Editorial
Challenges for improving patients’ experiences
of health care
Current thinking in health care defines a quality service
as one that is safe, effective, equitable and patient-
centred.1,2 Patient-centred care is regarded as encom-
passing six dimensions: compassion, empathy and
responsiveness to needs, values and expressed prefer-
ences; coordination and integration; information, com-
munication and education; physical comfort;
emotional support, relieving fear and anxiety; and
involvement of family and friends. Recent work with
patients with chronic illnesses suggests the dimension
of communication, information and education should
be widened to include support for self-management
on the part of the patient.3,4
Evidence to support the importance of patient-
centred care is beginning to receive the attention it
deserves. Research has been uneven and highly special-
ized: communication, privacy and dignity are well-
researched whereas involvement of family and friends,
and coordination of care have received comparatively
little attention. In addition, most research focuses on
patients’ experience in acute hospitals though there is
some from primary care, mental health settings and
end-of-life care.
The efforts of researchers, policy-makers and prac-
titioners to understand and improve patient experience
have been undermined by problems of language and
muddled thinking. The field is bedevilled by multiple
terms with over-lapping but different meanings includ-
ing: family-centred care; relationship-centred care; basic
care; dignity and respect; customer care; personalized
and individualized care. Each term resonates powerfully
with different professions but most provoke either
mixed or negative reactions from some or all of them,
making it difficult to achieve a sense of common
purpose.
The multi-dimensional definition of patient-centred
care reflects the thickness and texture of patients’ sub-
jective experience, itself a product of both what
happens (transactions) and how the patient is treated
(relational).5,6 The following quotes serve to illustrate
how transactional (T) and relational (R) aspects of care
weave together to shape the quality of experiences as
positive or negative:
My father was diagnosed with advanced prostate cancer a
couple of years ago. It was a huge shock to the family. The
whole process of initially having a problem, going through
tests (T), getting a diagnosis (T and R) and choosing a treat-
ment option (T) was excellent. My Dad and Mum felt
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supported and well informed (R). As a daughter, I felt that
all my questions were answered (R) and that the staff enabled
me to be involved (R) – as my parents wanted me to be,
while ensuring my Dad stayed in control / made his own
decisions. (Daughter’s testimony)
She was treated like a parcel. The junior doctor ordered tests
but she was moved before the results arrived so they were
never received (T). In one of her moves, she was taken by a
porter in a wheelchair to the door of one ward (T). The
nurse in charge came to the door and barred the way, telling
the porter: ‘You’re not bringing her in here’. (R) My mother
felt anxious she would be lost inside the system. (Daughter’s
testimony)
Critically, the degree to which care is experienced as
exceptionally good or exceptionally bad is bound up
with the degree to which staff treat patients with
compassion.
All efforts to improve service quality stumble against
organizational barriers and although the infrastructure
and capability for improvement is developing, there is a
long way to go before providers are able to transform the
experience of care.7,8 Tackling short-comings in patient-
centred care is arguably more challenging than tackling
other aspects of quality for five reasons. First, problem
recognition. This is partly to do with ignorance about
the importance of patient-centred care and the belief
that patients are mainly concerned with issues such as
car parking. But it is also because patient-centredness
is mistakenly seen as an attribute of ‘caring’ individuals
and there is an assumption that people who choose to
work in health care are by nature, compassionate,
empathic and caring. In fact, in the same way that the
degree to which patient care is safe is determined by
the workings of the system, so the degree to which it is
patient-centred is determined by the system and not
by random acts of goodness on the part of individuals.
Second, problems with evidence. These are of two
kinds: the evidence that quality of experience is linked
to clinical outcomes and activities is overlooked,9,10
and the evidence that patients themselves contribute
to assessments of quality is considered weak and
lacking in credibility. This is partly because of recog-
nized problems with patient survey data and partly
because of misapprehensions and assumptions about
the status and relevance of qualitative data to
clinicians.11,12
The third challenge is problems of accountability and
responsibility. In some providers, executive responsibil-
ity for quality and patient experience rests with a senior
Editorial
nurse. It is a short step from the chief nurse being
accountable for patient experience, to patient experi-
ence being defined as exclusively about nursing, so
that the contribution of others is ignored.
Fourth, the nature of the problem. The multi-
dimensional nature of patients’ experience of care,
and the fact that staff attitudes and behaviours are impli-
cated, calls for different methods and approaches from
those used to correct purely transactional aspects of
care. Here the focus is not simply on changing what
gets done, it is on changing how staff relate to patients,
their mind sets, attitudes and feelings. Patients’ experi-
ence is shaped, directly and indirectly, in complex
ways by (individual) human and (cultural) organiz-
ational factors; the effort to understand and influence
these factors in order to improve patients’ experiences
is about ten years behind the patient safety movement.13
And finally, evidence of effective solutions is fragmen-
ted and tends to be descriptive rather than analytical.
Much of it depends on self reports and claims that are
not independently evaluated and most of the research
into methods of improving patients’ experience is
limited to one profession or staff group, or one dimen-
sion of care.
In the USA, a handful of hospitals are renowned for
offering a high quality patient experience.14 Studies
attribute their success to several factors: stable, strategic,
effective leadership of clinicians and managers; making
patient experience a strategic priority; clear communi-
cation of strategic goals; strong support for staff; involve-
ment of patients and families in service planning and
design, service improvement and governance; use of
ICT to support information for and relationships with
patients; high quality physical environments.15
The two factors that stand out as distinctively different
from the organizational factors associated with improve-
ments in effectiveness and safety are support for staff
and involvement of patients and relatives. Both make
good sense. The evidence on staff well-being and effec-
tiveness and patient experience shows the two are
related.6,16 – 18 And commonsense suggests that services
that welcome patients and families into their work and
decision-making are likely to have greater insight and
to be more responsive to their needs and wishes.
What the studies do not explain is how the hospitals in
the USA managed to achieve their reputations. What
were the steps, and what are the processes that have
made the difference? What kinds of structures and pro-
cesses work best for involving patients and families? And
what kinds of support for staff are effective?
Jocelyn Cornwell, Director
Joanna Goodrich, Senior Researcher
Point of Care Programme
The King’s Fund
2 J Health Serv Res Policy Vol 16 No 1 January
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from hsr.sagepub.com
Challenges for improving patients’ experiences of health care
11-13 Cavendish Square
London W1G 0AN, UK
Email: jcornwell@kingsfund.org.uk
DOI: 10.1258/jhsrp.2010.010144
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