Patient expectations and the paradigm shift of care in emergency medicine.

Patient expectation in health care continues to increase and this is something that needs to be managed adequately in order to improve outcomes and decrease liability. Understanding patients' expectations can enhance their satisfaction level. In the environment of the Emergency Department, with the acutely ill, serious and time-dependent issues as well as high level of stress, managing patient expectations can indeed be challenging. This paper discusses patients expectations and proposes implementation of elements of patient-centered care and value-based care into our existing health care systems today.

INTRODUCTION

Expectations, with reference to healthcare, refer to the anticipation or the belief about what is to be encountered in a consultation or in the healthcare system. It is the mental picture that patients or the public will have of the process of interaction with the system. Patients come to a consultation with expectations which they may or may not be overtly aware of. These expectations may be openly presented or the physician may have to attempt to elicit them. Reactions to unmet expectations can range from disappointment to anger. Thus, knowing the expectations of our patients can help avoid these reactions, enhance their healthcare experience, and reduce our exposure to liability. Studies have shown that as much as 70% of litigation relates to real or perceived problems involving physician communications, which influences patients’ expectations. Not meeting expectations can also result in non-compliance or suboptimal compliance and affect physicians’ reputation in a community.

Patients with unmet expectations may never complain to the physician directly but instead they just will not return for ongoing and follow-up care.[12] The days of absolute trust and blind obedience to doctors are over.

Understanding and managing patients’ expectations can improve patient satisfaction, which refers to the fulfillment or gratification of a desire or need. When we can “read” our patients, they are grateful. They will sense we understand them better because our responses are accurate and appropriate to what they expect and feel deep inside.

For patients in the emergency department, due to the acute and sudden nature of their problems, stress and anxiety levels are usually high. Managing the expectations of these patients and their families becomes even more challenging in an environment where many actions are time dependent.[3-5]

As we plan to meet the increasing expectations, it becomes inevitable that the elements of patient safety will have to be considered as well. When addressing satisfaction issues, matters related to medication errors, falls and fall precaution, timely laboratory results review and procedural verification (which are closely linked to patient safety as well) are indeed very relevant.

In general, quality in healthcare has two dimensions: the objective and technical part as well as the subjective and qualitative part. Much as the former is important, as we continue to develop the state-of-the-art healthcare system and infrastructure, the latter is just as critical. What patients think of their experience with the healthcare system must matter to the healthcare planners, managers and policy makers because this experience, as much as the technical quality of care, will determine how people use the system and how they benefit from it. Somehow, technological innovations in medicine seem to have shifted some of the physicians’ attention away from the personal care of patients.[13-4]

MANAGING PATIENT EXPECTATIONS

Exploring patients’ expectations is crucial for ensuring delivery of healthcare of the highest quality. Patients’ expectations continue to increase. Therefore, a satisfactory balance should be achieved between patient expectations, physicians’ perceptions, and priorities set by healthcare planners. Every patient who comes for consultation has expectations based on his understanding of the illness, cultural background, health beliefs, attitudes, and level of understanding. Patient demographics and visit characteristics also contribute toward this. How far the physician reaches an understanding with the patient will also have an impact on the successful outcome of the consultation.[4] The price healthcare providers and hospitals have to pay for dissatisfied patients and customers is indeed high, thus the investment of some time to understand this issue is certainly worth the while.

Some of the general expectations of patients include:

the need to be listened to

the need to receive clear explanation and instructions about their condition

to be treated by staff who show care/concern/compassion and

to be treated by staff who are professional in their work

Some examples of unrealistic expectations of patients would include:

wanting to discuss several major problems, all in one standard consultation

prescription to be given without a consultation

ability to call the physician 24 h a day for any problems and

thinking that the physician will always know the exact diagnosis at first consultation and start treatment immediately

To manage unrealistic expectations and unreasonable requests from patients, the astute physician would know:[6-7]

that they should not allow patients to manipulate them with unreasonable demands

they have to take a step back and assess why certain requests are put forth. This exploration can also enhance communications skills

they need to explain clearly in simple terms, avoiding medical jargon, why certain treatment and management is necessary. Physicians’ logic may not be obvious to patients and our decision making can be complex, thus, the need for explanation

they need to be clear as to why further tests and consults are needed

that a patient's request for a second opinion from another physician is acceptable and,

that as a last resort, the patient can be referred to another physician for care, if both parties cannot come to an agreement and see eye to eye.

