On February 8th 2012, the Ontario Ministry of Health and Long Term Care issued an Action Plan for Health Care, subtitled “Better patient care through better value from our health care dollars.” On page 7 of the document the Ministry says “Our Plan is obsessively patient-centred.” The document explains this term by saying that Ontarians should have:
1. Support to become healthier
2. Faster access and a stronger link to family health care
3. The right care, at the right time, in the right place.
These directions are of course admirable, but why has it taken so long to set goals in Ontario for patient-centred care?
Barbara Balik from The Institute for Healthcare Improvement says that there are references to “patient-centred care” in the literature dating back to the 1950’s. One early prominent leader in the movement for patient-centred care was the Picker Institute which 24 years ago (in 1988) identified eight essential dimensions of patient-centred care including: access; respect for patients’ values and preferences; coordination of care; information, communication and education; physical comfort; emotional support; involvement of friends and family; and preparation for discharge and transitions in care.
My first experience with trying to implement patient-centred care was when I was CEO of Sunnybrook Health Sciences Centre in the mid 1990s. At Sunnybrook we implemented the Human Becoming Theory through the leadership of our Chief Nursing Officer, Gail Mitchell, who was a proponent of the nursing theorist Rosemarie Rizzo-Parse. Through the implementation of Parse’s theory, Sunnybrook patients were empowered by giving them greater opportunity and support in making choices about the care they received; in other words patients were asked to decide what they wanted from their care providers.
Also during that time at Sunnybrook we attempted to put into action the recommendations from the five years of research conducted by the Picker-Commonwealth Program for patient-centred care outlined in the 1993 book entitled Through the Patient’s Eyes. As suggested in that book, we conducted extensive patient surveys and designed our staffing models and care processes more in response to the way patients said they wanted them to operate. For example, we attempted to have fewer staff come into contact with individual patients so that the ones that did spent more time with patients thus increasing continuity of care.
But we were just a hospital and our changes ended at the hospital walls. The highly fragmented structure of the Ontario health care system made (and still makes) achieving patient-centred care across the continuum quite challenging. Individual hospitals and other health care providers today are working diligently on their versions of patient-centred care but overall there has been limited inter-organization collaboration on these activities.
The government has begun to provide leadership on patient-centred care only in recent years. They initially focused on access to care with a wait time strategy and the creation and expansion of new primary care models. Later they put a focus on quality with the Excellent Care For All Act (ECFAA). ECFAA contains some essential elements for patient-centred care including: annual quality improvement plans which are publicly reported; patient/client/caregiver surveys to assess satisfaction with services; declaration of values that will be developed after public consultation; and patient relations processes to address patient experience issues. However, at this time ECFAA still only applies to hospitals so true patient centred care across the continuum is elusive.
I welcome the recently published Ontario Action Plan for Health Care and I welcome that the government says that it is “obsessively patient-centred”. The Plan still needs a lot of fleshing out of its detailed actions and it still needs greater quantification of its performance goals and targets. Nevertheless, it exists! I cannot remember when the Ontario Government has issued such a plan in all my years working in this sector.
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Thanks, Tom, for both the historical perspective and the update on new government initiatives in Ontario. I am involved in some initiatives related to advancing patient-centered care and patient engagement in the chronic dialysis patient population – and find it to be difficult work. Patients require much education on their potential role as ‘partners’ in their care; physicians and staff require much education and training also. At the operational level, I am finding that a measured, incremental approach to implementation of patient-centered care and patient engagement initiatives is best. After all, this is really about culture change, which we all know takes a long time.
Thanks once more. I enjoyed the post.
Tom – great commentary on patient centred care and your experience with it at Sunnybrook.
I think we are seeing slow steps because we don’t know or are afraid of the implications of what patients want. And sometimes what patients expect from the system in general can mean a better patient experience but at the same time reduce system effectiveness/efficiency.
Finding the balance between patient specific desires and the expectations of system performance/access/availability become crucial. For instance, your example of fewer staff involved with individual patients was important in the hospital, however at the primary care setting, the emphasis is on team based care with the patient seeing the right member of the care team depending on the problem of the day. Reconciling differing needs will be a challenge.
I thank you for this though. I think it is time for primary care reform – so that patients are matched with the right provider, that providers are properly coordinated for care provision and call services, and that access standards are met as examples.
Thanks!
What a thoughtful look at the evolution, and challenges, of patient based care in Ontario. Thanks for sharing!
Marci O’Connor
Better Care Faster
Community Manager
bettercarefaster.ca
To move forward it will be important to establish a specific time frame and credible process for defining the measurable goals prior to implementation in order to adopt patient centred care into day to day practice across the continuum of health services. This will be particularly important during an extended period of constrained budgets to counter a tendency of retrenching into familiar and established practices.