This interview with Maulik Joshi is the sixth in a series of brief chats between CFAH president and founder, Jessie Gruman, and health care experts - among them our CFAH Board of Trustees - who have devoted their careers to helping people find good health care and make the most of it.
Enabling People's Engagement in their Hospital Care
Gruman: What is the role of HRET with regard to people's engagement in their health and health care?
Maulik Joshi: The participation of individuals and their caregivers in hospital care has taken on increasing importance for us in all our activities as we have come to realize how central those attitudes and behaviors are to the delivery of quality care.
We have used the six aims from the IOM Quality Chasm report as the framework for our activities since it was published.' I would say that we have done a pretty good job of addressing all of them, although equity and patient-centeredness will require us to redouble our efforts.' We have started this process with some initial reports, but this will require sustained attention over time to change the culture of the hospital and health care delivery overall.'
Gruman: How do you approach this whole issue of people's participation in their care in the hospital? That is a somewhat rarified situation ' most of us are mostly not in a hospital when we are ill, and when we are, we are often too sick to actually be knowledgeably involved in our care, at least in the conventional sense.
Maulik Joshi: Without a doubt, a hospital stay is just one part of the continuum of health care.' Whether we are in a doctor's office, getting a home health visit, in the hospital or at home, there are opportunities to better engage patients and families in their care.' In working with our hospitals, we know we have an opportunity to engage patients and families at the point of care.' Part of the focus is what do we do at the bedside when a professional or staff member is talking with a patient or caregiver. And then there are the organizational or the environmental aspects: how to make it easier for patients and their caregivers to manage what can be a pretty difficult time.
We've been trying to identify better practices. There are some that we are testing and learning from and we need to do more of that. ' Opening up visiting hours, for example, is a practice that has proven to have positive benefits to patients, families and outcomes, though implementing this is not always easy.' All hospitals should make it as comfortable and possible for people to be with their family members and loved ones.
Gruman: What are some other changes you are looking at?
Maulik Joshi: We are doing some work on bedside change of shift reports, for example.' How do clinicians communicate information about a patient from one shift to the next and how can patients and families be involved, both as observers and as participants in that process?' We are experimenting with this now, learning how to fit it into the daily operations of different kinds of units.'
AHRQ has funded AIR to develop some materials that can be used to facilitate patient and caregiver participation in shift changes and we will use those materials to guide us with future research and guidance on this and on other areas, such as discharge planning.
Gruman: It strikes me that even those two changes represent a monumental shift in where and how people are able to participate in their own care and the care of those they love.
Maulik Joshi: You are right about that.' Little changes can make a big difference both practically and symbolically.' ' In the past, there was a stereotype of the patient as the passive recipient of our professional ministrations in hospitals. ' The shift from the status quo to what Don Berwick characterized as a 'Nothing about me without me' culture represents a huge organizational shift and requires corresponding shifts in individuals' attitudes and behaviors...on the part of administrators, clinicians and staff, as well as patients and caregivers.
Gruman: You are right it represents a really fundamental change in assumptions about roles and responsibilities. How are you approaching it?
Maulik Joshi: At the organizational level, we say it is about leadership. ' More leaders are becoming more convinced that this is important'they are looking at the facts on the ground and are realizing that they must work actively to make it possible for others to change.' You can see it in doctors' practices too: there is greater acknowledgement that chronic disease requires a different kind of care, that true shared decision making makes sense for patients.
The reality is that health care requires teamwork more so today than ever before. There are thousands of clinicians and staff members working today who are going to need to learn how to effectively work as a team while maintaining the scientific or other expertise of their own discipline.
We have an AHRQ-sponsored initiative on teamwork training that focuses on communication skills and how to ensure patient safety. The aim is to build skills that are important.' We're finding that it takes time but that people can actually learn how to do this and then act differently and produce different outcomes for their patients.
We also see the need to address people's engagement in their care in the physical arrangements in hospitals.' As we plan and design and construct facilities for future health care, we are starting to ask 'Is there a space for group visits? Where do families and doctors meet with the patient together?' It's hard enough to make a change of this magnitude in an engrained culture but to make it in a physical environment that doesn't accommodate it ' one that is make-shift or make-do or temporary ' we're going to have to do better than that.
Gruman: These efforts are really timely, but like you, I believe it's going to take a lot to make meaningful cultural changes. What's your level of optimism about this?
Maulik Joshi: From the hospital perspective, interest and readiness have never been higher.' We know we can't go on with the status quo. A singular focus on the efficiency of care or the quality of care will not lead to the improved outcomes that we and the American public expect.
If patients and families are not an integral part of our improvement efforts, we will fail. We don't know all of the right answers now. We do know, however, that no one size fits all: no one approach to making hospital care responsive and tailored to patients' needs is going to work in every setting. This poses both a challenge and opportunity.
We have some immediate concerns to address, but we also have to prepare today for concerns on the horizon.' For example, in 2042, minorities will be the majority of the population. How do you continue to deliver excellent care as your patient base and community rapidly changes?
We need to build a culture that is sufficiently flexible to address this and other challenges, and we need our multidisciplinary workforce to implement the specific practices and procedures and approaches like team care and multidisciplinary care planning with patients and caregivers. We are making good headway on the specifics, but culture takes time: we have a workforce in place and generations of new professionals joining every year who are increasingly trained to deliver care that better meets patients needs. I know the momentum is on the side of meaningful change. Some may consider this an anxious time in health care.' I think it is the most exciting time knowing that we can fundamentally improve how providers and patients work together to improve health care.