Needs analysis for establishment of GHS

The Gippsland Health Summit (GHS) aims to educate doctors, medical staff, health administrators and other health care providers in patient centered care, mindfulness, patient advocacy, engaging and communicating with our patients and empathy, so that we achieve better health care outcomes and improved levels of satisfaction for patients and professionals. It also aims to engage and educate patients in health literacy an in lifestyle change for better long term health.

Conference Needs Analysis

Whilst there is such training provided during University training and specialist courses, there has been no such training provided in Gippsland in recent years. There is also little opportunity for interdisciplinary education.  These are unique topics delivered in a novel way to engage stakeholders across the whole system. They are also topics that have been shown to need regular conscious review in order to maintain their practice. There will be opportunity for medical staff to learn from visiting experts, each other, patients, and other health professional disciplines during the Gippsland Health Summit.

The Australian Institute of Health and Welfare, reporting on Australian’s Health in 2012, noted that Australia will have difficulty funding and delivering equitable and accessible health services into the future. Chronic disease is on the rise all over the world. For example, 270 adults are diagnosed per day with diabetes in Australia.^[1] On current ratios and systems, by 2025, we will have 27% (109,000) less nurses than the current workforce and 3% (2,700) less doctors working in Australia than will be required. This does not auger well for the future, especially in rural and regional areas. People in rural and regional areas have more cost and access issues, poorer health outcomes, higher death rates and more hospital admissions than urban people.^[2] In the USA, the Hospital Consumer Assessment of Healthcare Providers and System (ACAHPS) survey found that effective physician communication will “translate directly into revenue gains for hospitals” (Ovretveit, P241).

It is incumbent on the whole community to focus its efforts to make sure that whatever policy decisions are made, we can respond to the health care needs of people living in Gippsland. Health care providers of all professions can have an impact in leading the whole community to engage in this effort, particularly doctors who often lead care teams.

The World Health Organisation (WHO) nominates ten facts that are central to patient safety, one of which is that patient and community engagement and empowerment are key to improving patient safety. Patient’s experience and perspectives are valuable resources for identifying needs, measuring progress, noticing errors or potential errors and evaluating outcomes.^[3]

Physicians across the western world are compensated by volume and success at curing health problems (Crock et al, 2013). However, the healing power of positive interactions has been well documented, and often forgotten in measurement of success in caring.  Rakel et al (2009 and 2011) compared recovery time and immune responses of three groups of patients with upper respiratory tract infections. Immune response was most vigorous and recovery time shortest in patients with empathic physicians. Recovery time was longest for the group with unempathic doctors – longer than those who saw no doctor at all! They concluded that empathy in the therapeutic encounter resulted in faster recovery times of flu patients.

In 2001, the Institute of Medicine described the primary determinants of health care quality; one of which was patient-centred care.^[4] They described this as “health care that establishes a partnership among practitioners, patients and their families”. Further to this, they concluded that patient-centered care is nothing less than a quality and business imperative”, and that “in general, most patients feel confident that they will receive competent technical care when they enter a hospital or health care centre. Beyond that, what matters most to them is being treated with kindness, compassion and dignity”.

Other research demonstrating the value of health care practitioners developing empathy, include Haslam (2007) “patients have better treatment adherence and suffer from fewer major medical errors while under the care of empathic doctors. Hojat and colleagues (2011) found “health benefits were greater for diabetes patients (better cholesterol and blood sugar scores) who were under the care of empathic doctors”. In another study Hojat noticed that empathy declines in medical students from 2nd year to 3rd year.^[5]

Whilst health professionals might consider themselves empathic, there are many patient stories to suggest otherwise. Of concern is that “empathy seems to be a mutable trait. Certain conditions can blunt expressions of empathy and conversely, certain awareness building and reflection activities seem to be able to up-regulate empathic behaviour “ (Malloy and Otto, 2012). Dewar and Frampton (2013) conclude, “compassionate actions and empathic responses can be taught” (p. 73). Despite an acceptance in clinical work, and in the research that empathy and compassion can make a difference to healing, there are few systems within the health system that actively challenge or review a practitioner’s ongoing levels of empathy or compassion.

In America, where value-based purchasing has considerably elevated the importance of patient-centered care, health care executives now identify improving the patient experience as one of their top priorities (Zeis, 2012).

Carl Rodgers (1951) provided evidence that unconditional regard; accurate empathy and congruence, were the most effective conditions for effective treatment. More recent literature still supports the importance of these factors. The client’s perception of the relationship is critical and all the presentations at this conference address improvements in this area. ^[6]  A 2008 study of patients in emergency services^[7] provided evidence that doctors in this setting were not skilled at displaying empathy or other conditions needed for optimal outcomes and in fact the most often reported patient experience was a negative one.  Speakers at the Gippsland Health Summit are actively involved in altering these types of behaviour by providing knowledge, strategies, and information. Research cited by Miller, Hubble and Duncan (2007) suggests that who provides treatment is far more effective than the type of treatment. Bringing empathy and compassion back into the health setting is likely to improve patient outcomes. ^[8] Norcross and Lambert provide further evidence of the role and importance of the relationship between therapist/treater and patient.  They suggest that most of the behaviours that improve relationships in this context can be taught.

