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Small Questions, Big Improvements in Patient-Centered Care

By Madge Kaplan | Thursday, January 28, 2016

Reaching out to learn about the person behind the disease or medical problem represents a paradigm shift in thinking. The idea of asking patients "What matters to you?" has resonated with patients and care teams in different parts of the world.

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[Photo credit: “Rosary” by Liz West via Flickr. CC BY 2.0.]

Rose, an 88-year-old woman with advanced dementia, was admitted to a geriatric unit in Scotland following a fall at home. She couldn’t talk, became agitated easily, and often tried to get up and walk on her own, which led to more falls. To keep her safe, a staff member had to sit with her nearly full time.

Geraldine Marsh, an Improvement Advisor for Older People’s Care on the NHS Glasgow and Clyde team caring for Rose, wondered if there was more she could do for her. So Marsh, who told the story on a recent WIHI program, decided to test an approach she’d heard about from her colleague, Jennifer Rodgers, chief nurse in pediatrics. The idea was to learn more about Rose as a person by asking her loved ones what mattered most to her. In response, one of her nieces said, “Now that you mention it, I don’t think I’ve ever seen my aunt without her rosary beads.”

They found the beads tucked away in Rose’s bedside drawer and placed them in her hands. Then Geraldine posted a sign above Rose’s bed, saying “When you come in the room, make sure Rose has her rosary beads.”

In a matter of weeks, Rose became calmer, less agitated, and less likely to wander — which was putting her at risk of further falls. And when Rose did get distressed, a nurse could usually calm her down by sitting with her and placing a hand over hers, holding the rosary beads.

What Matters to You?

In 2012, Susan Edgman-Levitan and Dr. Michael Barry published a provocative article in the New England Journal of Medicine about shared decision-making. They asked how care would change if providers opened their interactions with patients not with the routine medical prompt of “What’s the matter?” but rather the more person-centered question, “What matters to you?” IHI’s former President and CEO, Maureen Bisognano, turned the idea into a call to action in her 2013 IHI National Forum keynote.

Reaching out to learn about the person behind the disease or medical problem represents a paradigm shift in thinking. It encourages providers to relinquish their role as the single, paternalistic authority and instead become a coach and partner to patients. It helps patients articulate their wishes, goals, and concerns, and allows providers to hear them, so providers and patients can co-design a care plan around the patient’s priorities. Results from organizations testing this partnership model of care have been impressive: It can greatly enhance patients’ care experience — not only in better quality of life, but also improved care.

The idea has resonated with patients and care teams in different parts of the world. IHI’s person- and family-centered care team has been offering resources and highlighting exemplars to help more organizations adopt the approach.

Getting to Scale

But how do you move from a single question with one patient, such as Rose, to a system-wide practice?

In her remarks on the recent WIHI dedicated to the topic, panelist and IHI Executive Director Christina Gunther-Murphy said she sees the “What matters to you?” practice as the heart of patient-centered care. And she explained how IHI’s improvement methodology offers a systematic process for adopting the approach. It’s about starting small, she said, as Marsh did; one patient on one unit, and expanding in a series of small changes in PDSA (Plan-Do-Study-Act) cycles.

Christina advised providers to be thinking broadly from early on. The ultimate goal, she said, is to get the process to scale, so teams should consider hurdles that come up. For example, clinicians often worry if they ask “What matters to you?” how they will find time for the conversation. A physician or nurse might be able to have this discussion with five patients, but probably not with 50 or 150. Still, curiosity of this sort does not wind up being as time consuming as many providers fear. And some organizations are exploring who else on care teams, such as medical assistants, can initiate discussions with patients.

 WIHIWhatMattersToPatientsAndFamilies.mp4

Beth Hennessey and Paula Suter of Sutter Center for Integrated Care pointed to other hurdles, such as clinicians’ discomfort with the shift from physician-driven to patient-guided care. It takes training and strong support to make the right thing the easy thing. For example, the Sutter Center trains staff in motivational interviewing techniques that encourage asking open-ended questions and responding with empathy.

Another way to overcome hurdles is to adapt the question for various patients and settings. For example, to get at the same issues, a provider might ask:

  • Is there anything you’re worried or concerned about?
  • What should I know about you that’s not in your medical chart?
  • (Before surgery) What do you want to be doing in six months that you can’t do now?
  • (In hospice) What does a good day look like?
  • (With children) Draw me a picture of what you care about and your rules for us when we enter your room.

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An eight-year-old patient’s picture of “What matters most.”
 
Photo courtesy of Jennifer Rodgers, NHS Greater Glasgow and Clyde, Scotland.

With strong leadership support, Sutter Center for Integrated Care has made the question a cornerstone of person-centered care. They’ve built a learning system around the practice and are integrating it in strategic planning, including program development around electronic medical records and telehealth.

How did the NHS Scotland team get to scale after their success with Rose?

With their initial results, Marsh’s team spread the practice to more units, training nurses to ask patients or their families “What matters to you?” They displayed the responses above the patient’s bed or outside his or her door. And they did whatever they could to fulfill any wishes they could.

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Reduction in falls on the geriatrics unit of NHS Glasgow and Clyde where the
“What matters to you?” practice has been widely implemented.

The NHS Scotland team tracked the results of this small test over time. Within a year and a half, they’ve seen a steady rise in patient and staff satisfaction. They’ve also seen remarkable results in care outcomes — in four wards, incidents of falls fell by 18 percent and in one by as much as 37 percent.

As Marsh summarizes: “We were blown away by what happened when we routinely asked “What matters to you?” Our cognitively impaired patients become calmer, less withdrawn, and less depressed. And the data revealed they were also safer because we were finding their unmet needs. We had no idea the impact this small change would have on patient safety.”

You may also be interested in:

Listen to the full recording of this show in the WIHI archive, along with slides, resources, and the chat discussion. Subscribe to the WIHI podcast by searching for “IHI” through iTunes or your favorite podcast app.

Read how the Sutter Health team found a way to help an older patient attend lunches with his ROMEO club — “Retired Old Men Eating Out.”

See IHI’s vision for “What matters to you?”

Learn more about innovations in patient-centered care through these IHI offerings:

Have you tried this with a patient or family member? We’d love to hear your story. Email us a description (or video) of your conversation about to WhatMatters@ihi.org.

 

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