Implementing Person-Centered Care through Guidelines

GagliarA

By Anna R Gagliardi, PhD 

Scientist, Toronto General Hospital Research Institute, University Health Network Associate Professor, University of Toronto Chair, Implementation Working Group, Guidelines International Network (G-I-N)Steering Group member, G-I-N North America Community

Person-centered care (PCC) informs, educates, and engages health care consumers (patients, families, well public), and can be achieved by involving consumers in their own care, and in health system design and evaluation (1). PCC improves consumer knowledge, relationship with providers, satisfaction with services, treatment compliance, cost-effective service use and health outcomes (2,3,4). While advocated by governments and health system policies, it is less clear what organizations should do to achieve PCC, although such evidence is emerging. For example, Aboumatar et al. found that 52 high PCCH-performing American hospitals used several patient-level (e.g. nurse rounds, executive rounds, discharge rounds, post-discharge calls, communication boards in patient rooms) and organization-level strategies (e.g. acronyms to prompt desired staff behavior, staff development, audit and feedback to staff) to implement PCC (5).
With respect to guideline development, efforts are underway to prepare and involve consumers in the process of generating guideline questions and recommendations (6). With respect to guideline implementation, only one study investigated how guidelines can be used as a vehicle for disseminating consumer-oriented implementation tools such as summaries or decision aids (7). In previous research we analyzed the content of guidelines and found that 50% provided information to educate or engage consumers (8). More recently we analyzed 137 guidelines published in 2008 or later and found that they lacked such implementation tools (9). A systematic review found that consumers viewed guidelines as sources of health information, support for informed decision-making, and as resources to manage their own care but were uncertain about how to find, assess, and use guidelines (10).

This may highlight an opportunity for guideline developers to enhance the person-centeredness of their guidelines by including implementation tools for consumers, and for providers to share with consumers. A variety of options are available (11,12):

Type of engagement

Type of support

Examples

Inform

Information that provides patients with knowledge about their condition and an understanding of how to manage it

Condition Information and evidence about the condition, prognosis, what to expect, and its management
Activities of daily living Information and advice on how to undertake generic activities such as hygiene, dressing, preparing meals, transportation
Lifestyle advice Information and guidance on lifestyle behaviors that support disease management
Activate

Information or tools to prompt action for actively managing the condition and enhancing quality of life

Support for condition Reminders, diaries or other prompts to support adherence to medication or recommended lifestyle behaviors
Action plans for condition Guidance specific to medical condition, providing signs of worsening condition, how to self-adjust treatment, and response if deterioration continues
Monitoring Self-evaluation tools to log and monitor physiological measures for personal assessment, and to share with clinicians
Psychological strategies Mechanisms for problem-solving, goal-setting, reframing, relaxation

Collaborate

Information or mechanisms that lead to interaction and engagement

Communication with clinicians Guidance and prompts to facilitate communication with health care professionals
Available resources Links to or contact details for organizations that offer information, psycho-social support, or financial aid
Social support

Links to or contact details for organizations that offer support, mentoring, or socializing

References

  1. Coulter A, Ellins J. Effectiveness of strategies for informing, educating and involving patients. BMJ 2007;335:24-7.
  2. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2012;3:e001570.
  3. Nelson KM et al. Implementation of the patient-centred medical home in the Veterans Health Administration. JAMA Intern Med 2014;174:1350-8.
  4. Rathert C, Wyrwich MD, Boren SA. Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev 2013:70:351-79.
  5. Aboumatar HJ, Chang BH, Al Danaf J et al. Promising practices for achieving patient-centered hospital care. Med Care 2015;53:758-67.
  6. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Graham R, Mancher M, Miller Wolman D, et al., editors. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US); 2011. Summary. Available from: http://www.ncbi.nlm.nih.gov/books/NBK209538/
  7. Van der Weijden T, Pieterse AH, Koelewijn-van Loon M, Knaapen L, Legare F, Boivin A, Burgers JS, Stiggelbout AM, Faber M, Elwyn G. How can clinical practice guidelines be adapted to facilitate shared decision making? A qualitative key-informant study. BMJ Qual Saf. 2013;22 855-63.
  8. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6:26.
  9. Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open 2015;5:e007047.
  10. Loudon K, Santesso N, Callaghan M, Thornton J, Harbour J, Graham K, Harbour R, Kunnamo I, Liira H, McFarlane E, Ritchie K, Treweek S. Patient and public attitudes to and awareness of clinical practice guidelines: a systematic review with thematic and narrative syntheses. BMC Health Serv Res. 2014;14:321.
  11. Grande SW, Faber MJ, Durand MA, Thompson R, Elwyn G. A classification model of patient engagement methods and assessment of their feasibility in real-world setting Pat Educ Counsel. 2014;95:281-7.
  12. Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke HL, Schwappach A, Purushotham N, Jacob S, Griffiths CJ, Greenhalgh T, Sheikh A. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic Review of Self-Management Support for long-term conditions. Southampton, UK: NIHR Journals Library, 2014.

About this author: 

Anna Gagliardi is a Scientist at the University Health Network’s Toronto General Hospital Research Institute and an Associate Professor at the University of Toronto. She held a five-year Canadian Institutes of Health Research New Investigator salary award from 2008 to 2013 to develop expertise in knowledge translation. This refers to developing and evaluating approaches for optimizing the translation of evidence generated through research into high quality health care. Anna’s research explores how to improve the quality and outcomes of health care services that persons (patients, families, well public) receive. In particular, Anna’s research focuses on how: (1) clinical practice guidelines can be better-designed to support health care decision-making by persons and health professionals; (2) multidisciplinary teamwork can be supported to improve satisfaction with, and the efficiency of health care delivery; (3) higher risk implantable medical devices can be monitored to prevent or minimize patient harm; (4) person-centred care can be delivered to women across their lifespan; and (5) person-centred hospital care can be implemented and evaluated.