Engaging the patient in their own care is also central when a system is under-resourced. Patients who have the skills and confidence to actively engage in their health care:

• Are less likely to require emergency room visit or hospital stay
• Are More likely to adhere to treatment plans
• Adopt healthy behaviour change
• Are associated with better health outcomes
• Incur lower costs ^[9]

The Salzburg Statement on Shared Decision Making (2010 and 2012)^[10] and the WHO Patients for Patient Safety Program, conceived in 2004, both hold as central pillars that patients’ voices must be brought to health care systems and policies, to empower and promote patient engagement for better patient safety outcomes.

Better patient care and more patient centred care requires a different kind of care from doctors, nurses, allied health and health administrators. To understand this, we need to build partnerships. “At the heart of this is recognition that professional knowledge is necessary but not sufficient for good decision making. The patient’s personal knowledge about what matters most is often as or more important” (Mulley and Wennberg, p51) It is unknown whether the health care professionals in Gippsland are aware of this research.

“Many people within health care are trained as if health care is an interaction primarily between individuals; they are not trained to improve systems” (Smith, p277). Further to this, “studies indicate that most doctors have problems in understanding health statistics, including those from their own area of specialty” (Wegwarth and Gigerenzer, p.137). 

If patients can discuss these matters amongst themselves and so can the providers of the care, they are much more likely to be relevant and make the desired impact, in partnership together, (conversation and action). The Gippsland Health Summit seeks to provide opportunity to build these partnerships through education, networking, promotion and engagement of all members.

The IHI initiated a 90 day research and development project in 2011, to understand the patients’ experiences in hospital.^[11] “The project identified five primary drivers of exceptional patient and family inpatient hospital experience of care: leadership; staff hearts and minds; respectful partnership; reliable care; and evidence-based care.” They concluded, “when everyone involved in care is focused on how to have better partnerships with those we serve, and processes are put in place to support such partnerships, the experience of patients and families — and health care outcomes — will improve.”

The JOGNN published a study considering the experience of parent satisfaction with the care provided to them and their babies in a neonatal intensive care unit (NICU). Although there were several gaps identified in the evidence, the researchers concluded that “partnering with families and increasing communication and support appears to be a place to begin this work given the current state of the science, but we need to have more answers to the complex question of providing excellent care to both infants and their families in the NICU.”^[12] Rademakers et al (2012) sought to understand patient centred care from patient preferences and experiences, and found that “all patients regard patient-centred care as important and report positive experiences. However, there is a discrepancy between patient preferences for patient-centred care on one hand, and the care received on the other. “^[13]

Fear of failure can be an important barrier to change. Health care professionals have an important role in enhancing the patient’s self-efficacy, or confidence in their own ability to realise a particular goal. This involves not only providing reassurance and constructive feedback, but also giving them the skills and resources they need to achieve success.  To do this practitioners need to have the knowledge and skills to motivate and encourage patients to behave in ways that enhance health outcomes. Speakers at the Gippsland Health Summit will be focusing on practical strategies health professionals can use to build patient motivation and engagement in their health.

The Beryl Institute has this to say:

“Patient experience begins and ends with good communication, so in examining patient experience from the physician’s perspective, it is an ideal place to start. If one cannot communicate, the knowledge you have or the skills you bring, can only accomplish so much. As we think about the fundamentals of service and human interaction, communication, be it verbal or non verbal, sits at the core of efforts to delivery quality and compassionate care.

Consider these important ideas:

1. Effective communication in healthcare is not something glamorous to have or an optional add-on. It is a core clinical skill.
2. Communication is not just a personality trait, but also a matter of habitual behaviour that can be modified, learned and retained.
3. Experience alone is a poor teacher of communication skills, unless it is continually developed with formal education grounded in the rapid changes in health care.
4. Based on this, we need to ensure that communication is not something we take for granted. It is a skill to be learned, a muscle to be built and an important component of the physician’s toolkit.”^[14]

The more motivated the patient to participate in their own health care the more likely they are to make the needed changes and the grater chance of an optimal outcome.

