Article Text
PDF
Abstract
Objectives Health and social care systems, organisations and providers are under pressure to organise care around patients’ needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). Our qualitative study examines determinants of PCC implementation from decision makers’ perspectives across diverse HSCOs.
Design Qualitative study of n=24 participants in n=20 semistructured face-to-face interviews conducted from August 2017 to May 2018.
Setting and participants Decision makers were recruited from multiple HSCOs in the region of the city of Cologne, Germany, based on a maximum variation sampling strategy varying by HSCOs types.
Outcomes The qualitative interviews were analysed using an inductive and deductive approach according to qualitative content analysis. The Consolidated Framework for Implementation Research was used to conceptualise determinants of PCC.
Results Decision makers identified similar determinants facilitating or obstructing the implementation of PCC in their organisational contexts. Several determinants at the HSCO’s inner setting and the individual level (eg, communication among staff and well-being of employees) were identified as crucial to overcome constrained financial, human and material resources in order to deliver PCC.
Conclusions The results can help to foster the implementation of PCC in various HSCOs contexts. We identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.
Trial registration number DRKS00011925.
- patient-centered care
- implementation
- qualitative research
- decision-maker
- health and social care organizations
- quality In health care
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
- patient-centered care
- implementation
- qualitative research
- decision-maker
- health and social care organizations
- quality In health care
Strengths and limitations of this study
Based on purposeful sampling, we interviewed decision makers and addressed varying conditions and availabilities of resources across types of health and social care organisations to implement patient-centred care (PCC).
Our sample might suffer from selection bias as participants might have had a higher intrinsic motivation and interest in the research topic than non-participants. Interviews were only conducted with decision makers in leading positions so that differences in perspectives across hierarchies cannot be identified through this study.
Future research should investigate whether the identified determinants are similar in other regions, especially rural areas, as our explorations are geographically restricted to the city of Cologne, Germany.
Further analyses should apply a more fine-grained view on determinants located outside the sphere of individuals or organisations and may provide policy implications to foster PCC implementation in organisations.
Introduction
Patient-centred care (PCC), defined as ‘providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions’ (ref 1 p. 40), has become a guiding principle in health and social care. While concepts such as the Chronic Care Model2 or the Integrative Model of PCC3 further specify PCC, a common understanding of PCC is lacking in research and practice.4 Overall, PCC is conceived as a multidimensional concept that includes principles regarding perspectives of patients’ psychological, psychosocial and physical needs. The concept also suggests concrete activities for implementing PCC such as patient information, patient involvement in care, involvement of family and friends and patient empowerment.3 5 6 The implementation of these activities have been shown to be associated with more positive health outcomes.7 8 The understanding of PCC elements often depends on definitions of professionals and the context of health and social care. Nevertheless, there is a consensus about core elements of PCC across professional groups (eg, psychological needs and patient involvement), but the focus and emphasis differ.4 9
While the need and public attention for PCC have increased,10 health and social care organisations (HSCOs) face scarce resources (eg, financial, personnel and material) due to a shift from acute illnesses towards chronic illnesses and more complex treatment processes in an ageing society. Ultimately, such developments can increase economic pressures and require organisations to maintain, accumulate and preserve their resources, which is defined as resource-orientation11 and obstructs PCC.12 Therefore, health and social care systems, organisations and individual caregivers are constantly challenged to organise care according to the tenets of PCC under constrained resources.13
To ensure successful implementation of PCC, determinants that facilitate and obstruct PCC must be investigated and addressed at all levels and types of care.3 4 6 14 Research locates determinants of implementation success in health and social care at three levels: (1) the individual level (eg, personality traits and skills15 16 or attitudes17), (2) the organisational level (eg, goal setting,18 participating management,16 19 20 resources,18 infrastructure16 21 and culture22) and (3) the healthcare system level (eg, regulations and patients’ rights or climate of politics14). The organisational level is a mediator between the individual and the system level and combined with the individual level it plays a major role here, since at these levels specific activities for implementing PCC need to be carried out to fulfil patient needs.
