IntroductionPatient-centered care is the goal of many healthcare organizations, but the ability of an organization to deliver patient-centered care is influenced by a number of factors both internal and external. Business practices, regulatory requirements, and reimbursement all can impact patient-centered care in any healthcare organization. Promoting patient-centered care requires an organizational culture committed to this paradigm, which also needs to be embedded in the mission and values of the organization.

Executives and administrators create the organizational culture that promotes patient-centered care. All leaders in the organization are responsible for using patient-centered practices and communications styles in their interactions with patients and their families. Furthermore, administrators oversee the policies and procedures that directly impact the culture of care. Analyzing areas of weakness within the organizational structure and culture via established assessments like the Patient-and Family-Centered Care Organizational Self-Assessment Tool, it is possible to create multidisciplinary teams that promote the organization’s vision of patient-centered care.

Factors Influencing Patient-Centered Care

Business Practices

Administrators and executives of the healthcare organization guide the business practices within their organization. In essence, the executive and managerial layers will influence the organizational culture, guiding philosophies and values, spending practices, and the different standard operating procedures that healthcare workers need to follow. Executive layers and nurse leaders can both influence the ability of the staff to administer patient-centered care in accordance with the mission of the organization.

Patient-centered care can be defined as care that is oriented towards the best interests of the patient, above all other interests including even financial concerns. Yet at the same time, the executives are entrusted with the responsibility of keeping the organization alive and able to fulfill its mission in the community. Patient centered care needs to be balanced with financial expediencies. In some cases, there will be conflicts between the interests of the healthcare organization, its allied partners in the community, insurance, and government, and the interests of the patient. There are many managerial and leadership levels at which the choice made by a practitioner can resolve such conflicts – for example between a more profitable and less profitable procedure of roughly the same efficacy.

Policies, procedures, regulations, organizational culture, the influence of leadership are all areas that can influence the ability of the front-line worker to deliver patient-centered care. Each of these aspects of the core business practice reflects the priorities of the organization. If the organization holds patient-centered care as its main priority, the actions of the front-line workers will reflect that. If not, they the actions of the front-line worker may not reflect patient-centered care.

Regulatory Requirements

Regulatory requirements sometimes create conflict between the interests of the patient and the interests of the healthcare organization. The organization may even experience conflicts between the legal framework and its own ethical tenets. Often, the regulatory requirements present funding and financial challenges for the organization, which will also impact the ability to deliver patient-centered care.

For example, regulators are often concerned with the safety of patients, using empirical studies that aggregate data from many patients in different populations. This data might conflict with what is best for a single, individual patient. Nurses need to be empowered to make decisions in an evidence-based practice environment, working within the regulatory framework to prevent any legal conundrums. In a situation with conflicting interests, the regulation must be upheld as long as the best interests of the patient can still be maintained and nurses can remain loyal to their ethical codes. Otherwise the best course of action for the patient could violate the regulation. Ascription to regulatory requirements places the healthcare worker at the point of conflict, and they may find themselves constrained in their ability to deliver care that is truly patient-centered.

Reimbursement

Reimbursement can also be an influencer in terms of the ability of a healthcare worker to deliver patient-centered care. Depending on the policies of the healthcare organization, the patient might only receive the care for which the patient will reimburse. Healthcare leaders can make patient-centered decisions, which incur additional charges for the organization but which nevertheless help it fulfill its organizational goals and mission. The most extreme example of reimbursement shortfalls may arise when the patients who do not have health insurance at all, and might not...

Nurses serve as advocates for patients specifically for this reason, promoting patient-centered care as a normative standard in the healthcare profession.
Payers often specify a lot – they will frequently determine what drugs they will pay for and which ones they will not pay for, for example. Decisions made by outsiders to the nursing profession, but which impact delivery of care, represent the trade-off between the best interest of the patient, the interest of the healthcare provider to cover costs, and the interests of the payer. Providers may occasionally refer to evidence when making their payout decisions, but are unlike healthcare workers in that they are not ethically beholden to evidence-based patient-centered care. The procedures, programs of treatment, or medications the payer will cover may not be those that a healthcare team would have recommended.

As is the case with regulators, payers often make their decisions more based on aggregate data than what might be good for a single, individual patient. As such, reimbursement policies will typically reflect a broader sort of approach to policy-making than at the level of healthcare organization administration. The results of an epidemiological study, for instance, might be in conflict with what is best for one particular patient seeking acute care in the organization. There might be special medical situations, for example, where the generic drug does not work for someone at all, but the patented drug is not covered – these sorts of situations arise all the time and put a constraint on the ability of the healthcare organization to provide care that is genuinely focused on the patient.

Healthcare professionals, and in particular healthcare leaders, should be aware of these trade-offs between financing and patient-centered care. Conflicts occur often enough that it is important to understand how they come about, how to resolve them strategically, and how resolutions can improve patient care. Most importantly, providing patient-centered care means understanding the priorities that the healthcare organization has, so that where there is apparent conflict between the best interest of the patient and policy, regulation or payer rules, that the healthcare worker knows how to resolve that conflict. That is one of the major roles for leadership in the healthcare organization.

PFCC Results

The Patient-and Family-Centered Care Organizational Self-Assessment Tool (PFCC) evaluation highlights the strengths and weaknesses of my organization with respect to the delivery of patient-centered care. The leadership/operations domain has some very strong areas – there is a clear statement of commitment to PFCC, and leadership sets out expectations and processes to ensure accountability. However, patient/family inclusion is not written up in many of the organization's policies, procedures, programs and governing board activities. So while operationally the commitment to PFCC is strong, there are still some areas where improvements can be made.

PFCC is front and center in the mission, vision and values of my organization, and is built into the core values by which the organization operates. An area of considerable weakness, however, is with respect to advisors. There are no patient/family representatives on the various hospital committees, there are no patient/family advisory councils and we only score a 3 for having patients/family on the rounds. In essence, while leadership is generally well-engaged with PFCC, there is actually very little input from patients and family. The implementation of the mission, vision and tactics towards PFCC is entirely the responsibility of management and staff as a result.

The hospital does not score well, in general, in the area of quality improvement. The one area of strength in this domain is that patients and family are interviewed as part of walk-arounds. But the remainder of the best practices in this domain are genuinely not followed at my hospital. As per the above lack of interaction between the hospital's strategic leadership and patients, the latter group has no strategic voice, they are not part of task forces or quality teams, do not participate in meetings of any type. Overall, this continues with the trend that our hospital has of putting the entire onus on management and staff to implement the PFCC policies, as the actual patients and family do not have any meaningful input into the policies, strategies and practices.

The personnel domain is a mixed bag, in terms of how well my hospital performs. First, there is the expectation for collaboration with patients/family in things like performance appraisals. Their feedback is built into the appraisals, giving them at least that avenue for the provision of…