First Meeting of the Patient at the Centre of Care Initiative Reference Group, Manila, Philippines, 4-5 July 2006 : report

First Meeting of the Patient at the Centre of Care Initiative (PCI) Reference Group

Manila, Philippines 4-5 July 2006

<8) '%s ~

-~---

if

World Health Organization

Western Pacific Region

( WP)MNHIICP/MNH/2.4/001

English only

Report series number: RS/2006/GE/36(PHL)

REPORT FIRST MEETING OF THE PATIENT AT THE C~TRE OF CARE INITIATIVE REFERENCE GROUP

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 4-5 July 2006

Not for sale Printed and distributed by:

World Health Organization Regional Office for the Western Pacific Manila, Philippines October 2006

'\: l'

J.

~.~ .:j ~ ~.

I . • \."

~_ .•

,

iHANILA.l'HlLH ~)E\.L!>

NOTE The vi~ws expressed in this repll;1 are those of the participants in the First Meeting of the Patlent at ~h~ Centre of Care Initiative Reference Group and do not necessarily reflect the pohcles of the Organization.

•

I

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the First Meeting of the Patient at the Centre of Care Reference Group, which was held in Manila, Philippines from 4 to 5 July 2006.

SUMMARY The First Meeting of the Patient at the Centre of Care Initiative Reference Group was held at the Regional Office for the Western Pacific in Manila, Philippines, from 4 to 5 July 2006. Established as a sounding board for the biregional initiative, the reference group met to revie\v the initial working documents and recommend ways to effectively carry the work forward. The meeting was attended by five members of the reference group and eight WHO staff - seven from the Western Pacific Regional Office and one from the South-East Asia Regional Office. Also present were two representatives from La Trobe University, Australia, the contractor engaged by WHO to provide technical services in the implementation and documentation of the initiative. The objectives of the meeting were: (1)

to orient members on the Initiative - rationale, aims, outputs and work plan - and the team responsible for taking it forward; to update members on the progress of the Initiative thus far; to discuss key themes, issues and arguments put forward in the background scopint paper and suggest priority areas for inclusion/emphasis in the publication and/or policy framework; to obtain feedback and advice from members about the current draft of the outline of the publication. the policy framework, and the in-country consultation process; to seek member endorsement of project information for inclusion on the Patient at the Centre of Care Initiative website and for use in project-related correspondence and advocacy materials; and to agree on the group's ways of working for the duration of its working life.

(2) (3)

(4)

(5)

(6)

The meeting was conducted in a loosely structured manner that encouraged open and candid discussion and debate. Aside from the overview and the comprehensive presentation on the rationale, importance, focus, and planned activities and products of the biregional ir,:tiative, two members had the opportunity to present ongoing initiatives and experiences in their own countries. Some members and WHO staff also shared reference materials with those who attended the meeting. The members acknowledged the timeliness and importance of the biregional initiative, and announced its support for WHO in promoting the patient-centred and rights-based approach to health care, particularly in the Asia-Pacific region. It was noted that the draft documents had already identified and addressed a wide range of issues and concerns covering the four main health constituencies: (1) consumers and patients, (2) health practitioners, (3) health care institutions, and (4) health systems. However, the meeting stressed the need to further operationally define the focus of the initiative, and to deepen and structure the content of the policy framework and the four policy domains so that they would provide better guidance to

countries. It also made many important suggestions on how stakeholder consultations could be conducted effectively, and what advocacy and social marketing approaches could facilitate the spread of the patient-centred care movement as well as the adoption and implementation of appropriate policies and interventions by health ministries and other concerned sectors.