Previous research has contributed to the understanding of determinants of PCC implementation. However, this partly results from the experiences of best-practice examples or organisations that have a great deal of knowledge on PCC (eg, refs 18 22). Moreover, due to varying conditions for different HSCOs types (eg, differences in financing structures between ambulatory and inpatient care organisations), availabilities of resources may differ across types of HSCOs. Within the German healthcare system, health and social care services are delivered at home (eg, from long-term outpatient nursing or palliative care facilities), in outpatient HSCOs (eg, offices for general and specialist medical care or psychotherapeutic care,) in inpatient HSCOs (eg, hospitals for acute medical care, rehabilitation clinics for restorative rehabilitating care or hospice care) or semi-inpatient HSCOs (day-care facility).23 These different contexts might be associated with different determinants for PCC implementation and strategies to deal with resource scarcities.
Our study aims to address these gaps and advance research on determinants for PCC implementation and strategies to address determinants across HSCOs. Implementation of PCC is here defined as decision makers’ perspectives about PCC activities related to patient’s needs that are or should be implemented in their organisational contexts and routine care. We aim to identify determinants of PCC implementation on the organisational and individual level using a conceptual framework.24 Moreover, coping strategies through which HSCOs may reconcile strained resources with an increasing pressure to implement PCC are explored. The study provides a general overview of determinants for PCC implementation across different HSCO contexts and identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.
Methods
Study design
The data used in this article stem from the research project OrgValue (Characteristics of Value-Based Health and Social Care from Organizations’ Perspectives). OrgValue is embedded within the Cologne Care Research and Development Network (CoRe-Net) towards value-based care for vulnerable patients in Cologne, Germany,25 which currently includes three subprojects. The subproject OrgValue analyses the implementation of patient-centredness while considering the HCSOs’ resource orientation in the model region of the city of Cologne. The implementation of patient-centredness was assessed through face-to-face interviews with decision makers in various HSCOs contexts.11 This study presents results of the qualitative interviews with decision makers in HSCOs.
Sampling
The HSCOs included in the sample reflect all types of organisations in the city of Cologne, which are involved in the care of patients in their last year of life or patients with coronary heart disease and a mental or psychological comorbidity (patient groups studied within CoRe-Net).25 These included general practitioners (GPs) and private practice specialists (delivering symptom-oriented diagnostics and acute treatment), psychotherapists (delivering psychotherapeutic care), long-term outpatient care (delivering nursing and or palliative care), outpatient rehabilitation services and rehabilitation clinics (delivering restorative rehabilitating care), long-term inpatient care, including hospices, (delivering nursing or palliative care for severely ill patients) and hospitals (delivering acute medical care).
Participants of the interview study were clinical and managerial decision makers as key informants of these HSCOs caring for the selected vulnerable patient groups. Selecting key informants is a valuable approach, which is frequently used in order to assess the knowledge of employees who generally have decision-making authority.26–28 A preliminary panel discussion with practice partners from these HSCOs revealed that key informants have the most extensive knowledge about their organisation in terms of processes, structures, culture, resource allocation and deficiencies, strategies and organisational behaviour, for which we wanted to collect information in our study. It was important that the participants are or were involved in patient care or are in constant exchange with patients or care providers in the organisation. Depending on the type of HSCO, clinical and managerial decision makers can be different persons within an organisation (eg, hospital CEO and chief physician) or one person fulfilling two functions (eg, GP in private practice). By interviewing multiple representatives per HSCO type, information from multiple perspectives and different degrees of involvement in patient care or managerial processes could be obtained. Clinical and managerial decision makers were recruited via networks of practice partners and cold calling. Based on purposeful sampling,29 semistructured face-to-face narrative interviews were conducted.
Data collection
The semistructured qualitative interview guide29 revolved around three main questions:
How do decision makers define PCC?
What obstructs or facilitates the implementation of PCC in their organisations?
How do organisations deal with their resources and what resources are needed or lacking to implement PCC?
Each topic was operationalised by core questions facilitating story-telling and narrative-generating subquestions. The interview guide was flexibly adapted to the decision maker’s type of care organisation, the position or background, or the course of the conversation. The first step was to assess decision maker’s understanding about PCC according to Scholl et al 3 in order to ensure that there was a consensus on core elements of PCC (key questions were: ‘What characterizes PCC in your organization?’; ‘Do you remember a case where PCC was delivered at its best/not at all?’ [needs and activities]) (see online supplementary appendix 1). The discussion about the understanding of PCC was the basis to derive determinants of PCC implementation and strategies to address determinants across HSCOs in a second step (key questions were: ‘What were possible reasons that care was (not at all) delivered in a patient-centered fashion?’; ‘What are strategies in your organization to create the conditions necessary for PCC?’). Interviews were conducted face to face with one interviewee. In three cases, group interviews (with a maximum of three people) were conducted when decision makers brought in other organisational members who they felt were important to include when talking about the topics outlined in the study invitation.
