Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Drive, Outram Road, Singapore Find articles by Fatimah Lateef Received 2010 Apr 8; Accepted 2010 Apr 18. Copyright © Journal of Emergencies, Trauma, and Shock This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. Keywords: Expectations, emergency department, patient-centered care, value-based care, satisfaction, patient safety, outcome measures, value-based care 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.[1,2] 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.[1,3–4] 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:
Some examples of unrealistic expectations of patients would include:
To manage unrealistic expectations and unreasonable requests from patients, the astute physician would know:[6–7]
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 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.[8,9] The approach to PCC can be divided into three broad areas:
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] 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]
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?
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. 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] Source of Support: Nil. Conflict of Interest: None declared. 1. Hoy E. Measuring patient experiences of care. Bull Am Coll Surg. 2008;93:13–6. [PubMed] [Google Scholar] 2. Farooqi JH. Patient expectation of general practitioner care. Midd East J Fam Med. 2005;3:1–6. [Google Scholar] 3. Taylor D, Kennedy M, Virtue E, McDonald G. A multifaceted intervention improves patinet satisfaction and perceptions of Emergency Department care. Int J Qual Health Care. 2006;18:238–45. [PubMed] [Google Scholar] 4. Sun BC, Adams J, Orav EJ, Rucker DW, Brennan TA, Burstin HR. Determination of patients satisfaction and willingness to return with Emergency care. Ann Emerg Med. 2000;38:426–34. [PubMed] [Google Scholar] 5. Taylor DM, Wolfe RS, Cameron PA. Analysis of complaints lodged by patients attending Victorian hospitals, 1997-2001. Med J Aust. 2004;181:31–5. [PubMed] [Google Scholar] 6. Altman JH, Reich P, Kelley Mj, Rogers MP. Sounding Board. Patients who read their hospitals charts. N Engl J Med. 1980;302:169–71. [PubMed] [Google Scholar] 7. Stevens DP, Stagg R, Mackay IR. What happens when hospitalised patients see their own records. Ann Int Med. 1977;86:474–7. [PubMed] [Google Scholar] 8. Patient- and family-centered care and the role of the emergency physician in providing care to a child in the ED. (American Academy of Paediatrics and American college of Emergency Physicians) American Academy of Paediatrics. 2006. [Last accessed on 2010 June 11]. Available from: www.pediatrics.org/cgi/doi/co.1542/peds.2006-2588 . [PubMed] 9. Family centered care and the paediatrician's role. Pediatrics. 2003;112:691–7. [PubMed] [Google Scholar] 10. The Joint Commission. Accreditation Program: Ambulatory Healthcare. National Patient Safety Goals. 2009: The Joint Commission on Accreditation of Healthcare Organisation. [Last Accessed on 2010 Apr 17]. Available from: http://www.jointcommission.org/ 11. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Preferences of patients for patient-centered approach to consultation in primary care: An observational study. BMJ. 2001;322:468–72. [PMC free article] [PubMed] [Google Scholar] 12. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;152:1423–33. [PMC free article] [PubMed] [Google Scholar] 13. Stevenson FA, Barry CA, Britten N, Barber N, Bradley CP. Doctor-patient communication about drugs: The evidence for shared decision making. Soc Sci Med. 2000;50:829–40. [PubMed] [Google Scholar] 14. Davies PG. Patient centeredness. J Epidemiol Community Health. 2007;61:39–49. [PMC free article] [PubMed] [Google Scholar] 15. Carlton T, Cheetham A, DeSilva K, Glazebrook C. International schizophrenia research and the concept of patient-centeredness: An analysis over two decades. Int J Soc Psychiatry. 2009;55:157–69. [PubMed] [Google Scholar] 16. O’Connor AM, Legare F, Stacey D. Risk communications in practice: the contribution of decision aids. BMJ. 2003;327:736–40. [PMC free article] [PubMed] [Google Scholar] 17. Berwick DM, James BC, Coye M. The connections between quality measurements and improvement. Med Care. 2003;41(1 suppl):130–8. [Google Scholar] 18. Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007;297:1103–11. [PubMed] [Google Scholar] 19. Chung CH. The 10 Cs for Emergency physicians. Hong Kong J Emerg Med. 2005;12:1–5. [Google Scholar] |