Providing patient-centered care consistently in clinical practice requires practitioners who are able to recognize that different clinical situations require different approaches and are skilled enough to adapt and, where needed, integrate methods. When patients face tough treatment decisions, shared decision making alone is appropriate. Where clinicians perceive a need to change behavior to improve health outcomes, motivational interviewing could be used. These 2 methods can be integrated when behavior change and choosing between competing options are relevant. Identifying the appropriate application of these patient-centered methods, alone and in combination, will assist practitioners in achieving a patient-centered clinical practice. Finally, we acknowledge the considerable challenge of implementing shared decision making and motivational interviewing into routine practice, let alone integrating them seamlessly as complex patients’ needs arise. We believe, however, that we will see little progress in patient-centered care unless these approaches are valued as core elements of good practice; they should be taught, assessed, and integrated into daily practice, then appropriately measured and rewarded. By so doing, we envision a better future for medical practice.[15]

In Australia, a patient-centred approach is supported by the Australian Charter of Healthcare Rights, the National Safety and Quality Framework, other national service standards, reports of state-based inquiries, and a range of jurisdictional and private sector initiatives.

References

Crock, C, Findley, J.T., Horowitz, S.F., Lee, K.J. and Omtzigt, W.J. (2013) The Role of Physicians in Patient-Centered Care. In The Putting Patients First Field Guide, Frampton, S.B., Charmel, P.A. and Guastello, S, p235- 253.

Dewar, B and Frampton, S., (2013) Compassion in Action in The Putting Patients First Field Guide, Frampton, S.B., Charmel, P.A. and Guastello, S, p69-89

Haslam, N. Humanising Medical Practice: The Role of Empathy. Medical Journal of Australia, 2007, 187(7), 381-82

Hojat, M., Louis, D.Z., Markham, F.W., Wender, R and others. Physicians’ Empathy and Clinical Outcomes for Diabetic Patients. Academic Medicine, 2011, 86(3), 359-364

Malloy, R. and Otto, J. A Steady Dose of Empathy. Hospital and Health Networks Daily, June 7 , 2012

Mulley Jnr, A.G. and Wennberg, J.E., (2011) Reducing Unwarranted Variation in Clinical Practice by Supporting Clinicians and Patients in Decision Making, 2011. In Better Doctors, Better Patients, Better Decisions. Ed.Gigerenzer, G and Muir Gray, J.A., The MIT Press, Massachusetts

Norcross and Lambert compendium of evidence-based relationships, Psychotherapy in Australia, vol 19, no 3, May 2013

Ovretveit, J., Do Changes to Patient-Provider Relationships Improve Quality and Save Money? Vol 1: Summary of a Review of the Evidence. London, Health Foundation, 2012

Rakel, D.P., Barrett, B, Zhang, Z, Hoeft, T. and others Perception of Empathy in the Therapeutic Encounter: Effects on the Common Cold. Patient Education and Counselling, 2011, 85(3), 390-397

Rakel, D.P., Hoeft, T. J., Barrett, B.P., Chewning, B.A. and others. Practitioner Empathy ad the Duration of the Common Cold. Family Medicine, 2009, 41(7), 494-501

Smith, R.S.W., (2011) The Chasm between Evidence and Practice. In Better Doctors, Better Patients, Better Decisions. Ed.Gigerenzer, G. and Muir Gray, J.A., The MIT Press, Massachusetts

Wegwarth, O. and Gigerenzer, G. (2011) Statistical Illiteracy in Doctors. In Better Doctors, Better Patients, Better Decisions. Ed.Gigerenzer, G. and Muir Gray, J.A., The MIT Press, Massachusett

The Australian Commission on Safety and Quality in Health Care (ACSQHC), www.safetyandquality.gov.au

WHO www.who.int

Discussion paper Draft for public consultation September 2010

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington: National Academies Press, 2001.

Planning Group

Dr Yousuf Ahmad, GP, Inglis Medical Centre Sale

Dr Elisabeth Wearne, GP, Gippsland Lakes Community Health

Dr Joel Fanning, GP, Leongatha Health Care

Dr Elise Ly, GP, Leongatha Health Care

Ms Denise McInnes, Clinical Director, Central Gippsland Health Service

Ms Karen McLennan, Manager Community Services, Chair Wellington Shire and Wellington PCP

Ms Jodie Martin, CEO Gippsland Women’s Health

Dr Debra Smith, Psychologist, Commonsense Connections

Ms Jeanette Gibson, Psychologist, Sale Counselling

Ms Nicola Finlay, Physiotherapist, East Sale RAAF Base

Ms Loy Perryman, Academic Coordinator, Monash University School of Rural Health

Ms Alda Dunlop, Monash University School of Rural Health

Ms Kelly Fitzgerald, Executive Officer East Gippsland Primary Care Partnership

Mr Bruce Smith, Shire of East Gippsland

Ms Sharee Johnson , Psychologist, SKJ Consulting

Conference Theme

Patient centered care and the role of the mind in healing.

Learning Objectives

Overall Conference

1. To explain the meaning of Patient Centered Care and to understand how this will improve patient safety and the delivery of health care in Gippsland.