Supplementary file 1
All interviews were conducted by two researchers trained in interviewing with one leading and one assisting in varying combination. The interviews took place at the interviewee’s office or in an adjoining room (eg, a conference room) and lasted on average of 65 min (min: 29 min, max: 148 min). Interviews were audiotaped, transcribed verbatim and anonymised by an external professional typist. Interviewees provided written informed consent before the interviews.
Patient and public involvement
There was no patient involvement in this study. For the purposes of participatory research, representatives from the health and social care practice were involved in the development of the design of the overall research project (OrgValue) at the outset of the study. Representatives were contacted through the CoRe-Net. In a collaborative meeting, participants discussed in terms of the qualitative study how to gain access to the study participants, the extent of interviews and who should be the appropriate contact person as decision maker in the respective type of organisation. All results of the overall study will be disseminated to the participants.
Data analysis
All transcripts were entered into MAXQDA software (VERBI GmbH, Berlin, Germany). Qualitative content analysis was chosen to explore the participants’ unique perspectives in order to extract on the descriptive level of content and not to provide a deep level of interpretation and underlying meaning.29 The analysis of the interview content was conducted independently by two multidisciplinary researchers (KIH, HAH and VV in varying combination) to ensure the validity of the data interpretation by minimising subjectivity of data interpretation.29 A coding frame including core elements of PCC and determinants for implementing PCC was developed by combining deductive and inductive approaches. First, content-related codes were constructed by descriptive coding/subcoding and provisional coding/subcoding.29 The conceptual model of Scholl et al 3 was used to identify codes that denoted the decision maker’s understanding about PCC activities related to patient’s needs (see online supplementary appendix 1). Several dimensions of the Consolidated Framework for Implementation Research (CFIR)24 were used to structure and combine the identified codes that denoted determinants of PCC implementation. The CFIR is a well-established framework that combines existing theories for determinants of effective implementation and divides five categories of determinants: intervention characteristics, outer setting, inner setting, characteristics of individuals and processes.24 We used the categories ‘inner setting’ and ‘characteristics of individuals’ of the CFIR to capture and categorise the determinants of PCC implementation.
The inner setting relates to the HSCOs’ inner arrangements of strategies, structures, processes and culture. Characteristics of individuals focus on the employees within the HSCOs. As described above, determinants for PCC implementation that relate to the healthcare system and interactions between HSCOs settings (outer setting) were gathered but were not part of this study. Finally, in our case, PCC was not one specific formalised intervention, and therefore our study did not intend to explore processes of actual implementation but rather determinants of PCC implementation.
The coding frame was repeatedly discussed and recoded among the researchers and a group of qualitative research experts to ensure its consistency and validity.29 Online supplementary appendix table 1 provides an overview of the considered categories including a short description for each code. The results are presented as textual fragments of the participants’ narratives to illustrate the relationship between the theoretical concepts and the data. Relevant passages were translated into English for this article.
Supplementary file 2
Results
In total, 20 interviews were held with 24 decision makers on 20 different dates. The 24 interviewed decision makers divided into private practice GPs and specialists (n=3), psychotherapists (n=3), long-term outpatient care (n=4), outpatient rehabilitation services and rehabilitation clinics (n=4), long-term inpatient care (n=5) and hospitals (n=5). Online supplementary appendix table 2 provides an overview of interviewee characteristics in the full sample (n=24).
The remainder of the results section is structured along our research questions (figure 1) and according to the CFIR scheme (online supplementary appendix table 1). Determinants of PCC implementation related to the organisational (inner setting) (table 1) and individual level (characteristics of the individual) (table 2) are described with emphasis on organisational strategies to maintain, accumulate and preserve resources under increasing demands for PCC (resource orientation).
Determinants of PCC implementation at the organisational and individual level. PCC, patient-centred care.
