Patient-centered approaches have been shown to improve health status, patient compliance and outcomes, and even reduce the cost of care. Yet, not many hospitals would claim, at this point, that they are truly patient centered.
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Patient-centered approaches have been shown to improve health status, patient compliance and outcomes, and even reduce the cost of care. Yet, not many hospitals would claim, at this point, that they are truly patient centered. Patient centeredness can mean many things: new care delivery models, engaging patients in their care, and on a larger scale, building a "patient-centered culture."
Before we can change culture, we need to know what it is. Organizational culture is difficult to define. A commonly accepted definition was provided by Edgar H. Schein, the organizational psychologist who wrote the 1992 book, "Organizational Culture and Leadership,"
"A pattern of shared basic assumptions that the group learned as it solved its problems...that have worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems."
Geert Hofstede, the influential Dutch researcher in the field of organizational culture, defined it more simply as: "The collective programming of the mind that distinguishes the members of one organization from others."
It's not a program. It's not a mission statement. Culture is the way the organization thinks and feels about its purpose and its function, and how it goes about solving problems and fulfilling that function. It's a shared belief system among all of its members that influences how they behave. So, what does it mean to have a patient-centered culture?
The Institute of Medicine defines patient-centeredness as healthcare that establishes a partnership among practitioners, patients and their families to ensure decisions respect patients' wants, needs and preferences and that patients have the education and support they need to make decisions and support in their own care. This "encompasses qualities of compassion, empathy and responsiveness to needs, values and expressed preferences of the individual patient."
A patient-centered culture is one where the organization thinks about its purpose and fulfills function in the context of this definition. Rather than merely treating illness, it does so in a way that respects and reflects the patient's needs. This includes the concept of the patient experience, but is not the same thing as "patient satisfaction." In fact, the relationship can be defined by the idea that to improve patient experience, hospitals need to create a patient-centered culture founded in principles of compassion, service and high quality.
Why is it so difficult to change culture?
Why do organizations struggle so mightily to change culture? Part of the problem is that in healthcare, what we call culture is often too theoretical — healthcare is stuck at the "vision" stage. We've failed to define how the culture will manifest itself. How do we "operationalize" culture? What does it mean to actually be patient-centered?
An important point of clarification is that "culture programs" and long-term culture change are two different things. The former promises quick results, the latter is about long-term process and behavioral changes that result in a steady and sustainable shift in thought and practice. This shift is manifested in everyday decisions, including how we look at talent. Organizations that hire a candidate out of desperation to fill an open position, or keep a technically proficient employee who is not patient-focused or adaptable, are making conscious decisions that shape their culture.
The role of behaviors (vs. process)
Behaviors — behaviors that are reflective of a culture — have real and significant impacts on healthcare outcomes. For instance, it's been shown that cultures that tolerate disruptive behavior, or don't sufficiently emphasize behaviors such as commitment and accountability, negatively impact patient safety. Alternatively, patient safety is positively impacted by a culture that values communication.
How does culture influence the work? How does the culture manifest itself? How do we link culture to behaviors and outcomes? What behaviors are important?
Here's an example: A hospital struggling with patient satisfaction scores had nursing experts observe the behaviors of the nursing staff. They concluded that the hospital did not, in fact, have a patient-centered culture. Rather, the consultants identified the culture as "nursing-centric." The observed behaviors of nurses, by and large, reflected the needs of nurses. The organization of their work and responses to situations were built around the most efficient completion of nursing tasks, without sufficient consideration of the needs of patients — a perfect example of behaviors that make up the culture.
What behaviors, then, correlate with a patient-centric culture? In the world of industrial organizational-psychology, we think about "behavioral competencies." These are the behavioral "skills" displayed by successful individuals. In our experience, thinking about the definition of patient-centeredness, these are some of the many critical competencies:
- Compassion and empathy. Individuals need to be driven by how much they care about patients and their well-being.
- Emotional intelligence. Compassion without the emotional intelligence to understand a patient or the family's needs is of little value.
- Communication. Among providers, patients and their families, the desire to communicate and the ability to do so are critical.
- Collaboration. Providing patient-centered care requires coordination of people and resources.
- Adaptability. This is critical — first to appreciate the need to change the culture, and second, to be able to modify behaviors to meet patients' needs.
Something a bit unique to healthcare is that some of the competencies we are looking for are sometimes in conflict with traditional healthcare organizational culture. For instance, collaboration can conflict with a culture that places an unhealthy value on professional autonomy.
The impact of talent strategies
The National Center for Healthcare Leadership recently presented results of a study showing that deliberate and progressive talent strategies impact quality of care and culture. Competency-based interviewing, leadership learning programs aligned specifically with the organization's strategic goals, managers held accountable for the development of their direct reports and 360-degree feedback used for administrators, physicians and nurses all correlated with improvements in core organizational performance measures.
No department has a greater influence on setting the tone of a culture than human resources. The staff's attitude toward safety, change and the ability to remain steadfastly focused on the patient and family experience starts with the ability to attract, select and retain the right people, and the ability to successfully and consistently train them on the behaviors that contribute to the desired culture. Similarly, performance management programs need to reward these behaviors.
Healthcare has been challenged in this regard. The traditional focus on academic, clinical and technical experience and skills (while important) has stifled the development of progressive, "culturally-focused" talent strategies. Even some sophisticated and successful healthcare systems only recently brought HR to the senior team, or recognized that HR — rather than an administrative department — is key to achieving organizational goals. Many only recently began to create specialization within HR, particularly for talent acquisition and organizational development.
Keys to success
Building a patient-centered culture is a long term, complicated project, but here are a few keys to success.
1. Senior leaders need to understand what culture change is and place the appropriate value on the behaviors that contribute to that culture. Leaders need to model the behaviors that embody the values of that culture.
2. Managers need to understand what culture change is and why it's necessary. They need to go beyond the traditional "administrative" role of most managers and appreciate that developing a patient-centered culture is not merely another task, but their primary purpose.
3. Similarly, front-line staff must understand why changes are necessary. Imposing new, supposedly patient-centered, processes will fail if staff don't care about the patient's experience and needs.
4. Leaders, managers and front line staff need a structure and tools that support these efforts, including:
- Clear definitions of the behaviors that are expected, those that support the desired culture. These need to be clearly communicated to front-line staff, nurses, managers, physicians and leaders.
- Hiring tools including structured, behavioral interviewing and behavioral assessments at all levels of the organization, which provide the ability to evaluate these behavioral competencies in candidates.
- Efficient and effective 360-degree evaluations.
- A performance management system that considers and reinforces the desired behaviors.
- Ongoing, consistent training on patient-centered behaviors, including tools that provide insight into individual strengths and weaknesses so that staff can modify behaviors to improve patient and colleague interactions.
Conclusion
Patient-centered care is not a program. It's not something a hospital does in addition to providing care. A patient-centered culture incorporates the patient's needs into every strategy, project, task, solution and thought process. Culture change doesn't happen by chance. It's the result of a consistent focus on the behaviors that make up that culture. This includes deliberate talent strategies that support a patient-centered culture.