CONTENTS

I. 1.1 1.2 1.3 2. 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3. 3.1 3.2 3.3 3.4

INTRODUCTION .................................................................................................. I Objectives ............................................................................................................. I Opening of the meeting ......................................................................................... 2 Organization of the meeting .................................................................................. 3 PROCEEDINGS ................................................................................................... 3 Terms of Reference of the Reference Group ........................................................ 3 Introduction to the Patient at the Centre of Care Initiative ................................... 3 Presentation on Patient at the Centre: Reorienting Healthcare Practice for the 21" Century ............................................................................................... 5 Discussion on the polic)' framework ..................................................................... 6 Discussion on the country consultations ............................................................. II Discussion on advocacy and social marketing .................................................... 12 Wrap-up and concluding session ........................................................................ 13 CONCLUSIONS AND RECOMMENDATIONS ............................................. 13 General ................................................................................................................ 13 Policy framework .................................................................................................. 14 Country consultations ......................................................................................... 16 Advocacy and social marketing .......................................................................... 16

ANNEXES: ANNEX I ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 ANNEX 7 ANNEX 8 OPENING REMARKS .......................................................................... 17 LIST OF TEMPORARY ADVISERS AND SECRETARIAT ............... 21 TIMETABLE ......................................................................................... 23 PRESENTATION: PATIENT AT THE CENTRE: REORIENTING HEALTHCARE FOR THE 21 ST CENTURy ................. 25 DRAFT POLICY FRAMEWORK AND MATRIX .............................. 29 PRESENTA TION: 2020 VISION FOR HEALTH IN MALAYSIA ......... 39 PRESENTATION: HOSPITAL ACCREDITATION IN THAILAND .... .43 COUNTRY CONSULTATIONS; CHECK LIST OF QUESTIONS .... .45

Key words Health care/Patient centred care/Quality of care/Patient safety/Health policy/Health system responsiveness/Health c,'ld human rights/Philippines

- 1-

I.

INTRODUCTION

Overall socioeconomic development and unprecedented advances in science and technology have made the attainment by all peoples of the highest possible level of health closer to reality than ever before. However, health outcomes have not been consistently optimal. Patients and other health care consumers have been increasingly concerned about the quality of care they receive, particularly with the apparent "epidemic" of medical errors, even in developed countries with more mature and advanced health care systems. Concerned that health systems are not able to meet the needs and expectations of the public, especially the patients, the WHO Regional Office for the Western Pacific has embarked on the Patient at the Centre of Care Initiative as a biregional effort with the South-East Asia Regional Office. This effort further responds to resolution WPRlRC55.RI, passed by the WHO Regional Committee for the Western Pacific at its fifty-fifth session in September 2004, requesting WHO to draft a policy framework reflecting the significance of psychosocial factors affecting health outcomes. A document outlining the pertinent issues was prepared in 2005, and work on a draft policy framework is under way. The planned process involves a series of in-depth stakeholder consultations in selected countries in the Asia-Pacific region, as well as a reference group of experts to provide guidance to the Initiative. The First Meeting of the Patient at the Centre of Care Initiative Reference Group was held at the Regional Office for the Western Pacific in Manila, Philippines, from 4 to 5 July 2006. The meet,ng was organized for members of the reference group to review the initial working documents and make recommendations for improvement. It served as a forum for the members and the secretariat to exchange their views and experiences and to further guide the preparation of a policy framework for reorienting health systems towards patient-centred care. It placed emphasis on the setting of a clear direction for taking the work forward, and on reaching consensus regarding effective approaches and priority actions for the development of the policy framework on patient-centred care, for the stakeholder consultations in selected countries in the Asia-Pacific Region, and for advocacy and social mobilization. 1.1

Objectives (I)

To orient members on the Initiative - rationale, aims, outputs and work plan - and the team responsible for taking it forward. To update members on the progress ofthe Initiative thus far. To discuss key the~1es, issues and arguments put forward in the background scoping paper and suggest priority areas for inclusion/emphasis in the publication and/or policy framework. To obtain feedback and advice from members about the current draft of the outline of the publication and/or policy framework and about the in-country consultation process. To seek member endorsement of project information for inclusion on the Patient at the Centre of Care Initiative website and for use in project-related correspondence and advocacy materials.