Determinants of PCC implementation related to the organisational level (inner setting)
Determinants of PCC implementation related to the individual level (characteristics of individuals)
Determinants of PCC implementation related to the organisational level: strategies, structures, processes and culture
Strategies
Organisational incentives and rewards
In single cases, interviewees described informal (eg, appreciation) and formal rewarding systems (eg, remuneration for innovative ideas relating to care improvements or problem-solving within the organisation). In contrast, showing non-patient-centred behaviour was considered inappropriate and could ultimately threaten continuation of employment. Cancellation of contracts was described as one organisational policy to deal with deficiencies in PCC provision.
Learning
Interviewees described the importance of gaining information on the organisation’s level of patient-centredness, but the form and extent of collecting such data varied among care providers. Formalised learning measures included quality circles with regular quality surveys, key indicator analyses, risk profiles, supervision, checklists, patient surveys and case reviews within the team. These were reported rather by inpatient, larger HSCOs. Less formal forms of gathering information covered complaints by patients, relatives or staff members. The value of information of these data was evaluated differently across decision makers. For example, the extent to which patients could make a meaningful judgement about quality features—especially concerning the medical treatment—was questioned.
Management of innovations and changes
Some interviewees perceived the German healthcare system and the organisation they were working in as rigid and reluctant to change. The implementation of innovations in these contexts was therefore perceived as a complex management task, because it requires comprehensive adaptation processes, even with less complex innovations. Decision makers described their dependency on the readiness (willingness and competency) of the middle-level management and the front-line staff for successful implementation of innovations throughout the organisation. Both levels need to accept the value of the innovation and implement it in their daily actions. To increase readiness, it requires conviction about the innovation as well as participation and communication in the implementation process. Particularly opinion leaders should be addressed. Medical care centres were described as more innovative than others in terms of structures, that is, care structure and processes.
Leadership behaviour and engagement
Decision makers described it as important to set an example and to define expectations for a patient-oriented attitude or a ‘good spirit’. To support PCC, control was exerted, for example, by considering the applicant’s attitudes towards patient orientation as decision criteria in the hiring process of employees and management staff. Another strategy mentioned was to demand and encourage for implementation and also to monitor it. Leaders who were not directly involved in patient care felt committed to fostering an environment in which front-line caregivers can do their job with the patient. It was also mentioned that employees need to be able to make decisions independently of their supervisor, to have flat hierarchies and to formulate clear responsibilities.
Conflict management
In general, leaders perceived it as a duty and strategy to ensure smooth processes and to manage conflicts. Conflicts within the team were named as one reason for a negative working atmosphere. Patients were described as sensitive to negative moods among team members and as affected by these, particularly in terms of satisfaction and well-being. Therefore, one provider stated that conflicts should never be dealt in front of a patient and that care provision should always be prioritised.
Process orientation
Clear-cut definitions and processes helped to warrant adequate care of patients. Time management was seen as an important component for efficient care. Still, a certain degree of flexibility within the processes was important to tailor processes to the specific needs of a patient (see: flexibility of care). For example, a high workload (eg, too many patients; insufficient number of staff) disrupted a smooth flow of processes and provision of care by increasing waiting times and decreasing the time devoted to the individual patient. Interruptions in the process must be resolved, (eg, using strategy meetings and quality management evaluations). The importance of interdisciplinarity within process flows and planning was emphasised. Standardised guidelines (eg, clinical practice guidelines) were considered as a recommendation for objective patient needs but not as a strict guideline for specific patient care. It was reported that process steps were defined in inpatient nursing using the Plan–Do–Check–Act Cycle to adapt guidelines to the needs of the residents. Checklists were occasionally used to ensure compliance with process steps, especially when the patient is admitted. The relevance of effective process design seemed particularly high in centres (eg, breast care centres and medical care centres).
Resource orientation
Interviewees mostly linked PCC to the availability of various resources. Scarcities of personnel resources, which were described as strongly related to a lack of financial resources, were mentioned most often. For example, organisations had to draw on (more affordable) ancillary staff. This issue was exacerbated by the limited availability of adequately skilled staff and professional staff facing a high workload during their shifts. Often, decision makers perceived difficulties in striking the right balance between PCC and quality demands, on the one hand, and scarce resources and rigid guidelines, on the other. Compared with other organisations, outpatient and inpatient nursing facilities particularly highlighted the problem of scarce resources.
