Healthcare like all other industries is a victim to fads & slogans. Fads come and go, and some linger for longer than others. In Asia there is one slogan that is prevalent across countries – that of “International Standard Care and Service” (国际标准的医疗及保健服务). Therefore, many hospitals will advertise that they provide international standard care to attract patients, but what actually is this? I will address that answer in another post. The purpose of today’s post is to discuss another related and extremely common slogan that is a current fad for hospitals in China and which is used extensively in their marketing material, that of “Patient Centered Care” (“以人为本“的服务, 以患者为中心的医院).
What really is patient centered care? This is one of those phrases which sounds like the right thing to say, is very “airy fairy”, is great to use in marketing, but when one stops to deeply consider what it actually means can struggle to define it. When I hired for senior management positions I would always ask the candidate to first define for me what “international standard care” means. Invariably the candidate in answering the question would include “providing patient centered care”. So, then I would ask them to define patient centered care. Without exception, the candidate would hesitate, then after some seconds, say “put the patient at the center”. When asking them to expand on exactly how that would happen the candidate would have no answer.
This notion of patient centered care is not a new concept in China. There is a good post here discussing how 全心全意为人民服务 was used 60 years ago and that today many hospitals will use different phrases which mean the same thing, i.e. Patient Focus, Patient Centric, Patient Benefit, Patient Engagement, Patient Empowerment, and Shared Decision Making. So, what is patient centered care? Let’s review some studies done on this topic.
Edvardsson, Watt, and Pearce (2017), examined how patient ratings of perceived caring and person-centeredness are associated with perceived nursing care quality in an acute hospital, and found that patient experiences of caring and person‐centeredness are associated with perceived nursing care quality. In this research patient centered care in nursing was noted to include aspects that include care that safeguards patient dignity and autonomy as well as inviting and respecting shared decision‐making, choice and control. The study used patients from 13 inpatient wards at a metropolitan tertiary acute‐care hospital in Victoria, Australia, where a consecutive sampling procedure was used to recruit patients admitted to any of the participating 13 wards during 2 weeks in December 2012. The main findings of this study were that the caring behaviors of staff were directly linked to the manner in which patients experience quality of nursing care. However, we need to keep in mind that there were several limitations to this study, being that it was done at a single hospital site in Australia, the method of data collection was through self-reported questionnaire with just a 40% return rate – i.e. perhaps those with a positive experience were more motivated to self-report; and the survey was carried out over 2 weeks in December when perhaps the impending Christmas holiday may have had an effect on participants’ perceptions (i.e. more positive).
I’ve found that many organizations will point to implementation of a quality management system (such as Joint Commission Accreditation & DNV-GL) as proof of providing patient centered care. However, is this association valid? You may be surprised to find that it is not according to a study by Groene et al. (2015) which reported “Patient Experience Shows Little Relationship with Hospital Quality Management Strategies”.
This study focused on determining the relationship between quality management and patient experience with care. The study was based on the increased demand for use of patient reported experiences in determination of the quality of healthcare offered today. I think we would agree that the factor of a positive patient experience is key to the definition of patient centered care.
The study was undertaken from randomly selected hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study. The main pathways used to contribute to the data in the study included acute myocardial infarction, stroke, hip fracture and deliveries; while outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. The research found there was an absence and wide variation in the institutionalization of strategies to engage patients in quality management or implementation of strategies to improve patient-centeredness of care.
What does this mean? It shows a direct gap in Quality Management Systems (QMS) whereby patient-centered care is not yet sufficiently integrated into quality management. This is important because quality management integrating patient centered care is likely to lead to better reported patient outcomes and healthcare ratings, as patient centered care will be ingrained within a system’s internal operational systems and processes meant to enhance efficiency and effectiveness. Another possible gap, and which this study lists as a limitation, is that the research used a cross-sectional study design which does not conclusively establish causality between the variables under study. Further, of the 548 hospitals approached to participate in the study only 192 agreed. Perhaps the hospitals that agreed have CEOs who are more proactive and have more confidence in their quality management system (or the opposite), thus it may not be a true representation? This risk of self-selection is noted in the study. The researchers also noted that a reason for the unexpected results may be due to strategies to improve patient-centeredness being within other departments such as patient complaint programs, which were not covered in the study.