(2) (3)

(4)

(5)

-2-

(6)

To agree on the reference group's ways of working for the duration of its working life.

1.2

Opening of the meeting

Dr Linda Milan, Director, Division of Building Healthy Communities and Populations, Western Pacific Region, and responsible officer for the Patient at the Centre of Care Initiative, welcomed the members of the reference group and the secretariat to the meeting. She thanked the members who were present, citing the importance of the first meeting and of their invaluable participation and contributions. At the same time, she acknowledged the difficulty of bringing together all of the members. She pointed out that some members previously provided inputs and signified their willingness to be involved in further work even though they could not be present physically. Dr Richard Nesbit. Direl:tor of Programme Management and Acting Regional Director, Western Pacific Region, gave the opening remarks (Annex 1). In his address, Dr Nesbit noted that significant strides had been made towards patient safety and quality of health care, including patient-centred care, since the publication of To Err is Human in 1999. He pointed out that the movement for patient-centred care was "rooted in universally held principles of human dignity and human rights which are enshrined in international law", and that "patient-centredness of health services is an essential key to ensuring that health systems meet patient needs." Attributing the Initiative and drive for patient-centred care to Dr Shigeru Omi, Regional Director, Western Pacific Region, who was on extended leave while running for the post of WHO Director-General, Dr Nesbit added that quality of care, . especially patient safety, is among WHO's priorities. Dr Nesbit explained that the South-East Asia and Western Pacific Regional Offices were promoting patient-centred care in the Asia-Pacific region because such holistic and responsive care considers the needs, expectations and preferences ofthe patients, their families and the communities where they live. He cited the Regional Committee's call for WHO to develop a policy framework that addresses issues on human dignity, patients' rights and needs, and the role of the family, the community and the larger society. The end goal, he explained, was to improve health outcomes through enhanced quality of care resulting from enabling policies. In concluding his address, the Acting Regional Director confirmed WHO's intention to lead "a movement that consolidates and builds on the groundswell of ongoing efforts." He stressed that it was time to go beyond rhetoric since existing evidence justified a framework of strategic actions. He expected that the meeting would provide a clearer understanding of the current situation and the way forward in order to promote patient-centred care and mobilize all stakeholders and constituents to push the agenda forward.

-3-

1.3

Organization of the meeting

As presiding officer, Dr Milan proceeded with a round of introductions by the members and the secretariat (Annex 2). She noted the good mix of expertise and perspectives of both groups, and expressed high hopes for an open, candid and fruitful discussion. Referring to Dr Nesltit's expectations of the meeting, she invited everyone to freely express their thoughts, Issues, concerns and experiences in order to facilitate the consultation process and the formulation of the policy framework and other planned products of the Initiative. Noting that the agenda and timetable were meant to loosely define how the meeting would proceed for the two-day duration, Dr Milan advocated for a free-wheeling and less structured meeting where ideas could be bounced off from one agenda item to another, following the thread of discussion (Annex 3). The meeting could even venture into other areas of concern that it considered relevant and important to enrich the working documents and make them more useful to decision-makers and other drivers and implementers of pertinent policy reforms and interventions. She encouraged the members to make presentations and share documents that they brought with them. The members and the secretariat agreed that as long as the meeting met its objectives, this way of working would be stimulating and effective. 2. 2.1 PROCEEDINGS

Terms of reference for the reference group

Dr Milan invited the reference group members present to review the draft terms of engagement and expected outputs. The terms of reference would be in effect for the current, planned duration of the Initiative until the movement is launched in an international forum sometime by the end of 2007. Since all the members, including those who were unable to attend the meeting, had seen the draft terms of reference before they accepted the invitation to join the reference group, and because no change was proposed by the members present in the meeting, the terms of reference were finalized without any revision. 2.2 Introduction to the Patie~t

at the Centre of Care Initiative

Mrs Remedios Paulino, Short-Term Professional, Western Pacific Region, and focal point for the meeting, presented an overview of the Patient at the Centre of Care Initiative. She traced its beginnings to September 2003, when Dr Omi stated in a press conference that one of his priorities in the Western Pacific Region was "to put the heart back into medical practice." The Regional Committee supported and reinforced this thinking and direction through resolutions WPRlRC55.Rl, WPRlRC54.R2 and WPRJRC53.R6, requesting the Regional Director (1) to collaborate with Member States and the South-East Asia Regional Office in producing a draft policy framework that reflected the significance of psychosocial factors affecting health outcomes, (2) to support Member States to improve the quality of health care and ensure that