Interviewees described different strategies to maximise PCC under scarce resources. For example, fostering personnel development (eg, skills and competencies) was identified as supportive to PCC. Collaboration in networks of different providers was another strategy to manage lacking resources for fulfilling patient needs. It became clear that larger organisations (eg, hospitals) possess broader financial leeway to overcome scarcities or to invest in staff. Moreover, interviewees assumed that non-profit HSCOs tend more to use financial resources for the benefit of PCC (eg, staff number or quality) which, according to the interviewees, might be handled differently in organisations under for-profit ownership. Another strategy mentioned as a vision was the organisation’s focus on a limited range of healthcare services (eg, with regard to the complexity and of care needs).
Employee retention and satisfaction
According to the interviewees, caregivers cannot make patients healthy and satisfied if they do not feel equally valued. Therefore, employee satisfaction emerged as one determinant for PCC that is related to resource orientation. Various strategies were mentioned to strengthen or preserve the employee’s resources, foster staff satisfaction and ultimately tie professional staff to the organisation. Those included, for example, adequate payment, occupational health management, a good working climate, work–life balance (eg, time for leisure and recreation), opportunities for further training, job autonomy and supportive technical equipment.
Add-on services
Organisations offered additional (eg, non-reimbursed) services for patients, which primarily targeted the dimensions of psychosocial needs and continuity of care. Specific activities concerned, for example, services for relatives and care outside consulting hours or beyond the treatment period. Although these activities were often not reimbursed, decision makers perceived them as crucial for patients and the care process. Another incentive for providing additional services was peer pressure, meaning that organisations offered additional services (eg, entertainment) to gain a competitive advantage for their organisation or increase business development.
Structures
Staffing and workload
Interviewees described that the number of staff available, the ratio of professional to ancillary staff and the workload influenced PCC. Staff-related factors (eg, availability) and the staff–patient ratio were described as a precondition for the provision of patient-centred nursing. Moreover, these factors determined flexibility of the organisation in times with high sick leave. Particularly in long-term inpatient care, temporary employment was described as inevitable yet undesirable (see: professional qualification). Organisational strategies to strengthen personnel resources included the reinvestment of financial surpluses into the body of personnel.
Technical infrastructure
Across organisational boundaries, several interviewees saw available equipment as a precondition for adequate patient treatment. Mostly, the term was automatically referred to as medical or technical equipment. One outpatient caregiver described that patient communication was complemented by use of non-technical equipment (eg, flip charts) to increase patient involvement in care.
Health information technology was generally confirmed as increasingly relevant during the care process. Different examples for the application of information technology (IT) in healthcare practice were mentioned, ranging from the integration of individual patient preferences by electronic care planning to the use of tablet PCs to assess patient-related information. Sometimes, insufficient or fragmented IT structures were described as a challenge in everyday practice, for example, by hampering cooperation with other care providers or by consuming too much time.
Rooms and buildings
Interviewees described that the arrangement or design of rooms and buildings should ideally match the care processes and meet patient needs. Hospitals and other inpatient providers faced historically developed architectural structures that could hardly be changed. Strategies to deal with physical barriers included a redesign or interior change of rooms and buildings to the fullest possible extent (eg, media entertainment). Outpatient care providers mentioned the possibility of shifting from one room to another on demand.
Processes
Continuity of care
The importance of continuity in the care process was highlighted. Organisations strived to ensure care provision by the same person throughout the treatment process. Thereby, care providers were assumed to be better able to familiarise with the specific patient, observe and address health state changes. Temporary employment in case of understaffing was regarded as a hindrance to the provision of continuous care and therefore to PCC, since these employees are usually not familiar with the processes and structures in the particular care organisation. Moreover, in case of readmission, retreatment or follow-up visits, the opportunity to contact the same HSCOs as previously was considered desirable. The use of guides (eg, a case manager) was mentioned as a strategy to ensure continuity.
Timeliness of care
Next to continuity, the timeliness of care was stressed as important for PCC. Timeliness means that a patient’s access to treatments matches the urgency of that patient’s physical or psychological needs. In order to be able to assess the urgency of a situation, according to the interviewees, this requires guidelines and skills (eg, to recognise such situations or capacity to act) of those who have the first contact with the patient (eg, reception staff). The extent of bureaucracy proved to influence timeliness of treatment, including, for example, approval and reimbursement of therapies, the purchase of special home care equipment and anamnesis of non-relevant information for care needs.
