIME CARE
1. Update, empathize
keep patients informed of delays (they are reassured
if they know you know; more reassured if they know
you’re trying to expedite)
if you cannot expedite, acknowledge their
frustration, re-affirm your commitment to their care
“Doctor said he would visit before discharge. He didn't visit and
then discharge was extended for hours without being seen.”
18. LET PATIENTS EXPLAIN
1. Open-ended inquiries
What do you think is going on? …causing this?
What do you think would help?
What are your preferences? …goals? …plans?
2. Is there anything else?
“getting the patients to feel comfortable that they have the
right to ask questions and confirm whatever the doctor is
saying within their own mind that this is what is supposed to
happen”
19. EXPECTATIONS: WHAT SHOULD PATIENTS
EXPECT?
1. What happens next
Short-term previews, e.g.
You’ll get an intravenous antibiotic and we’ll check your
blood counts and your lung exam over the next couple of
days
We’ll arrange for a CT scan of your abdomen and if it
shows XXX we’ll discuss the need for surgery with you
You should fill this prescription to continue prednisone for
another week, continue the other medicines you were
taking at home, and you will see Dr. Doomuch next week
on Tuesday.
“Doctor visited me early in the morning before my
discharge. He was very informative & friendly!”
20. EXPECTATIONS: WHAT SHOULD PATIENTS
EXPECT?
2. Coordinate/corroborate/explicate/equivocate
try to coordinate plans with attendings, nurses, social
workers, etc., before briefing patient
if the patient (or other team members) have a different
idea or preference for what will happen, try to check it
out without dismissing the patient’s perspective
try to be specific in outlining plans, especially at
discharge (and test understanding with teach back)
if you’re not sure (about
diagnosis, interventions, discharge plans), it is okay to
say so
Notes de l'éditeur
Potholes are usually something to be avoided. But now (click) they are also a mnemonic for things we would always like to include in our interactions with patients, especially at admission and discharge (or at the beginning and end of episodes of care [for those residents who do not have primary responsibility for hospitalized patients]). These are our Always Events – [read list]
Analogous to a surgical time-outa "time out" immediately prior to all invasive procedures with active verbal communication between all members of the surgical/procedural teamReview the written instructions with the patient and make sure the patient follows along with youAsk patient to repeat important instructions back to youAsk patients if there are questions (see Test Understanding)
- May also include nursing and social work
- How do you reach your doctor(s)?
- Among the most frequent patient dissatisfaction comments were those that reflected distress when team members gave patients different or conflicting information