Patient-Centered Care: PFCC Assessment and Improvement Strategy

Introduction

Patient-centered care is the goal of many healthcare organizations, but the ability of an organization to deliver it is influenced by a number of factors both internal and external. Business practices, regulatory requirements, and reimbursement can all 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 communication styles in their interactions with patients and their families. Furthermore, administrators oversee the policies and procedures that directly impact the culture of care. By 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

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

Patient-centered care can be defined as care oriented toward the best interests of the patient, above all other interests — including financial concerns. At the same time, executives are entrusted with the responsibility of keeping the organization viable and able to fulfill its mission in the community. Patient-centered care must therefore be balanced with financial realities. In some cases, there will be conflicts between the interests of the healthcare organization, its allied community partners, insurers, and government on one side, and the interests of the patient on the other. There are many managerial and leadership levels at which practitioners can resolve such conflicts — for example, choosing between a more profitable and a less profitable procedure of roughly equivalent efficacy.

Policies, procedures, regulations, organizational culture, and the influence of leadership are all factors that shape the front-line worker's ability to deliver patient-centered care. Each of these aspects of core business practice reflects the organization's priorities. If the organization holds patient-centered care as its main priority, the actions of front-line workers will reflect that. If not, those actions may fall short of a genuinely patient-centered standard.

Regulatory requirements sometimes create conflict between the interests of the patient and those of the healthcare organization. The organization may even experience tension between the legal framework and its own ethical principles. Regulatory requirements frequently present funding and financial challenges that further affect the ability to deliver patient-centered care.

For example, regulators are often concerned with patient safety, drawing on empirical studies that aggregate data from many patients across different populations. This data may conflict with what is best for a single individual patient. Nurses need to be empowered to make decisions within an evidence-based practice environment, working within the regulatory framework to avoid legal complications. When interests conflict, regulations 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. When that balance cannot be achieved, the best course of action for the patient may risk violating a regulation. Adherence to regulatory requirements places the healthcare worker at this point of conflict, potentially constraining their ability to deliver truly patient-centered care.

Reimbursement also influences the ability of a healthcare worker to deliver patient-centered care. Depending on organizational policy, a patient may only receive care for which reimbursement is available. Healthcare leaders can make patient-centered decisions that incur additional costs for the organization but nevertheless help fulfill its mission and goals. The most extreme example of reimbursement shortfalls arises when patients have no health insurance at all — they may receive only the bare minimum of care in an emergency room rather than the more comprehensive and proactive care they could benefit from. Nurses serve as patient advocates precisely for this reason, promoting patient-centered care as a normative professional standard.

Payers often exert significant control over care decisions — frequently determining, for example, which drugs they will and will not cover. Decisions made by parties outside the nursing profession, but which directly impact care delivery, represent a trade-off among the best interest of the patient, the provider's need to cover costs, and the payer's financial interests. Payers may occasionally reference clinical evidence when making coverage decisions, but unlike healthcare workers they are not ethically bound to evidence-based, patient-centered care. As a result, the procedures, treatment programs, or medications a payer will cover may not align with what the healthcare team would recommend.

As with regulators, payers typically base their decisions on aggregate data rather than on what might be best for a single individual patient. Reimbursement policies therefore tend to reflect a broader, population-level approach to policy-making rather than the patient-level focus of the healthcare organization. An epidemiological study's findings, for instance, may conflict with the optimal treatment for one particular patient seeking acute care. Common situations arise — such as a generic drug being ineffective for a specific patient while the patented alternative is not covered — that constrain the organization's ability to provide genuinely patient-focused care.

Healthcare professionals, and in particular healthcare leaders, should be aware of these trade-offs between financing and patient-centered care. Conflicts occur frequently enough that it is important to understand how they arise, how to resolve them strategically, and how those resolutions can ultimately improve patient care. Most importantly, providing patient-centered care requires understanding the organization's priorities so that when apparent conflict arises between the patient's best interest and a policy, regulation, or payer rule, the healthcare worker knows how to navigate that conflict. This is one of the major responsibilities of leadership in the healthcare organization.

PFCC Organizational Self-Assessment Results

The Patient- and Family-Centered Care Organizational Self-Assessment Tool (PFCC) evaluation highlights the strengths and weaknesses of the organization with respect to the delivery of patient-centered care. The leadership and operations domain has some notably strong areas — there is a clear statement of commitment to PFCC, and leadership sets expectations and processes to ensure accountability. However, patient and family inclusion is not written into many of the organization's policies, procedures, programs, or governing board activities. While the operational commitment to PFCC is strong, there are still areas where improvement is needed.

PFCC is front and center in the organization's mission, vision, and values, and is built into the core values by which the organization operates. A considerable weakness, however, lies in the area of patient and family advisors. There are no patient or family representatives on hospital committees, no patient/family advisory councils, and the organization scores only a 3 for involving patients and families in rounds. In essence, while leadership is generally well-engaged with PFCC, there is very little actual input from patients and families. The implementation of mission, vision, and tactics related to PFCC therefore falls entirely on management and staff.

The hospital does not score well overall in the area of quality improvement. The one strength in this domain is that patients and families are interviewed during walk-arounds. The remaining best practices in this domain, however, are largely not followed. Consistent with the general lack of interaction between strategic leadership and patients, the latter group has no strategic voice — they do not participate in task forces, quality teams, or meetings of any kind. This pattern reinforces the broader trend of placing the entire burden of PFCC implementation on management and staff, with patients and families having no meaningful input into policies, strategies, or practices.

The personnel domain presents a mixed picture. On the positive side, there is an expectation for collaboration with patients and families in performance appraisals, giving them at least one avenue for providing feedback on patient-centered care. Staff and physicians are well aware of the organization's commitment to PFCC and are trained in its principles. That said, patients and families play no role in interviews or the onboarding of new hires.

The environment and design domain reflects the degree to which the physical layout takes into account the needs of patients and families. Consistent with how the hospital is run overall, patients and families are considered in the physical environment, but they are not part of the planning or design process. Designers and leadership make those decisions on behalf of patients, without actively engaging them.

In the information and education domain, the organization's web portal provides excellent resources for patients and families, but little else is offered. There is no clinician email access, no patient/family interaction or resource rooms, and no additional resources such as apps to facilitate information dissemination. The active engagement component is missing, even where there are signs of strong commitment to meeting patients' and families' needs.

Diversity and disparities is an area where the hospital performs fairly well. It scores well on several dimensions — collection of race, ethnicity, and language information; access to interpreters; and educational materials available at a variety of literacy levels. The hospital performs less well in navigator programs for minority and underserved patients, where support is minimal.

In charting and documentation, the first dimension is fairly strong: patients and families have access to patient charts, providing full transparency. Patients are not able to make entries themselves, which is appropriate given that they are not medical practitioners — they can provide feedback to the medical staff, who then make the appropriate chart notes.

Care support is one of the largest domains, and the hospital generally scores well here, recording either a 4 or a 5 in each dimension. Family members are considered part of the care team, with 24/7 access; they can join rounds, receive support from staff, participate in rapid response events, and receive updated medication histories on each visit. There is thus active engagement with families where direct patient care is concerned, though not in areas like facility design or policy development.

Conclusion

Patient-centered care can potentially help the organization improve its standing in the community, increasing its ability to deliver higher quality care with measurable performance outcomes. Using the PFCC inventory, it was determined that performance is good on most care parameters. However, there is still room for improvement in several key areas, most notably in relation to patient access to information and education.