Flexibility of care
In any care situation, the flexibility of care was considered necessary for delivering PCC implying that processes and individuals allow for adjustments in care that value a patient’s day-to-day needs and preferences. This may include, for example, altering standardised care plans when patients prefer to shower on a different day. However, interviewees also reported a lack of flexibility in structures and processes, especially in hospitals. If regular processes and responsibilities are maintained in emergency cases, although immediate action including deviation from the usual procedures is required, this might threaten the patient’s health.
Internal communication and networking
Communication processes were separated into formal communication or informal communication. Formal communication covered regular events, such as case meetings, team meetings or tumour boards. Interviewees described the involvement of various disciplines in formal cooperation, sometimes depending on the specific patient’s needs and background, as ways to ensure PCC. The integration of different knowledge bases for medical treatment decisions and the involvement of additional non-medical (eg, social-service) perspectives in the care process were described as advantages of formal cooperation structures.
Informal communication channels were mentioned as a complementary, yet faster, way to network and cooperate internally. Possibilities for internal communication were sometimes described by providers of inpatient care as restricted when hierarchies, demarcated departmental structures or activities, and professional boundaries (eg, between nurses and physicians) existed.
Culture and climate
Decision makers described the communication and mutual consideration within an organisation as a key determinant for a good atmosphere for patients and staff members. Interviewees stated that with the help of good cooperation and a good working atmosphere, all employees are able to follow a patient-oriented attitude and action without the need for specific hierarchies, strategies or training.
Fostering an active collaborative culture within neighbourhoods and with other HSCOs was also mentioned as a strategy to improve patient care. Decision makers considered non-profit HSCOs better able to work in the interest of the patient since making profit does not need to be balanced against patient needs. Also, decision makers named specific guiding principles, usually with a religious origin, which shape their organisation’s culture. The implementation of these principles was assumed to be supported, for example, by signing a mission statement form or having an inspiring leader who actively represents the culture and values of the organisation.
Determinants of PCC implementation related to the individual level: characteristics of individuals
Coping strategies
Finding a position in which employees are able to provide care according to their qualification and beliefs was considered necessary for being able to cope with the challenging task of providing care. Interviewees named the attendance of mentoring meetings, exchange with colleagues or the development of joint practices as opportunities to better cope with challenging situations. In very problematic situations related to personal conflicts with patients, interviewees considered referral to another care provider as necessary.
Physical and emotional well-being
Interviewees described a direct link between the physical and emotional well-being of caregivers and the provision of PCC, since only those employees who experience well-being can also provide good care in the long run. Moreover, employees who experience well-being in a care organisation were considered more likely to remain employed for a longer time and therefore support the provision of continuous care (see: Continuity of care). Interviewees considered a reduction of working hours or job-sharing strategies to leave room for sufficient recovery from the demanding task of care provision.
Skills and capabilities
Interviewees mentioned psychological traits, professional qualifications and development,and communication skills as important factors at the individual level to determine the provision of PCC. Staff members who are motivated, empathic, respectful, patient, open, flexible, active listeners and who have good problem-solving skills were considered to be better able to provide PCC than those lacking these traits. Moreover, orientation towards the patient is supported when care provider and patient get along well with each other. Interviewees highlighted the importance of looking at psychological traits when recruiting new staff members in order to create a functioning team. Additionally, sufficient qualification and willingness of staff members for professional development was considered a prerequisite for PCC provision. Being able to communicate in the patients’ mother tongue was considered as relevant as the educational background of the care provider. A high level of, for example, registered nurses instead of nursing assistants, facilitates care coordination since each staff member can take over all tasks. Staff members who are trained for the treatment of particular patient groups (eg, breast cancer, dementia and palliative care) can take over more specialised tasks and relieve general nurses from several duties. Communication skills including withstanding difficult and unpleasant conversations were considered particularly important competences. Having a plan in mind for communicating bad news, such as diagnoses, and being honest were both considered necessary for managing such situations without overwhelming patients. Interviewees stated that the best medical care could even be endangered if it was not accompanied by adequate communication and easily understandable explanation of the disease and treatment process.