For EDs to make meaningful progress in enhancing patient care, safety, satisfaction, and quality, staff must listen and respond to patients and customers. Communications delays must be cut. Treating patients as individuals, managing their pain, and providing adequate information on treatment are all crucial, as are patient safety elements. The best approach would be to communicate well and try to develop a trusting relationship. Physicians should be honored that our patients trust us with their health. At all times, we must strive to ensure patients understand the rationale for treatment and what to expect e.g. duration of therapy, side effects, costs, etc. Finally, we must always leave room for them to question, especially if there are concerns not addressed.

As we move into the future, the continuum of care for patients will continue to evolve and a paradigm change becomes inevitable in order to make patient care more meaningful, efficient and impactful. The focus will continue to be on improving patient care and the value of healthcare for patients. This is where approaches such as the value-based system of care and patient-centered care become relevant.

PATIENT-CENTERED HEALTH CARE

Patient centered care (PCC) is an approach gaining much emphasis these days. It is one where we consciously adopt patients’ perspectives, and mainstream them into all aspects of the healthcare system and its related processes. It involves navigating the healthcare system through patients’ eyes. PCC represents customized patient care, viewed as a commitment to treat and manage patients as thinking and feeling persons with the ability to change and develop. It requires healthcare personnel to be open, flexible, and respectful in the provision of all aspects of care. It is also a partnership between patients and their healthcare providers. PCC is alignment with the 21st century, modern patients who are increasingly asking to be partners in their own care, highlighting also, ownership of their health, and healthcare.[89]

The approach to PCC can be divided into three broad areas:

Respect for patient values, preferences, and expressed needs: This is crucial as many patients feel that they lose their identity as individuals when they come to hospital and become “one of the cases.” They feel the importance to be recognized as unique and to be actively involved in decision making relating to their care and treatment. Their cultural beliefs and practices too will be respected. This approach helps to preserve their dignity. It also helps to evolve their role from a passive one to a more active and knowledgeable one, in their best interest. It enhances their participation and thus empowerment. With the motivation, they will tend to be more compliant and pay greater attention to physicians’ advice and communications and this is a step in the right direction toward enhancing patient safety and safe practice as well.

The coordination and integration of care: Patients feel vulnerable when they are faced with illnesses and they feel the need for competent and caring healthcare personnel. They need to make that “connection” and feel comfortable with all aspects of the care i.e. front line or acute care, auxiliary as well as support staff. The seamless patient and process flow will help with this objective and at the same time, enhance patient safety elements.

Information, communications, and education: Adequate information must be shared with patients and this would include clinical, management, and even prognostic information. This is very relevant to increase the understanding of the concept for self-care and individual health promotion. Patient safety guidelines do emphasize this aspect of care as well. For example, with better communications and education, errors in prescribing and errors in omission can be gradually reduced, especially if we communicate better our intent, explain the effects of drugs, and why certain medications are required (or not required).[10]

The quality of PCC in a hospital or institution is one that will transcend all other programs and activities. It represents the whole broad picture of institution-wide care and requires the “buy-in” from all levels of staff. It is one of the ways recommended to enhance, maintain, or even restore patients’ trust and confidence.[11-13]

PCC must be a manifestation of an organization-wide culture, including the leadership, who must set the tone. Having said that, large academic centers must also strive to find the balance to strike, considering the myriad of needs and interest of clinical specialists, nurses, medical educators, researchers, administrators, and other staff.[14-16]

With the understanding of PCC, it is certain that more time commitment will be required, especially pertaining to patient contact, care, and communications. In the busy emergency department, where resources such as manpower are already stretched to the maximum, this can add to the waiting time and overcrowding issues. These may delay care and certainly pose a challenge to front line emergency department staff. Moreover in the ED, the lack of prior relationship between patients and the healthcare providers as well as the acute nature prompting ED visits can pose further challenges to the creation of a meaningful, effective partnership. Cases in the ED, such as violence and abuse, time-sensitive diagnoses, and resuscitation as well as sudden death, make it necessary to have thoughtful, advanced planning for the PCC approach.[3]

VALUE-BASED HEALTH CARE

A value-based system is one where the focus is on value and in rewarding innovation that advances medicine. It strives to improve health and healthcare value for patients. Physician leadership is crucial as improving the value of healthcare for the patient is something only medical teams can do. The principles that need to be focused on would include the following.[17-18]

Understanding that the goal is value for patients

This may appear very basic but our current practice do not stress on this sufficiently. In fact, success has always been defined as increasing revenue and operating surpluses. Insurers too want to be profitable and physicians want more patients in order to increase revenue for their practice. There will also come a time when many may move into private practice. Patients, on the other hand, want good health outcomes, not more visits, and increased cost. Improving value for patients is clearly the only valid goal for ethical reasons.