-4social and cultural determinants were taken into account. and (3) to guide countries on integrating ethical issues into their public health policies. Another resolution, WPRlRC53.R7, called for the reorientation of the health system "to ensure the quality of personal and population-based health services," which is one of the nine essential public health functions. Mrs Paulino cited other events and developments in WHO and in the international development community that served as the foundation and driving forces behind the Patient at the Centre of Care Initiative. The more notable were: (1)

WHO's definition of health and WHO's objective and function as articulated in the 1948 constitution; World Health Assembly resolution on quality of care, especially patient safety (WHA55.18), as well as other similar resolutions on quality improvement relating to specific programmes and health interventions; various international conventions and consensus documents that enshrine health and human rights values and principles. especially the Universal Declaration of Human Rights and the International Covenant on Economic, SOfial and Cultural Rights; World Health Report 2000 that identified "responsiveness" as one of three key indicators of health system performance;

(2)

(3)

(4)

(5) (6) (7) (8)

launch of the Ethics and Health Initiative in 2002 and the World Alliance for Patient Safety in 2004; identification of patient-centred care as the first of five core competencies of the health workforce for the 21 st century; Declaration on Patient-Centred Healthcare by the International Alliance of Patients' Organizations (IAPO); and WHO's adoption of medium-term strategic plans for 2006-2011 that address several patient-centred care elements.

The meeting participants were also given an overview of the goal, objectives. approaches, and planned activities and products of the Initiative. In addition to the creation of a reference group, th~ plan included, among others: a policy framework for endorsement by the Regional Committee through a resolution; in-depth stakeholder consultations in selected countries; a website; a resource book that compiles the evidence base and ongoing initiatives; and possibly a popular book and an international symposium on patient-centred care. All of these are to be achieved by the end 0[2007. The overview elicited several comments and concerns from the members. but said points were also discussed at length in the succeeding agenda items, and accordingly reflected under those items as appropriate.

-5-

2.3

Presentation on patient at the centre: reorienting health care practice for the 21 st century

Dr Vivian Lin, Professor, School of Public Health, La Trobe University, and leader of the team that provides technical services to WHO in the implementation of the Initiative, presented a comprehensive outline of the rationale, importance, focus, and indicative content of the main product and activity of the biregional initiativethe policy framework and matrix and the in-country stakeholder consultations (Annex 4). In 2005, Dr Lin and her team prepared a scoping paper that delved into the pertinent issues and parameters that should be considered in reorienting health care to place the patient at the centre of the health system. Dr Lin discussed key points, issues and concerns, and possible action steps distilled and determined from that comprehensive review and anal:;:sis of current evidence and good practice. There is a convergence of re-emerging and current thinking and orientation towards more patient-centred care. Among them are: primary care and the Alma-Ata Declaration; consumer empowerment; health promotion (particularly health-promoting hospitals); health and human rights; evidence-based medicine; health care quality and safety; health system responsiveness; and even complementary and alternative medicine. The driving forces are mainly inadequacies in medical education, patient information and choice, health care coordination, quality systems, financing incentives and health care governance. There is pressure for health sector reform everywhere. including the Asia-Pacific region, brought about by advances in scientific knowledge, increasing consumer awareness and expectations, and changing health care needs. Health sector reform is especially wanted for chronic conditions that require continuing contact with health care providers, both individual and institutional. There seems to be as many notions and definitions of patient-centred care as there are advocates and activist~ but there is an emerging core of characteristics: information and communication; appropriate and responsive care; commitment to quality, safe and ethical care; coordinated care teams working in partnership with patients and their families; safe, functional, welcoming, and culture-friendly physical environment and care settings; and supportive or enabling organizational and health system policies and incentives. Opportunities for instituting reform exist at the demand and supply sides of the health care system. Through the Patient at the Centre of Care Initiative, WHO could establish shared values and articulate a vision for transforming health care, as well as operationalize them through a WHO-led movement that takes ongoing efforts to scale. Effective actions and interventions could be clustered around four policy domains corresponding to the major health care constituencies: (l)

