Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

A balance of quality care and patient satisfaction Jay M. Milstein To cite this article: Jay M. Milstein (2015) A balance of quality care and patient satisfaction, Hospital Practice, 43:1, 28-30, DOI: 10.1080/21548331.2015.995413 To link to this article: http://dx.doi.org/10.1080/21548331.2015.995413

Published online: 24 Dec 2014.

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Date: 15 March 2016, At: 04:07

http://informahealthcare.com/hop ISSN: 2154-8331 (print) Hosp Pract, 2015; 43(1): 28–30 DOI: 10.1080/21548331.2015.995413

LETTER TO THE EDITOR

A balance of quality care and patient satisfaction Jay M. Milstein Division of Neonatology/Department of Pediatrics, University California, Davis, Sacramento, CA, USA

Keywords: Curing, healing, integrative care, patient satisfaction, quality care, wholeness

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History Published online 25 December 2014

Imagine eavesdropping on a highly plausible discussion between two families in the waiting room of an intensive care unit. One family member states, “These folks really took care of our mom despite all the complications. They led us down paths we’d never known or explored; it was very meaningful. We felt valued”. A member of the other family responds, “Our experience was totally opposite from yours. We felt demeaned, confused, and unsupported. Those final memories of and for our dad were deplorable”. In the current millennium, health systems have come under increasing scrutiny. Metrics are being applied to both the quality of care as well as the perception of this quality in terms of patient satisfaction. Institutional and patient/family goals are to maximize or optimize both. Yet there often seems to be a disparity between the attainment of high-quality care and patient satisfaction. Perhaps patient satisfaction is dependent on more than just high-quality care that is curative in nature – and dependent also on more holistic care that is healing in nature, which addresses their human experience as well. In 2004, Wachter and Shojania [1] published their text, Internal Bleeding. Extrapolating from their text, we may strive to reach our goals and eliminate the chasm between quality of care and patient satisfaction. Their dedication reads: “For the patients and caregivers let down by the system they trusted”. Of equal interest their closing lines reads: “As healers and as patients, we will all be more compassionate with – and more understanding of – each other. We are all in this together”. Their closing comments may provide a segue to a possible solution. Historically medicine was practiced from a paternalistic perspective [2]. In essence, decision making was physician-driven. At the other end of the decision-making continuum, autonomous patient-driven decision making

prevailed. When compassionate communication exists between the caregivers and the patients, it permits a compassionate presence, one infused with trust and empathy, to coexist along the entire continuum [3]. In essence, independent of where patients and their caregivers fall along the continuum, when compassionate presence exists, the relationship between them is preserved. Furthermore, a compassionate presence creates a relationship that may be invaluable to long-term care independent of the designated decision maker. When a compassionate presence coexists between the caregivers and the patients, even if the patients have chosen autonomous roles in their decision-making process, the patients do not experience a sense of abandonment even though their decisions may not be consistent with physicians’ recommendations, had a paternalistic model been in effect [3]. Ongoing support remains critical to the physician–patient relationship as families continue to confront additional challenges as care continues. When such a relationship is established, the outcomes measured, whether quality of care or patient satisfaction, are more likely to be in synchrony with each other. If both adhere to a common goal with a sense of trust and empathy (compassion) [3], then pursuit of such a goal engenders a sense of satisfaction on both sides. If one were to visualize a balance of curing measures grounded with a mindset of ‘doing to’, addressing the biologic and physical elements of disease, and healing measures grounded with a mindset of ‘being with’ [4], addressing the human elements of illness (Figure 1), a yin/yang duality balancing healing and curing can coexist (Figure 2) [5]. Healing and curing are introduced in parallel. Because a loss can be experienced in the absence of death, bereavement is represented as a continual process from the outset. Continual hope and the transition from

Correspondence: Jay M. Milstein, MD, Division of Neonatology/Department of Pediatrics, University of California, 2516 Stockton Boulevard Ticon II, Room 354, Sacramento, CA 95817, USA. Tel: +1 916 734 8921. Fax: +1 916 456 4490. E-mail: [email protected] Ó 2014 Informa UK Ltd.

