Patient- and Family Centered Care: "Resident Performance from the Patient's View"

Patient and Family Centered Care (PFCC): Lessons from Graduate Medical Education

Medicine Grand Rounds March 15th, 2011

Richard M. Wardrop III, M.D., Ph.D.WakeMed Faculty Physicians

Disclosure

• I had grant support to perform research from the Picker Institute and ACGME

• I currently serve as an external reviewer to the Picker Institute and their challenge grant program

Full Disclosure - My Research Focus

Then Now

Objectives

Introduction• Review what PFCC is• Review history of PFCC• Give resources for PFCC

practice• Show examples of

successful implementation of PFCC in GME and beyond

Research• Share some data from

my experience at Carilion– Mixed methods project

• Speculate on what we can do here in PFCC and in GME

Background Setting

• The PFCC movement is enormous

• There is no fixed history

• Multiple players on multiple levels

• The work of others is very humbling

• Just good medical practice?

• We have to start somewhere….

How can I get you to practice PFCC?

• Patients like it?• Patients feel

empowered?• It saves money?• It leads to safer care?

• It does not cost anything extra?

• Anyone can do it?

We are (I was 2008 – 2010)…..Carilion Clinic

• 500+ physicians in a multi-specialty group practice and eight not-for-profit hospitals.

• Specializing in patient-centered care, medical education, and clinical research.

What is PFCC?

• “Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care patients, families, and providers.”

• “Patient- and family-centered care applies to patients of all ages, and it may be practiced in any health care setting “

www.familycenteredcare.org

Core Values of PFCC

• Dignity and Respect• Information Sharing • Participation • Collaboration

Core Values of PFCC – Picker Institute

• Respect for patient values, preferences, and expressed needs

• Coordination and integration of care

• Information, communication, and education

• Emotional support and alleviation of fear and anxiety

• Inclusion of family in care

• Transition and continuity

• Physical Comfort• Access to care

www.pickerinstitute.org

Core Values of PFCC

Belief oriented….Planetree Foundation• that we are human beings, caring for other

human beings• we are all caregivers• care giving is best achieved through kindness and

compassion• safe, accessible, high quality care is fundamental

to patient centered care• is a holistic approach to meeting people's needs

of body, mind and spirit• families, friends and loved ones are vital to the

healing process

Core Values of PFCC

Belief oriented….cont• access to understandable health information can

empower individuals to participate in their health.• the opportunity for individuals to make personal

choices related to their care is essential• physical environments can enhance healing,

health and wellbeing• illness can be a transformational experience for

patients, families and caregivers

www.planetree.org

Pause

Pause…. Are you saying…. • “I agree with that – why do we need to

hear this?”• “I already do all these things…I’m good”• Or are you saying “I want to do more but

the system won’t let me….”• “I’m to busy to worry about this…..” • Out of respect for my audience… welcome

your thoughts

Brief History of PFCC – Divergent Events / Efforts Converging on a point….

• Started with the Planetree Foundation in 1978

• Had many roots in pediatrics and HIV/AIDS population

• A system in need of major change – Institute of Medicine Reports and C.E. Coop

Brief History of PFCC

• The Institute for Family Centered Care

• Picker Institute for Patient Centered Care

• Center for Patient and Family Centered Care - MCG

• National Priorities Partnership– AHRQ, CDC, CMS,

IOM, Joint Commission and 20+ others

– Defined Priorities in Patient Care – many of which adhere to PFCC principles

www.qualityforum.org/about/npp

Brief History of PFCC

• Other Organizations involved with guidelines or statements– SCCM– ABIM– American Hospital

Association– American Academy of

Orthopedic Surgeons– Countless medical centers

recognized

Resources

• Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices

– free 178 page document

• Supported by RWJ• Other titles available

from evidence based architecture to bibliographies for resources and referenceshttp://www.familycenteredcare.org/resources/other/index.html

Resources

• Picker Institute– Picker Surveys– Challenge grants– Profiles of

successful Centers– Downloadable

seminars and workshops

– Other grants and resources

http://www.pickerinstitute.org/Research/pickerchallenge.html

Reading and Resources for GME

• GME Assessment and Tips

• Books• Downloads….from

ABIM• http://www.abimf

oundation.org/

Making it real…..