health consumers -r better informed and more empowered patients, families and community leaders; health professionals - highly skilled and more responsive health care workers and practitioners;

(2)

-6(3) (4) health care institutions - more effective and supportive health services and facilities: and I · health systems - better systems design, rules and incenti ves to support patient-centred care.

The draft policy framework and matrix (Annex 5) will be used as one of the working documents for in-country stakeholder consultations planned to be undertaken in selected Member States in the Asia-Pacific region. two in South-East Asia and two in the Western Pacific Region. The consultations aim to test the relevance and feasibility of the policy matrix and options, explore alternative framing of issues in different health systems, gather country experiences with policy interventions, and obtain a sense of priorities for action. Dr Lin listed some issues that the meeting could discuss further: large volume of literature but limited evidence base for Asia-Pacific countries; the applicability of experiences of developed countries; and the extent or intensity of the reform to be pursued - incremental and catch~-up, or revolutionary and leap-frog approach. 2.4 Discussion on the policy framework and matrix

The meeting participants reviewed and discussed the draft policy framework and matrix, especially the choice and inclusiveness of the domains and the initial entries of possible measures and interventions for each domain. The appropriateness of the title and focus of the Initiative was a key issue. The term "patient-centred care" could be interpreted as limiting the area of concern only to clinical cases and in-patient care, or to illness and sick people. It does not adequately capture issues of well ness and the larger population and environment that the health system serves and operates in. Not all health consumers are patients or sick people, and all health stakeholders and constituents are also people - the providers, the managers, the policy-makers and all of civil society. The meeting deemed it needful to use a more encompassing or inclusive term. The following terms were suggested: humanizing health cl....e, community-centred care, and people-centred care, people-focused care, people-oriented care, partnership, humanistic care, health with a human heart, to care is human, health care as if people mattered, health promotion and well-being. It was recognized that languages have contextual nuances and that individual countries could use alternative renderings that fit their own culture of communication. A quick round-the-table opinion poll resulted in a majority vote for "people" as the key word to be used. The participants had a convergence of thinking about what would basically constitute or characterize patient- or people-centred care: respect for privacy and dignity as a person, e.g. being informed and involved in decision-making, having a voice and having a choice; systems and processes designed around the consumer's needs and preferences, recognizing the psychosocial dimensions of need; continuity of care effected through teamwork and partnership with families, shaped by considerations of afford ability, ethical standards, safety, and efficacy. and grounded on evidence: and supportive methanisms for feedback. quality improvement. and health services and policy development.

-7It was agreed that an appropriate operational and amplified definition would be needed to clarify the focus and the boundaries of the framework, taking into account universally held principles such as human rights and the right to health, and what moral and ethical values are held dear and what aspects of health care are given greater importance in Asia-Pacific cultufes. It was further noted that the unprecedented rise of chronic conditions, partly due to population ageing, posed a special challenge and burden to the health system as the chronically ill need regular contact with health providers, community support, and continuing care in the home. What is considered as holistic care, or treating the whole person, could fall short of expectations in the Asia-Pacific context, where health care is viewed as a concern of an extended family of relatives and friends. The patient-centred approach to health care was deemed relevant to all health systems - sophisticated, maturing, emerging and primitive. It was pointed out that starting with the basics was a golden opportunity that should not be missed. Policy guidance should be directed to govemments as the main actors and to all stakeholders who also play important roles in affecting the desired change in the health system, incrementally or as a revolutionary turnaround. Further, values of family, respect for medical authority, and traditional practices (including healing practices) are predominant in the Asia-Pacific,.:ontext, and these should be strong elements in the policy matrix. It was pointed out that reorienting health systems through an incremental process or through a revolutionary approach that spans all components at all levels was a decision that individual countries would have to make, but the policy matrix could use a best-buy approach and provide a menu from which countries could make their choices. Core, bottom-line recommendations that are properly linked to even just certain qualitative levels or scenarios of development of health systems could be identified, and "evidence" could be drawn from a wider base of hard and soft sources, with some qualifying remarks or elaboration on applicability. Equity dimensions and the trade-off with efficiency goals must also be considered in all the policy domains.