So, should we determine from the study above that implementation of QMS does not assure patient centered care? Not according to a recent study by Hijazi et al. (2018) who determined participation in the accreditation process as the most important factor influencing patient centered care, as during the accreditation process the conduct of leaders and participation of staff in the process led to enhanced organizational operations directly impacting patient care, thus improved patient centered care.
Their study aimed to examine the impact of applying quality management (QM) practices on patient centeredness within the context of health care accreditation and to explore the differences in the views of various health care workers regarding the attributes affecting patient-centered care. This study was guided by the research questions: “What QM practices are associated with patient centeredness in hospital settings?”, “What is the relative importance of the QM practices that influence patient centeredness in hospital settings?”, “Are there any differences in the importance of QM practices that influence patient centeredness based on staff’s clinical and administrative functions in the hospital?”, and employed a cross-sectional survey design wherein 4 Jordanian public hospitals were investigated. Interestingly, the research determined participation in the accreditation process as the most important factor influencing patient centered care as during the accreditation process the conduct of leaders, and participation of staff in the process, led to enhanced organizational operations directly impacting patient care thus improved patient centered care.
I feel compelled to point out that I feel a major flaw in this study was that no patients were included in measuring patient expectations and satisfaction, with only hospital staff being interviewed. The authors themselves at the beginning of the paper even noted how the focus should be on the issues that patients value most rather than making assumptions on what they (the staff) value. However, strangely they then failed to check with patients on what they value the most. This was surprising given that the 3rd question in the questionnaire was “the hospital resolves patient complaints”.
As an aside, the authors noted that in Jordan “there is a lack of evidence that QMS accreditation provides any benefits”, and therefore attracts criticisms that it is costly and time consuming, leading to the research questions asked. The question of whether accreditation actually leads to improved profitability is one of the most common questions I am asked, and the reason why I am interested in doing some independent research in this area. It is very easy to find accreditation agencies claiming that implementation of a QMS will improve profitability, however I have found no independent research to support this claim. I can see the logic of why this would be the case (reduced errors etc.), and it would be good to test this hypothesis.
The Jordanian study showed that the QMS accreditation process could be what determines the impact certification will have on an institution (improved quality of care), rather than adoption of a quality management system long term. This anecdotally matches my experience with hospitals having a flurry of activity before a QMS survey to make sure that they have all the requisite records in place, and then defocusing once the survey is over. Therefore the positive impact on patients’ perception of “patient centered care” is temporary.
In looking at these recent studies regarding patient centered care I tried to find something specific to China, and discovered this study by Li et al. (2015) “Evaluating patients’ perception of service quality at hospitals in nine Chinese cities by use of the ServQual scale”.
The main objective of this study was an investigation of patients’ perception of service quality at hospitals in nine Chinese cities by use of the ServQual scale and proposed some measures for improvement. The main factors considered in the study of patient perception in this research included; Tangibility – things perceived by the five human senses; (2) Reliability – consistent performance, free of non-compliance; (3) Responsiveness – prompt and efficient voluntary response to requirements; (4) Assurance – ability of employees to convey trust; and (5) Empathy – provision of sensitive individualized care by the organization.
The results were very mixed. In some areas there was a positive perception on tangibles and reliability, while none in other areas. In some age groups (typically older) there was a positive perception on reliability, empathy and assurances than younger age groups (this may be because the older age group have very poor service in history as a comparison?). Some areas showed positive perceived service quality while others perceived poor service quality.
The study did conclude that due to China having a medical care system with three tiers covering rural and urban locations, resource allocation is uneven, with the best resources found in the city while community-based medical care systems have insufficient capacity to provide services; meaning they cannot properly fulfill the function of providing primary care.