Letter to the Editor

DOI: 10.1080/21548331.2015.995413

Healing

nt eav eme

Death

hop

Ber

Ber

Curing

Con tinu al

eav eme

nt

e

Integrative*

*Midset of “Being with” and “Doing to”

Diagnosis t0

Time

Hopelessness

Wholeness

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Figure 1. Integrative paradigm of care.

Course

Curing

Healing

Figure 2. Yin/Yang duality of care.

hopelessness to wholeness are added [4]. In Figure 2, the white area, yang, represents the curing elements of care, and the black area, yin, represents the healing elements of care. The course through a disease and illness is represented by the scroll running from the top, which corresponds to the onset, to the bottom, which corresponds to the end. The two horizontal lines demonstrate the shifting balance or duality between curing and healing at different stages of the disease and illness [5]. The usual measurable outcomes related to quality of care fall in the domain of the so-called ‘doing to’ and curing side. Although performance along the curing side has impact on patient satisfaction, we hypothesize that patient satisfaction is impacted to a greater extent by performance along the healing side of the paradigm of integrative care [4]. Delivering care that variably balances curing and healing elements may help patients and their families find a path to wholeness.

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Physicians, nurses, social workers, chaplains, respiratory care therapists, epidemiologists, and other personnel (including pharmacists, physical therapists, infection preventionists, lean six sigma quality and safety experts, managers, administrative support, and administrators) may comprise a comprehensive multidisciplinary team. The first four disciplines may resemble a palliative care team, whereas the more extensive list corresponds to a team focused on quality measures, particularly patient safety indicators. Designation of the first four is intentional, because each discipline may be vital to holistic care, which may be particularly valuable in providing healing measures and enhancing patient and family satisfaction. My hypothesis is this: If the healing and curing elements are implemented in parallel, patient satisfaction is likely to improve. Creating a shared decision-making environment along with a mindset of healing measures could be implemented throughout a health system. Alternatively, and perhaps more realistically, it could be utilized by service line, department, or geographic area within a health system to demonstrate its utility in enhancing patient satisfaction on a pilot basis. Health system ‘report cards’ reflect on performance in curing as well as healing domains. Performance in the healing domains may actually have a greater impact on the scores given. Hypothetically if one’s father, grandmother, or other loved one died during a hospitalization, but he or she and the family were treated compassionately, with their cognitive, emotional, and spiritual needs addressed, the sense of wholeness may enhance the degree of satisfaction [4]. Such explorations may ultimately be of much greater value than still another review of the facts of the case, including yet another patient safety indicator that may have arisen. ‘Being with’ the family and facilitating an experience of family members being with each other may be of the utmost value at these critical times in their lives. Introducing a compassionate presence, in which there is a fundamental sense of genuineness (empathy and trust) on the part of the caregivers and patients alike, is imperative. Ideally, this relationship has to be established over a more extensive period and not solely at a terminal moment in the patients’ course. The viewpoints of the caregivers and patients may not be aligned; however, it is essential that the patients and families do have a mutual sense of trust and respect. Rather than ask how patients or their families are feeling in terms of a comprehensive symptom review, it may be far more meaningful for the caregivers to explore how the patients or their families feel about having a particular disease. Raising a few simple thoughts, ones that open up dialogue or at least contemplation regarding the cognitive, emotional, and spiritual reactions to the illness, may enhance crossing over from the factual, curing side of care to the healing side. These healing moments may be particularly rich in terms of patients’ and families’ experiences and perceptions of these moments in the hospital.

Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

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J. M. Milstein

References

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[1] Wachter RM, Shojania KG. Internal bleeding. The truth behind America’s terrifying epidemic of medical mistakes. New York: Rugged Land; 2004. [2] Kon AA. The shared decision-making continuum. JAMA 2010;304:903–4.

Hosp Pract, 2015; 43(1):28–30

[3] Milstein JM. “I’m troubled, Doc!” – Reflection on the care of elderly patients. Clin Geriatr 2013;21:10. [4] Milstein JM. Our moral imperative: finding a path to wholeness. Clin Pediatr (Phila) 2014;Epub ahead of print. [5] Milstein JM, Raingruber B. Choreographing the end of life in a neonate. Am J Hosp Palliat Med 2007;24:343–9.

A balance of quality care and patient satisfaction.

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