Overall, the participants saw the need to improve, operationally define and qualify the terminologies used in the Initiative, especially in the policy framework and matrix. Concerning the individual domains of the policy matrix, discussions covered the following: ~ (1) Domain 1 (consumers, patients and their families, community leaders). This domain needs to be more inclusive of communities, civil society and volunteers. For individuals and families, the desired outcomes are increased health awareness and literacy, enhanced skills for selfmanagement and peer support, greater capacity to participate in care decisions and service quality improvement. For the larger constituencies in this domain, the desired outcomes are increased capacity of the voluntary sector and community-based organizations to extend mutual assistance and greater involvement in health services planning and governance.

-8-

Education for patients and individuals and their families should aim to highlight realistic outcomes of health care delivery. inform about the characteristics of a good doctor (or what to look for in health practitioners), and instil responsibility for sticking to care plans after these have been mutually determined, as well as for making lifestyle changes. The profile and status of the family doctor or general practitioner need to be raised in the eyes of the pftients and consumers, as this will also enhance the gate-keeping functions of primary care providers and improve the efficiency of the health system. (2) Domain 2 (health professionals and providers). This domain needs to include all providers of health care, not only those who have "qualifications". As such, "health practitioners" would be a more appropriate name for this domain. Knowledge, attitudes and skills that constitute the core competencies of health practitioners as patientcentred care providers need to be identified and promoted. Professional education and development should emphasize counselling, communication and relational skills while highlighting and reinforcing positive values such as compassion and empathy, cultural sensitivity and building trust and confidence. For example, medical schools could use real patients with chronic conditions for students to practise their interpersonal skills and to gain hands-on experience with patient interaction. Policy Interventions at individual, organizational and system level must be well linked to lead to the correct levels and distribution of the workforce. Domain 3 (health services, facilities and institutions). This domain focuses on the organizational level, in contrast to Domain 2 that focuses on the individual provider level. It was recognized that leadership, good staffing and workload management, efficient organization of the care process (especially coordinated care by a multidisciplinary team), quality assurance systems with appropriate technology support, systematic training on practice management, readily accessible date- and time-noted patient records, and a balanced scorecard approach all contribute to an enabling environment for individual practitioners. Providing financial and other incentives that are commensurate to level of knowledge and experience, and that demonstrate commitment to and recognition of the value of the healthl1Norkforce, lead to higher staff productivity, satisfaction and retention. The meeting also stressed that customer orientation and a physically and mentally stimulating environment enhance both the well-being of patients and their families. Examples include: improved visiting hours, "family areas" where patients can be with their families for longer periods of time, and opportunistic health education and promotion in waiting rooms, e.g. videos, lectures and demonstrations.