• Real examples from a large teaching institution……

Beacon of PFCC

• Medical College of Georgia

• http://cpfcc.org• Started movement in

1993 by including patients in design of Children's Hospital

• In 2002 set behavioral standards for all staff

MCG – UME and GME

Since 1993• Institutional

commitment to change clinical environments to PFCC

• Developed family faculty for patients and families to serve as expert advisors and teachers

• Foster resident involvement with family and patient advisors

• Create opportunities that allow residents to apply this to their practice

• Developed standards for how teaching rounds will take place

MCG – UME and GME

• Involve patients and families in faculty and resident recruitment

• Integrate patients and families into research efforts

• Teaching examples at MCG– MS Clinic– Behavioral Health– Cystic Fibrosis– Family Medicine

Clinic– Cancer Center– Peri-natal clinic

• Research– ePHR HTN project

Relating ACGME Competencies to PFCC at MCG in GMECore Competency PFCC Principles

Patient Care Forming collaborative partnerships with patients and families

Medical Knowledge Know or be familiar with PFCC literature

Practice-based learning and improvement

•Working with patient on chronic disease management•Working with PFCC advisors

Interpersonal and Communication Skills

•Engaging in a two way dialogue with patients

Professionalism •Introduction 100% of time•Timely information that is useful and accurate•Respect for privacy

Systems based practice Health care team includes patient and family

PFCC Success….in a clinical unit

Neurosciences Center of Excellence - at MCG: PFCC experience– Patient satisfaction 10%-95th%tile– Length of stay on Neurosurgery

decreased 50%– 62% decrease in medication errors – Staff vacancy from ~8% 0% (wait list)

MCG Institutional Improvement?

• Increased / Improved– Patient satisfaction– Clinical quality– Payer mix– Market share– Profitability

• Decreased– Malpractice claims

Show me the Money!

Featured in PBS Documentary – Remaking of American Medicine

Summary

• PFCC has a 30 year history at least

• At its deepest levels, we probably all agree with it

• Differences are in the execution

• Research exists• Success stories exist• Real improvements

in a medical center can happen

• It can not only co-exist with GME but also drive GME

Resident performance from the patient’s view: A novel prospective assessment of performance and performance improvement in delivering patient-centered care

A common motivating theme is some experience…..• Dr. Harvey Picker – Picker Institute

• Angelica Thieriot – Planetree

• Me – what got me interested?

Grand Parents and Parents

The questions I started having as I started at Carilion• Should doctors finish training without

getting feedback from patients?• If we give them feedback will they be

better in cultivating good communication and productive relationships with patients and families?

Medical Educators – Patient Care, Supervision, Teaching, and Feedback

The Problem

• As a young attending I felt a few pieces of information were missing as I went to fill out the ACGME competency based evaluations….

The Art of Feedback

• Make observations and collect facts

• Time and data dependant

• Need a framework to standardize feedback

• Provide a mirror image

The Problem

• It occurred to me during my 7th or 8th two week block…– when a patient fired

one of the residents I was supervising and

– then a nurse complained about a different resident

– then a patient gave the same resident praise….

• I was not really sure what was going on between the residents and patients when I was not around to observe them.

What to do?

• Spying?• Using a wire tap?• Video taping?

• Interrogating the patients?

• Sneaking around?

What to do?

• Patient care is complex and emotional

• Supervising residents is complex

• There are only 24 hours in a day

• But I need to know!

What to do?

• Sentinel events (firing by patients, complaints, or praise) cannot dominate the entire recorded experience all the time….

• How to empower and enlists the patients in the feedback process consistently?

The Resources

• What did we have at our disposal to solve this problem...?