I feel this research shows that while the variables under study are well thought out, the study identifies a shortcoming that the Chinese health care system is unequal where parts of the system do not have capacity to offer primary care adequately. This in turn implies that the results of this study are flawed because different tiers of the Chinese medical system were compared similarly.
Another potential flaw not addressed in the study was the actual return rate – i.e. it is not known how many questionnaires were initially distributed. If the return rate was low then this could introduce an error of self-selection (i.e. those patients with a positive experience may have been the ones who took the time to fill out the survey – or the opposite). I also believe there is some issue regarding whether some of the survey questions could have been adequately answered by patients, including “Hospital knows staff’s needs”, “Hospital pays attention to staff’s interests”, “Hospital can show concern for individual staff” etc. How would patients know about this? Another criticism is regarding the finding that “The hospital management should be professionalization” (sic). My experience in China is that this requirement of “professionalization” is something that many people will state (perhaps to be seen as saying the right slogan), but no-one will give a definition of what it actually implies. What does “professionalization” in the context of China healthcare administration really mean? The inclusion of such a statement and finding without a definition highlights another weakness in the study.
Frankly, the prevalence of “saying the right thing” is not uncommon in both the East and the West. There is a multitude of managers who know the right slogans or catch-phrases to say that they believe senior management wants to hear, and then immediately after the meeting go back to doing the same old thing.
Phew, you got to the end. Thanks so much for reading so far 😊. So, what do we conclude from all these studies? Some say that international accreditation is not related to patient centered care, and some say it is. While another study says that the process of accreditation and not the accreditation itself is the important factor regarding patient centered care. With all my experience in Asia & particularly China I believe that there is no quick solution to providing patient centered care, although many hospital owners demand such a thing. Patient centered care requires a change in organization culture, and as a previous boss of mine in Bangkok who I highly respect once said, “it takes 3 years to implement a culture change, and 7 years to make it permanent”. That is, it can be done but don’t underestimate the size of the task.
Providing patient centered care is multi-faceted, not only involving international accreditation, but also leadership style, the commitment of the owner (or the board if they have the power), the resources committed to the endeavor, the expertise (knowledge) of who is leading the change, whether they have authority, and their personal attributes. You need someone strong, knowledgeable, trustworthy, and able to surmount the hurdles which will inevitably be thrown up along the way.
Finally, without a doubt if you provide patient centered care then your customers will love you and be extremely loyal. Which is what we all are striving for. If you need any assistance in providing a patient centered care culture, please feel free to contact me.
As always feel free to let me know your comments on providing patient centered care. I’d love to hear them. Also, feel free to let me know in the comments any other subject regarding healthcare management in Asia that you’d be interested in hearing more about.
Edvardsson, D., Watt, E., & Pearce, F. (2017). Patient experiences of caring and person-centredness are associated with perceived nursing care quality. Journal of Advanced Nursing, 73(1), 217-227. doi:doi:10.1111/jan.13105
Groene, O., Arah, O. A., Klazinga, N. S., Wagner, C., Bartels, P. D., Kristensen, S., . . . Sunol, R. (2015). Patient Experience Shows Little Relationship with Hospital Quality Management Strategies. PLoS ONE, 10(7), e0131805. doi:10.1371/journal.pone.0131805
Hijazi, H. H., Harvey, H. L., Alyahya, M. S., Alshraideh, H. A., Al abdi, R. M., & Parahoo, S. K. (2018). The Impact of Applying Quality Management Practices on Patient Centeredness in Jordanian Public Hospitals: Results of Predictive Modeling. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55, 0046958018754739. doi:10.1177/0046958018754739
Li, M., Lowrie, D. B., Huang, C.-Y., Lu, X.-C., Zhu, Y.-C., Wu, X.-H., . . . Lu, H.-Z. (2015). Evaluating patients’ perception of service quality at hospitals in nine Chinese cities by use of the ServQual scale. Asian Pacific Journal of Tropical Biomedicine, 5(6), 497-504. doi:https://doi.org/10.1016/j.apjtb.2015.02.003