(3)

-9(4) Domain 4 (health systems). There is a need for system-level incentives that truly promote ,ne provision of quality and patient-centred care, such as provider payment schemes that reduce under provision of care, encourage health promotion activities, and promote the appropriate use of diagnostic technology. Health insurance companies need to be made more accountable to the public, highlighting where money is spent and to whom the realized benefits accrue. A demand-side objective of improving financial risk protection and reducing financial barriers to appropriate care could be added. Such protection for low-income or disadvantaged populations could be provided through social health insurance schemes, targeted social assistance, and poverty reduction programmes. On the other hand, professional indemnity and legal protection for health practitioners have to be strengthened. Providing a wider choice of providers could be combined with public reporting of the performance of health providers, but this needs further study and preparation, especially in the Asia-Pacific setting. For health workforte planning, selection criteria could be set for entry into professional education. For example, special favour could be given to students from rural and disadvantaged areas, with the hope of expanding the rural workforce. Professional bodies could also be involved in setting selection criteria, standards for continuing education and professional development, and raising the profile of family medicine and general practitioners. The meeting observed that in the light of many socioeconomic and cultural barriers to getting good health information and care, not all legitimate health needs get translated into demand. Similarly, in the stark reality ofresource constraints and systemic inadequacies and weaknesses, not all legitimate demands from patients and other health consumers are met in the most appropriate, responsive and cost-effective manner, if at all. Thus, the balancing or proper mix of policies and interventions that will result in the best outcomes possible is a challenge that the policy matrix should begin to address. Dr Sultana Khanum, Director of Health Sector Development, South-East Asia, informed the meeting that the South-East Asia Regional Office was promoting patient safety in health care institutions as the initial focus of patient-centred care efforts in the Region. She observed that the issues and concerns raised by the meeting were very similar to those raised during a meeting of the WHO Consultative Committee for Programme Development and Management. Copies of the working paper for the technical discussions during that meeting were made available to the group. Dr Khanum expressed confidence that the results of the reference group meeting would be helpful to the South-East Asia Regional Office, as it was holding a meeting on patient safety on 12-13 July 2006, with the participation of all Member States in the Region. Reference group members were given an opportunity to share ongoing efforts in their respective countries and'~heir experiences in undertaking health reforms related to quality and patient-centredness of health care. Dr Milan specifically invited

- 10 - I'

Dr Maimunah Bte Abdul Hamid of Malaysia and Dr Anuwat Supachutikul of Thailand to present their country experiences. Dr Hamid gave a presentation on the "2020 vision for health" in Malaysia and provided the meeting with valuable insights on and lessons from the ongoing implementation of the plan. The 2020 vision emphasizes quality, innovation, health promotion, and respect for human dignity, as well as promotes individual responsibility and community participation. This results from the cultivation of a health system culture of caring ,,;~rvice, teamwork and professionalism. Wellness and person focus are among its health service goals. and the envisioned profile of the Malaysian health system and hospital of the future exhibits the dimensions of health care quality that really put the patient and other health care consumers at the centre of the health system (Annex 6). Dr Supachutikul outlined the current hospital accreditation standards and requirements, and guidelines in Thailand. He explained that the accreditation system aims to improve the quality and safety of care provided by hospitals, and that certain core values and concepts constitute the driving force behind the learning and improvement process that uses both self-assessment and external evaluation approaches. Individual commitment and teamwork. ethical and professional standards. learning and empowerment, continuity of care and community responsibility, and patient or customer focus are among the core values. Health promotion is integrated into every key system of the hospital, and every quality of care review - there are many - is an opportunity for health promotion. There is routine use of clinical tracer for learning and for improving aU components in the systems (Annex 7). The member-presenters were thanked for sharing their insights. which proved to be valuable to the work of the reference group. The following examples of other interventions were later shared with the group. (1)

In China, improvements in hospital food and ward temperature led to higher utilization of maternal health services, resulting in a significant reduction in maternal morbidity and mortality in the catchments area.

