Wednesday, June 02, 2010

Donald Berwick's vision for patient-centered health care

Here are some of the particulars from his article in Health Affairs:

Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has important differences from the more classical, professionally dominated definitions of "quality."

Heck, why did we even bother to go to med school?

Here Berwick contrasts his radical consumerist view with the more traditional model of professionalism:

Freidson’s definition of a profession contradicts the usual assumption of consumer-oriented production, in which the customer, not the producer, has the "authority," exercised by marketplace choices, to judge quality. In Freidson’s world of professions, excellence is in the eye of the professional. In the more normal world of products and services, excellence is in the eye of the customer.

I think it wrong for the profession of medicine—or any other health care profession, for that matter—to "reserve to itself the authority to judge the quality of its work."

Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient.

Patients and family members would participate in rounds.

Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, "Should patient ‘wants’ override professional judgment about whether an MRI is needed?" My answer is, basically, "Yes." On the whole, I prefer that we take the risk of overuse …

And what if this leads to enormous waste?

If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices—like lots and lots of patients’ choosing scientifically needless MRIs—then we should seek to improve our messages, instructions, educational processes, and dialogue...

... I wish we would abandon the word "noncompliance." In failing to abide by our advice or the technical evidence, the patient is telling us something that we need to hear and learn from.

For quantitative ratings, ask patients to rate on a 1–5 scale disagreement to agreement with the assertion: "They gave me all the care I needed and wanted exactly when and how I needed and wanted it." Seek 5s and study the low raters.

...firmly vest in patients and families control over decisions about care in all its aspects. Take over control only rarely and with permission freely granted.

I freely admit to extremism in my opinion of what patient-centered care ought to mean.

How do these ideas square with the mandate for the director of CMS to improve efficiency and reduce waste?

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