Attitudes towards PCC
Interviewees stated that PCC largely depends on the employee’s engagement and feeling of responsibility for care. Intrinsically motivated staff had a feeling of responsibility and compensated for disruptions during the care process. Care providers need to have a positive attitude towards the patient, but this should also be supported by the care team and supervisors, for example, by acting as role models, placing high value on patient-centred behaviours during employment probation or allowing enough time for the care of each patient.
Discussion
Providers of health and social care services face increasing pressure to implement PCC into their daily practice. This study explored potential determinants that facilitate or obstruct PCC implementation and strategies to reconcile PCC with resource scarcity. The determinants of PCC in the inner setting of HSCOs and at the individual level are influenced by factors at the outer setting (system level) in the provision of PCC. These interactions are addressed in the discussion of the results, although the results on the determinants at the outer setting and their influences on PCC are not presented in this article. When describing optimal care for patients, the interviewees usually addressed all core elements of PCC, as described in established concepts on PCC,3 reflecting a general agreement regarding the dimensions of PCC (see online supplementary appendix 1).
So far, no structures or incentive systems for organisations and providers exist on a national level in Germany to implement PCC. A few initiatives have been launched, such as training programmes on shared decision making as part of healthcare professional education.30 However, our preliminary results on the analysis of PCC determinants at the system level so far indicate that such training programmes are not sufficient. Rather, HSCOs and providers need to manage the implementation of PCC themselves. Therefore, the discussion of organisational strategies for implementing PCC is becoming particularly important. Interviewees described organisations’ strategies towards maintaining, accumulating and preserving their resources as they perceived difficulties in striking the right balance between PCC, quality demands, scarce resources and rigid guidelines. Indications of the interviewees regarding the challenges at the system level (outer setting) emphasise that financing conditions such as contribution rate stability, the separation between revenues from statutory or private health insurance or an avoidance of financial responsibility at the system level hinder organisations from meeting the needs of a growing number of patients with an increased need for care. As a result, HSCOs are hindered from investing in health innovations in order to ensure care that is in line with healthcare advancements. Human resources were therefore perceived as the most important resources because they are linked to other resources (eg, time or money) and can be influenced by the organisation. Fostering personnel qualifications and development as well as the concept of care for caregivers18 were therefore identified as main strategies to preserve different kinds of resources (personnel, financial and time) to support PCC. All interviewees stated that only healthy and satisfied caregivers are able to provide PCC on an ongoing basis. This corresponds to the finding that patient satisfaction is lower in hospitals with more burned-out, dissatisfied and frustrated nursing staff.31 Accordingly, strategies to maintain or improve the emotional and physical well-being of staff were described across different types of organisations. While individuals need to be qualified for their job, it is the organisations’ task to foster staff well-being and provide sufficient opportunities for continuous education.16
Individual characteristics that determined the provision of PCC, for example, empathy or the individual attitudes towards the uniqueness of patients and their needs, can only partly be influenced directly by the organisations. In line with this, the recruitment of adequate staff was highlighted as a main challenge by decision makers. Another important determinant for PCC at the individual level was the professional expertise of the employees. Our preliminary results on the analysis of determinants from the outer setting point out that decision makers wished for a more academic education of health professionals that, however, has not yet been integrated into current legal reforms. It was generally perceived as difficult to recruit staff with both professional expertise and soft skills. Soft skills such as empathy were also not learnt through previous educational structures. Instead, the organisations try to convey these skills through the culture of the organisation or through the example of leadership.
On the organisational level, the general commitment towards PCC with an emphasis on leadership behaviour and support as well as an organisational culture of learning emerged as key determinants for PCC implementation (eg, refs 14 16 19 20). These aspects closely relate to other determinants, since our interviews suggested that patient-oriented behaviour needs to be valued, rewarded or, if not achieved, reacted to appropriately by organisational leaders. Another key facilitator that emerged was continuity of patient care within and across organisations, which is consistent with previous work on PCC (eg, refs 21 32 33). While continuity in appointments or in people providing care cannot always be ensured due to work schedules, IT infrastructure was considered as one option to reduce problems with fragmented care. A complete and fast exchange of patient information should facilitate care within and across organisations, since a complete personal and disease history is available and does not need to be elicited at each new visit. Policy makers should therefore discuss more intensively opportunities of improved IT structures in HSCOs.1
According to some decision makers, especially in inpatient care, an external incentive for PCC would be to compete with other HSCOs. This perceived peer pressure, a PCC determinant in the outer setting, encourages HSCOs to develop strategies for more PCC. They spend extra resources and offer add-on services that enable PCC as consequence of the peer pressure effects and a lack of sufficient reimbursement by the healthcare system.