Medical practice should be organized around medical conditions and care cycles

Here is where health care delivery needs a revamp. Currently physicians tend to define their activities by their specialty. However, for patients, what matters is their medical condition. Organizing care around medical conditions rather than specialties is key to improving value to patients. A medical condition can be defined as a list of inter-related medical presentations that must be addressed in an integrated way, thus many specialists may have to come and manage the patient in an integrated way rather than the patients making various appointments, on different days to see each of these individual specialists. The current care “silos” would have to be broken down as it “fractures” patient care into various artificial segments. The more such segments a patient has to go through, the higher will be the chances of errors occurring (thus, patient safety consideration). This will come as a major change for healthcare personnel, but is worth implementing in strive toward seamless healthcare.

Results (such as risk adjusted outcomes and costs) must be measured.

This is important to monitor performance and chart the direction forward. To be most useful, outcomes should be measured over the complete care cycle. Physicians should lead the way in the development and use of these outcomes measures. The reasons for measuring must also be made known clearly to staff as many tend to view these as a threat. This perception can certainly affect performance. If it is led by physicians, it might be easier to overcome this misperception and thus may be easier for many to appreciate the power of these numbers to push for excellence. It is also known that motivated staff will gravitate toward areas that achieve true excellence.[18]

In the area of patient safety for example, some of the statistics which matters include numbers of drug related errors, wrong site procedures, and falls whilst in the department.

How then is value-based care appropriate to the practice of emergency medicine?

Understanding that the goal is value for patients

This is very relevant to the practice, as emergency care is acute and time-dependent care. Thus, there is the need to maintain high standards, be timely, efficient and at the same time provide satisfactory service, including communications. Patient satisfaction surveys done in emergency departments confirm that patients want these. Patient and public feedback is useful to be taken into account in evaluating service and care, and when introducing reforms.

Organizing practice around conditions and care cycles

How often have we seen a patient with the all of the following presentation:

Sepsis, with fever

Non-ST elevation acute myocardial infarction (MSTEMI), with elevated cardiac markers

Elevated D-dimer levels and with a

Non- healing diabetic foot ulcer

Emergency physicians (EP) will sort the patient's issues out through history, physical examination, and front line investigations. However, when it comes to admission, which specialty is going to take ownership of this patient? Will it be infectious diseases (for the sepsis), cardiology (because there is an associated NSTEMI), respiratory medicine (elevation of D-dimer), endocrinology (for diabetes mellitus) or the orthopedic surgeon (for the orthopedic foot ulcer). More often than not, the patient will stay longer than necessary in the ED as communications go on between the EP and various specialty doctors, to discuss who eventually gets the patient. Consider also the time spent sorting this out, communicating with patient, relatives and other doctors/staff and the duration the relatives have to wait, whilst we sort out the “differences” between us. Would it not be better and more efficient to admit the patient and then have the various disciplines/specialty doctors come around to manage him as a team, providing comprehensive care. This illustrates treatment/management around the medical conditions of the patient.

Results must be measured

ED statistics are almost necessary as a standard in order to assess how the department is performing. Many EDs measure parameters such as the number of patients seen by each staff, infection rate, door to ECG time, door to needle/ balloon times, time to CT scan for stroke patients, mortality, and many others. These statistics have to proactively acted upon as well in order to effect positive improvement and changes.

The value-based system will indeed help to empower the healthcare professionals, and not just the administrators, to be at the heart of care provision and decision making. It will help EDs fine-tune and evolve their processes and practices to meet the changing needs and evolving expectations of patients.

CONCLUSION

As healthcare is everyone's responsibility, health services are structures to aproportion accountability and incentives to patients, physicians, and other players. Coordination is the multiplier that transforms limited resources into effective health outcomes. Patients and physicians must have a relationship connected by open access to information, coaching, and support. Emergency physicians in Hong Kong have come up with a list of 10 Cs, helpful and applicable for quality emergency care and risk management: competence, confidence, comfortable, careful attitude, compliance with protocols, checklists, courtesy, being calm and controlled, compassionate, and considerate as well as timely and appropriate communications…the same values we all strive for.[19]