2. To develop a conversation between patients, their families and the health professionals working in Gippsland, that creates a culture of respect, high quality communication and establishes a community partnership.

3. To demonstrate the impact of empathy, compassion and patient engagement in achieving best health care outcomes.

4. To demonstrate specifically how patient engagement and patient centered care improves efficiency and reduces error in the delivery of health care.

Dr Catherine Crock  (including the Play: “Hear Me”)

5. To demonstrate the importance of patient and family involvement and empowerment, as partners in their own health care and to understand how this has a direct impact on patient safety.

6. To learn about the importance of engaging in partnership, to achieve better health outcomes. (Better health outcomes means optimizing health and reducing errors in care.)

 Mr Murray Altham

7. To learn new strategies to motivate and engage your patients/clients to inspire them into action and be more involved in their own health care.

Ms Pauline McKinnon

8. To explain the role of mental rest and stillness in the treatment of anxiety, and to increase knowledge about the application of stillness meditation as a treatment for anxiety.

 Ms Clair Crocker

9. To understand what private patient advocacy means, and to establish how it might affect the delivery of health care in Australia in the future.

 Dr. Elisabeth Wearne

10. To understand how the global movement of bringing compassion back into healthcare can enrich relationships, reduce burnout and stress, promote wellbeing and save time and money.

11. To demonstrate how paying attention to emotional, psychological and spiritual wellbeing can heal relationships.

Dr Tasha Stanton

12. To understand the brain’s role in the experience of pain and to understand the change that occurs in the brain (the nervous system) in people who have chronic pain.

13. To have an increased understanding of how we might treat the brain to reduce pain.

Expected Outcomes of the Activity

1. That participants will have a clear understanding of patient centred care as opposed to system or practitioner centred care.

2. That participants will have reflected on their level of empathy, and be able to develop strategies to improve these levels of empathy as a means of contributing to the patient’s healing. That GPs and health staff will enhance their existing skill base in regard to the therapeutic relationship.

3. That health care providers and GPs will change behaviour with their patients to a more empathic position as a result of changes in attitude reflected upon at the conference and in discussion.

4. That GPs and health care providers will build on their confidence in including significant others in treatment for patients, having particular reference to patients with psychiatric, and age care issues as these patients are unreliable witnesses to their own care.

5. That health organisations and practitioners will review their procedures and practice to include review of patient centredness, empathy, compassion and mindfulness, in the knowledge that optimising these qualities produce better health outcomes, greater efficiency and improved patient safety.

6. That a community of practice across disciplines be established around continuous improvement of patient centred care in Gippsland.

^[1]Australian Institute of Health and Welfare, Australia’s Health 2012

^[2]Australian Institute of Health and Welfare, Australia’s Health 2012

^[3]WHO Patients for Patient Safety, 10 facts on patient safety www.who.int

^[4]Institute of Medicine, Crossing the Quality Chasm, 2001 National Academy Press

^[5]reported in acpinternist.org, New Research links Empathy to Outcomes by Stacey Butterfield

^[6] Morawetz: What works in therapy: What Australian Clients Say. Psychotherapy Australia, vol 2, no 1, 2002; Lewis and Lopez, What clients say about what works in counselling, Psychotherapy in Australia, vol 14, no 4, Aug 2008.

^[7] Treloar: Borderline personality disorder: Patient perspectives of mental health and emergency mediine services, psychotherapy in Australia, vol 15, no 1 Nov 2008

^[8] Robinson When therapist variables and the client’s theory of change meet, Psychotherapy in Australia vol 15, no 4, Aug 2009.

^[9] Many references documenting that engaged patients drives more effective care. See Charmel, P.A., Stone, S. and Otero, D. 2013 The Patient-Centred Care Value Equation In The Putting Patients First Field Guide, Frampton, S.B., Charmel, P.A. and Guastello, S, p27

^[10] The Salzburg Statement on Shared Decision Making 2010 and 2012, see www.e-patients.net and www.salzburgglobal.org

^[11]Institute for Healthcare Improvement, Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care, 2011. Available at www.IHI.org

^[12] An Integrative Review of Parent Satisfaction with Care Provided in Neonatal Intensive Care Unit Michelle L. Butt, Jacqueline M. McGrath, Haifa (Abou) Samra, and Rebecca Gupta, JOGNN, 42, 105-120, 2013

^[13] Educational inequalities in patient-centred care: patients’ preferences and experiences Jany Rademakers, Diana Delnoij, Jessica Nijman and Dolf de Boer, BMC Health Services Research 2012, 12:261

^[14]Physician Perspectives on Patient Experience, Shankar, L.R. and Wolf, J.A. The Beryl Institute 2012

^[15] Elwyn, Epstein, Marrin, White, Frosch, (2014) Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems Ann Fam Med May/June 2014vol. 12 no. 3 270-275