The definition of standardised processes (internal, eg, standard operating procedures) and care procedures (external, eg, clinical practice guidelines) was considered important in order to effectively control processes and to provide care adherent to standards of care. However, interviewees stated that guidelines would only give orientation and processes and standards must be flexibly adaptable to the individual needs of patients. An individualised standardisation within HSCOs can therefore be concluded as a yardstick for PCC.34 35
As a strategy to increase patient value in care with equal resource consumption36 and to organise care around the patient,37 it was proposed to concentrate care within the HSCOs. This corresponds to Christensen et al’s38 idea to reorganise HSCOs towards types of organisations related to the complexity of the patient’s problem of care. For example, in the case of hospitals, they suggest that managerial control could be regained if general hospitals were replaced by two types of organisations. One type, called a ‘value-adding process clinic’, delivers standardised, routine treatments for patients with well-diagnosed conditions at predictably high quality. The other type, called a ‘solution shop’, organises care for more complex and ill-diagnosed patients.38
Limitations
Our results need to be seen in light of several limitations of this study. First, interviews were only conducted with decision makers in leading positions. The perspective of staff members in lower positions was not considered. Therefore, any differences in perspective cannot be identified through this study. However, people in lower positions would not have provided us with information about management-related, personnel-related or resource-related information and strategies in the organisation, which was also an aim of this study. Second, we only included representatives in the city of Cologne, which implies that we did not capture PCC determinants related to more rural areas. Third, our sample might suffer from selection bias. We assume that participants had a higher intrinsic motivation and interest in the particular research topic and might also be more likely to engage in activities that foster PCC. Finally, the understanding of PCC, its implementation in organisations and associated determinants often depend on individual definitions and the context of care. It requires an in-depth analysis to find commonalities and refined understandings of higher order meanings. However, the aim of this study was to provide an overview of determinants of PCC implementation considering various contexts. To complement our findings, additional analyses focusing on determinants of PCC in the outer setting will be published separately.
To conclude, as reflected by the wide range of determinants identified, PCC implementation requires performance measures that evaluate multiple dimensions.39 Some of those dimensions may be influenced by short-acting strategies (eg, equipment; design of rooms and buildings), while others require certain midterm or long-term strategies (eg, building networks or a culture). One particular pillar for the success of PCC seems to be the active involvement and engagement of management and decision makers. These persons are particularly positioned to relay the high importance for PCC,18 thereby supporting an atmosphere that values PCC6 and implementation efforts.20
Future research should investigate whether the identified determinants are similar in other regions, especially rural areas. Moreover, quantitative data on systematic differences between types or ownership of HSCOs are needed to validate the explorations of this work. Finally, future research should apply a more fine-grained view on conditions and regulations of the health and social care system, such as reimbursement regulations, and their association with PCC implementation.10 These determinants are located outside the sphere of individuals or organisations and may provide policy implications to foster PCC implementation in organisations.
Acknowledgments
We would like to thank the participating decision makers for their contribution to the project. We could not have done it without you. We gratefully acknowledge the support and cooperation within the CoRe-Net research group.
References
Footnotes
Contributors All members designed the study. KIH, HAH and VV designed and conducted data collection, critically reviewed by LA. KIH drafted and revised the paper in close collaboration with VV and HAH. KIH is guarantor. LA, SS, LK and HP critically revised the paper.
Funding This work was supported by the German Federal Ministry of Education and Research (grant no. 01GY1606).
Competing interests None declared.
Ethics approval The Ethics Committee of the Medical Faculty of the University of Cologne approved the study (reference number: 17–210).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Collaborators Christian Albus, Lena Ansmann, Frank Jessen, Ute Karbach, Ludwig Kuntz, Holger Pfaff, Christian Rietz, Ingrid Schubert, Frank Schulz-Nieswandt, Stephanie Stock, Julia Strupp, Raymond Voltz, Nadine Scholten.
Correction notice This article has been corrected since it was published online. The Collaborator group and Trial Registration number have been added.
Patient consent for publication Not required.