What we had experimented with….

How useful? Learner Centered? Patient Centered?

Evolved into this….

Learner Centered? Patient Centered?

Opportunity knocks…

• We had problem / hypothesis

• Call for grants from OSP

• Struck me at the right time

• I had time • We had core team• We had resources• There was money up

for grabs

Eureka! Make a new mousetrap…

• Ask the patients anonymously about the residents using a survey

• Make it competency based

• Make it portable• Make it easy

• Distribute it to everyone

• Share the feedback with the residents

Make a new mousetrap…

• Most of all make it patient centered

Hypothesis and Aims

• Hypothesis - the regular use of the a patient-centered, core competency-based survey tool combined with specific learner centered feedback would improve the performance of residents in delivering patient-centered care when compared to the conventional practice of attending-only assessment and feedback.

Hypothesis and Aims

• AIM 1: To adapt the evaluation tool into a concise, valid and reliable instrument that enables patients assess resident performance on 4/6 ACGME competencies.

• AIM 2: To compare residents who receive feedback and coaching using the tool developed under AIM 1 to traditional attending-only assessment and feedback.

Picker Challenge Grant Program• Started in 2005 for

projects in 2006• 4 per year at

$25,000• Requires matching

funds (in kind)• 2008 cycle had 119

applications• Grants focused on

research in PFCC in GME

• Picker Principles• $50,000 total /

project

• Transitioning Adolescent Patients (TAP) from Pediatric to Adult CarePrincipal investigator: Emily von Scheven, MD, MAS, Pediatric Rheumatology, University of California San Francisco

• Improving Patient Rounds (IPR)Principal investigator: Walter J. Moore, MD, Center for Patient- and Family-Centered Care, Medical College of Georgia

• Patient-Centered Training of Residents on a Medical Ward Principal investigator: Robert C. Smith, MD, MS, Internal Medicine,EW Sparrow Hospital/Michigan State University College of Human Medicine

• Resident Performance from the Patient’s ViewPrincipal investigator: R.M. Wardrop, MD, PhD, FAAP, Director of Resident Research, Internal Medicine, Carillion Clinic, Roanoke, Va.

Our team upon receiving award

The tool

The tool – used by patients, residents and attending

The Picker Principles - Assessed

• Respect for patient values, preferences, and expressed needs

• Coordination and integration of care

• Information, communication, and education

• Emotional support and alleviation of fear and anxiety

• Transition and continuity

Hypothesis and Aims

• AIM 1: To adapt the evaluation tool into a concise, valid and reliable instrument that enables patients assess resident performance on 4/6 ACGME competencies.

• AIM 2: To compare residents who receive feedback and coaching using the tool developed under AIM 1 to traditional attending-only assessment and feedback.

End points

Quantitative• Reliable?• Valid and on how many

scales?• Measure performance• Effect on performance

when combined with feedback?

Qualitative• Patients appreciate?• Residents appreciate?• Comments have any

meaningful content?

Other measures

• Residents evaluate themselves in these patient centered domains

• Attending physicians evaluate residents in patient centered domains

• Conduct patient-centered interviews regarding the process

Study Design

Group 1(Usual

evaluation)

Group 2(Patient Centered evaluation + usual

evaluation)

Month 1

Month 1

Month 2 Month 3

Month 2 Feedback 2-1PERPS, AERPS,

RERPS

Feedback 1-1AERPS, RERPS

Month 4

Month 3 Month 4

Feedback 1-2PERPS, AERPS,

RERPS

Feedback 2-2 PERPS, AERPS,

RERPS

End

eva

luat

ion,

cor

rela

tions

Attending Intervention – provide usual coaching

Study Attending Intervention – provide usual coaching +

coaching derived form PERPS)

Study Attending Intervention – provide usual coaching +

coaching derived form PERPS)

Study Attending Intervention – provide usual coaching +

coaching derived form PERPS)

