May 19, 2009
12:01 a.m. Eastern Time
"Patient-Centeredness" Matters In Its Own Right, Not Just As A Means To Other Quality Goals, Says Berwick
A Consumerist View Of Quality Of Care Would Require Radical Shifts Of Power From Clinicians To Patients, Leading Quality Improvement Expert Argues
Bethesda, MD -- Patient-centered care should be seen as a dimension of health care quality in its own right, not just because of its connection with other desired aims such as safety and effectiveness, Donald Berwick argues in an article published today on the Health Affairs Web site.
In an essay titled "What 'Patient-Centered' Should Mean: Confessions Of An Extremist," Berwick surveys the debate in the health policy community over how the principle of "patient-centeredness" should be defined and implemented. He offers his own definition of the term and spells out how his view would change the way the health care system operates.
"The concept of a medical home (a practice team that coordinates a person's care across episodes and specialties) is now reaching center stage in proposals for redesign of the U.S. health care system," Berwick begins his article. "The question remains open, however, about the degree to which medical homes will shift power and control into the hands of patients, families, and communities. In this paper, I argue for a radical transfer of power and a bolder meaning of 'patient-centered care,' whether in a medical home or in the current cathedral of care, the hospital."
Traditionally, the medical community has seen the question of patient-centered care through the lens of professionalism, says Berwick, the president and chief executive officer of the Institute for Healthcare Improvement in Cambridge, Massachusetts. In this framework, the medical profession possesses a special body of technical information beyond the reach of patients and others, and patient-centered care is important only to the extent that it furthers quality goals determined by the medical profession to be in patients' best interest. Berwick instead argues for a more "consumerist" approach in which the power belongs to the patient as customer, not to the medical profession as producer. An ideal medical practice, he says, would give patients not just what they "need," but also what they "want."
Patient Power: Trumping Hospital And Physician Prerogatives, And Even Evidence-Based Medicine
Specifically, Berwick defines patient-centered care as "the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care." He adds that in most cases, patients should be able to opt for "patient- and family-centered care," which would include "the experience of family and loved ones of their choosing."
This approach to patient-centered care would necessitate a number of striking departures from normal medical routine, Berwick asserts. For example, hospitals would have no restrictions on visiting hours except those chosen by individual patients; patients and family members would participate in rounds and in the design of health care processes and services; medical records would belong to patients, and clinicians rather than patients would need permission to access them; and technologies to facilitate shared decision making by clinicians and patients would be used universally.
Berwick anticipates and rejects a number of objections to his self-labeled patient-centered "extremism." Should patients' "wants" override the professional judgment of clinicians on matters such as whether an MRI is needed? Yes, says Berwick: "Evidence-based medicine sometimes must take a back seat." Would extreme patient-centeredness lead to the irresponsible overuse of social resources? No one can yet know the answer to this question; however, previous research indicates that greater roles for patients in decision making about surgery leads to less invasive care, and work by Dartmouth's John Wennberg and Elliott Fisher "suggests that supply drives demand, not the other way around."
In the end, Berwick says, his goal is to protect patients from the "indignity" that makes even physicians like himself fear becoming a patient. "Call it patient-centeredness, but, I suggest, this is the core: it is that property of care that welcomes me to assert my humanity and my individuality. If we be healers, then I suggest that that is not a route to the point; it is the point," he concludes.
Berwick's article is based on his Kimball Lecture, delivered 27 July 2008, at the American Board of Internal Medicine (ABIM) Foundation Summer Forum in Yountville, California.
After the embargo lifts, you can read Berwick's article at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w555
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Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.
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