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Patient- or person-centered care places the needs, desires, values, and rights of the patient at the center of their care. It seeks to partner with the patient, understanding and supporting their preferences within the boundaries of safety, evidence-based care, and available resources.
Research suggests person-centered maternity care may facilitate improved experiences for pregnant women, which in turn encourages them to return to the facility for general and reproductive health care, as well as subsequent births. It may improve postnatal care and lower newborn complications, which could decrease morbidity and mortality among women and babies.
Jacaranda Health served as the implementation partner for an IHI Breakthrough Series Collaborative designed to improve person-centered care at three health facilities located in and around Nairobi, Kenya. An in-depth literature review conducted prior to the start of the collaborative offered no workable ideas or concepts that could be adapted for this low-resource context. Many papers reported interventions in maternity focused around enhanced antenatal care and required intensive time and effort. As such, front-line health care providers who were members of the facility quality improvement (QI) teams developed nearly all the change ideas tested during this project.
During extensive baseline interviews performed soon after receiving care, patients stated which aspects of patient- or person-centered care were important to them and their own experiences in either the three collaborative facilities or three equivalent facilities that acted as controls for research purposes. The collaborative’s focus, therefore, was to try to change staff behavior to meet the needs of patients as expressed to interviewers.
Some aspects of patient- or person-centered care that this project addressed included health care providers introducing themselves to patients, referring to patients by their names, explaining and asking for consent before performing procedures and administering medications, asking if patients have questions, allowing patients to have a companion in the room while they labor and deliver their baby, and stopping verbal abuse of women in labor.
Many of the change ideas were designed to remind practitioners to do something they weren’t used to doing. For example, to establish the task of explaining the purpose of common procedures as a routine practice, we linked it with the admission process.
At times we would hear from health care providers that the absence of these behaviors in their practice was based on custom. For example, it would be unnatural to address a woman by her name, and it would be too difficult during fast-moving procedures like delivering a baby to pause to explain something or ask permission before administering medication. This is not uncommon; one article described both patients and nurses justifying abuse during delivery, saying it is beneficial for women because it ensures that they cooperate with the birthing process. However, we embarked on this collaborative because hundreds of women in baseline interviews said they would prefer these components of patient- or person-centered care to be part of their care experience. There was a major disconnect between the expectations of women seeking care and of providers who gave care.
As part of introducing any new aspect of patient- or person-centered care to collaborative teams, we invited them to reflect on the potential benefits of this change in practice. Their responses were wide-ranging and insightful. We also shared the results of the baseline survey interviews in which their own patients had indicated these behaviors were inadequately performed and important to them.
We found the most effective way of demonstrating the benefits of aspects of patient- or person-centered care was to have QI team members first introduce changes in their own practice on a temporary basis and reflect on the outcomes. Once convinced, we encouraged them to continue the practice and share their experiences with peers through storytelling. We know peer-on-peer influence is powerful. Nurses or other providers would share with their colleagues how introducing themselves to a patient seemed to develop trust. The patient shared more freely about her concerns, asked more questions, and became more involved in her own care. This approach was effective within peer groups but less so across professional groups, particularly from nurse to doctor where the difference in seniority and status inhibited the nurses from sharing. We had been unsuccessful at recruiting or retaining doctors on the QI teams, and this limited our ability to influence this cadre of staff.
The project also faced structural challenges. In most of the facilities in the project, patients reported that providers did not allow them to have a companion accompany them during labor or delivery. Some of the labor and delivery rooms in the maternity departments we worked with were extremely crowded. Four to five women shared a bed in the labor room, and the delivery room had three cots separated by curtains with only a couple of feet on either side for the attending providers to stand and work. Providers brought women into the delivery room just before they would push, and then moved them to the post-natal room very quickly after delivering to make room for the next woman who was ready to deliver. With so little space and so many women moving through the labor and delivery rooms, it was structurally impossible to accommodate companions in some of the facilities.
During the patient- or person-centered care collaborative, members of staff described very positive interactions with patients after introducing small changes in practice, such as calling the patient by their name. This greater openness and cooperation enabled them to provide better care.
There has been so much learning from this work. Some of the highlights about providing more person-centered care include:
- Much of patient- or person-centered care can be encompassed in two simple rules: “Do to others what you would have them do to you” and “Nothing about me, without me.”
- Small changes can make a huge positive difference to the patient and to you as you provide care.
- Don’t underestimate the role a patient can play in their own care when you engage them.
- Many aspects of patient- or person-centered care have no costs but require a bit of extra time up front. By preventing problems, you’ll save time in the long run.
Jacaranda Health continues to capture feedback from women about their experiences of care during antenatal visits and delivery as part of its digital health tool, PROMPTS, and provides anonymous feedback to hospitals to support improvement efforts.
Meghan Munson, MPH, is an Independent Quality Improvement Coach (formerly at Jacaranda Health) and IHI Faculty Member. Cathy Green, MBA, BSc, is an Independent Senior Improvement Advisor and IHI Faculty Member.