July 2008-June 2009

Study Design

Patient Questionnaire Distribution

Patient Evaulation of Resident Performance2380

1160

535

0

500

1000

1500

2000

2500

YTD Jul 08-Jun 09

Nu

mb

er

of

Su

rve

ys

Printed

Distributred

Collected

Patient Questionnaire Collection

Patient Evaluation of Resident Performance Surveys

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12 13

Academic Block

Nu

mb

er o

f S

urv

eys

Printed

Distributred

Collected

We did the unthinkable…

• Selected patient interviews by study faculty

• To focus survey• Have patients tell

us what the questions mean to them in their own words.

Patient Interview Data

14%

80%

7%

Is the writing on the survey too small?

YesNoMaybe

Patient Interview Data

7%

80%

14%

Are the words too difficult to understand?

YesNoMaybe

Patient Interview Data

74%

20% 7%

Is there enough room for comments?

YesNoMaybe

Patient Interview Data

80%

14% 7%

Do you like the idea of giving feedback directly to your doctor?

YesNoMaybe

Patient Interview Data

94%

7%

Will this process provide better patient-centered care in the future?

YesNoMaybe

Scale Validity and Reliability

Reliability (consistency)

• Consistency in the ratings on any measure is important

• Differences in rating not due to chance

• Measure Chronbach’s Alpha across all raters and ACGME domains

• All were >0.75 indicating the scale and the raters were using it consistently

Validity (accuracy)• Assessing validity determines

whether or not the survey is measuring what it was intended to measure

• The instrument had built-in content validity

• Structural validity testing only found 1 valid scale with no subscales (patients and attending rated with little variability between domains (good in one good in all)

Sample Comments from Patients (over 300 written)The good• “I know this looks like we just circled

all 5's but Dr B. truly met all of them. Our family was REALLY impressed with Dr B. of all the doctors we have seen. He stands at the top.” +/PC/ICS/P

• “Dr T shows great leadership, he is a listener and very helpful to me about getting to the problem and ruling out disease and ordering tests and explaining special tests. He LISTENS. That smile also will take him a long way. I'm glad he was on my team of recovery. My heart goes (out to him).” +/P/PC/ICS

• “Very compassionate, caring and professional. Takes time to listen to pts. (the resident) explained everything to myself and family in layman's terms to understand. Excellent Dr. Wish him success in the world. Thanks for excellent care.” +/PC/P/ICS

Other• “He (the resident) seems caring

my only problem is its hard to understand his when he's talking. Otheriwise he seems OK. I've only seen him once since my husband's been here. Everyone else has been very good to him.” +/-P/ICS

• “No contact. I have been in the hosp for over 35 hrs in this 3 day stay and never spoke with this Dr. (written by wife)” - P/ICS

Content of Comments from Patients (n=100)

Quality and Content of Random Patient Comments

0102030405060708090

Positive Negative No value Patient Care Systems-BasedPractice

Patient Care Interpersonaland

CommunicationSkillsQuality of Comment or Compentency

Nu

mb

er

of

Co

mm

en

t

Number of comments

Content of Comment

Next Phase – Learner Feedback

• Standardized• Scripted• Based on scores

from patients, self, and attending

• Open ended and closed ended questions

Resident Reponses to Feedback

0 2 4 6 8 10

Do you like the idea of receiving feedback from your patients?

Patient comments vaulable to you?

Will this process provide better patient-centered care by you?

Will this process lead to better patient centered care f rom physicians in training?

Resident Opinion about Feedback from Patients

Maybe

No

Yes

Resident Reponses to Feedback

0 2 4 6 8

Is the writing too small ?

Are the words to diff icult to understand

Are there enough room for comments?

Number Respondants

Resident Opinion about Survey

Maybe

No

Yes

Sample Resident Comments

Name two distinct things you learned from this process about yourself or about how patients view you.

• “I thought the patients would be more concerned with my medical decision making”

• “glad to know I helped my patients so much – it makes it easier to work so hard knowing this”

• “Patients value giving input into care”• “Patient’s know what is going on with

their care”• “It was more positive than I

expected”• “the patients view me more favorably

than I thought”• “I am my own worst critic”• “Patients think I am a great doctor”• “I need to interrupt patients less”

What one thing will you commit to change because of this process?

• “more discussion of the plan with patients or family”

• “I will stop interrupting patients so much”

• “Maybe going back to round on my patients in the afternoon (to update them)

• “trying to better incorporate patient preferences into management”

Comments and suggestions?• “Get as many back from patients as

possible to assure accuracy”• “Worried attending physicians may

not be best to hand out the surveys may skew the results towards good evals to not get anyone in trouble”

• “Pleasant patients may get more attention”

• “Patients with multiple co-morbidities may not get a form as frequently and this could create bias”

Resident Performance – prior to feedback

No significant differences between groups prior to feedback

Resident Performance – prior to feedback

No significant differences between groups prior to feedback

Resident Performance improved when associated with having received feedback – communication, patient care, systems based practice

*

*

*

*

*

Challenges for prime time use

• Curriculum• Making sense of the

data• Validity and reliability

testing in your populations

• Survey collection and distribution

• Finding meaning in the non-numerical data

Conclusions

• Patients provided regular feedback using the instrument and scales

• Patient appreciated providing feedback• The survey was reliable and valid. Scale

validity for one scale• Providing feedback during the year

improved performance of residents in the patients’ and the attending physicians’ “eyes” in several areas

Conclusions

• Patients regularly provided qualitatively rich and competency-based feedback

• Residents appreciate the feedback from the patients

• They feel it helps direct them for self- improvement in these areas

Implications for WakeMed

• Use these resources / ideas at your own level– Hospitalist face-

card• Do what you do only

potentially change focus – PFCC rounds on

Pediatrics– Stroke Rounds with

MD• Know who else feels

this is important• Ideas?

Many thanks to….

• The Picker Institute• ACGME leadership and staff• Carilion Clinic• Our team• Our faculty• Our residents• Our patients

Core Study Team

– Richard M. Wardrop III, MD, PHD, FAAP, FACP

– Chad J. DeMott, MD, FACP – Jon M. Sweet , MD, FACP – Program Director– David Baker, PhD – Robert Herbertson, MS – Sowjanya Kolluri, MD– Roshan Bowansingh, MD– Study Coordinators

• Dawn Bowles, RN• Jacqueline Baker, RN

– Grant Management: – W. Eryn Perry

Thanks and Questions?

Selected Bibliography

1. Putting Patients First: Best Practices in Patient Centered Care, 2nd Ed. Susan Frampton and Patrick Charmel eds. Josey-Bass Publishers. San Francisco, 2008.

2. Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices Institute for Family-Centered Care – 2008. Available online at www.familycenteredcare.org

3. National Partnership Priorities Executive Report. National Priorities Partnership – at the National Quality Forum. November 2008. www.qualityforum.org

4. Synthesis of Definitions of Patient-, Family-, and Relationship-Centered Care. Amy Cunningham. ABIM Foundation. www.abimfoundation.org

5. Patient- and Family-Centered Care and Graduate Medical Education: A Primer. Beverely H. Johnson. Presented at 2009 ACGME Educational Conference, Grapevine, TX. www.acgme.org

6. Patient- and Family-Centered Care and Resident Learning. Patricia Sodomka. Presented at 2009 ACGME Educational Conference, Grapevine, TX. www.acgme.org

Selected WebBibliography

1. Extensive references for specific specialties in PFCC available at the Institute for Family Centered Care www.familycenteredcare.org

2. Planetree Foundation. All in one site with complete model and programs. www.planetree.org

3. Additional resources results, links, survey tools, description of challenge grant awards and results available at www.pickerinstitute.org

4. Center for Patient and Family Centered Care at UCG. Links, research in PFCC and GME research www.cpfcc.org