(2)

In Malaysia, the quality of health services was greatly improved by the adoption of simple but effective interventions such as: competition and awards for customer-friendly counter services and comfort-enhancing therapeutic garden, and similar enhancements in facility and systems design; flexible and less restrictive visiting schedules; one-stop approach that reduced waiting times and minimized the need for multiple and multicentre visits ~ld consultations: and drugs dispensing at the bedside before discharge, obviating the need for patients or their kin carers to queue at the pharmacy. In Singapore, improved leveraging of government subsidy and increased fiscal autonomy of public hospitals led to more customer-friendly or patient-centred care and more efficient delivery of services. For example. doctors now go from hospital to hospital visiting patients instead of patients being moved about to see various specialists in their clinics. This and other similar changes were driven by the bottom-up approach to the paradigm shift, using quality circles involving all members of the

(3)

- 11 -

care team to maximize learning and innovation and improve internal business processes. (4)

In the Republic of Korea, cancer patients accessing the National Cancer Centre experience a deeper and more significant meaning of continuity of care as patients doing multiple visits are assigned to the same health practitioner.

The meeting recognized the apparent dearth of relevant evidence, particularly in the Asia-Pacific region. There is a need to explore all possible ways of generating or extracting information and getting the evidence right, as the policy framework and matrix must be a useful and doable document for WHO and for countries. Further, the public-private mix of the health care sector varies across countries, and promoting political and social acceptance by all c1airnholders and duty bearers must be addressed in the framework. Thus, the framework could benefit from an action domain that promotes knowledge management as a crosscutting concern and as contributory to effective implementation. The domains could also include possible barriers to implementation as indicated by previous experiences and lessons learnt, and suggested solutions. The meeting envisioned that the document would provide adequate guidance for a visionary leader to take action and mobilize and align resources for the needed paradigm shift. Adapting a health promotion approach, Dr Lin presented an outcomes hierarchy for the four domains, where policy interventions and outcomes at the different levels of the health system, and from the demand and supply sides, lead to patient-centred care outcomes: skilled and responsive health practitioners partnering with informed patients and health consumers exercising choice in health care towards effective health care utilization) resulting in reduced mortality, morbidity, disability and dysfunctions, and greater equity and improved quality of life for all. 2.5 Discussion on the country consultations

The meeting recognized the importance of conducting country-level consultations in selected member countries in the South-East Asia and Western Pacific Regions. It was deemed essential to present the draft policy matrix to stakeholders and elicit the desired information and inputs (Annex 8), and the comments pertained mostly to the methodology to be used and the composition and representation of participants. It was also pointed out that the consultations should benefit both the policy framework development process and the countries and participants involved. It was recognized that the consultation process may vary across countries and that countries must have the flexibility to determine what would work best in their unique contexts. Key informant ',nterviews, focus groups, and workshops could be considered singly or in combination and in building-up sequence as appropriate. However, there is a need to ensure the mix and representation of sectoral interests in all the countries from both the supply and demand sides of the health systemclinicians and other health practitioners and providers, health facility managers and administrators, educators, policy-makers, professional bodies, and health consumers, patients or non-patients alike, among others. Further, representation should not be

~

r ---- . : - 12 _ ,r

limited to the health sector. It would help to be able to identify and separate issues that mostly concern one specific health system, and issues that cut across countries and systems and have the potential for regional and even global application. It was suggested that the annotated outline of the popular book be used as a

working document, together with the policy framework and matrix that will be revised and enhanced in accordance with the recommendations of the meeting. The presentation on reorienting health care for the 21 st century, including the health promotion type diagrammatic pssentation of the linkages of the four domains and the desired health and social outcomes, would also provide a good understanding and appreciation of the rationale and imperative for the paradigm shift to patient-centred care that is being promoted by the Initiative. The participants agreed that Malaysia, the Republic of Korea, Thailand and possibly Bhutan, as suggested by Dr Khanum, would constitute the first set of countries where consultations would be held. The possibility of doing consultations in Palau to take advantage of other forums being held sometime during the year and to include other Pacific island countries and areas was also considered. Further, in the interest of a wider and more broad-based consultation process, the meeting saw potential value in WHO harnessing the country offices outside the Asia-Pacific region to utilize alternative, cost-effective mechanisms of consultation. A meeting of WHO representatives and country liaison officers in November 2006 would be a good venue to make this proposal. 2.6 Discussion on advocacy ~d social marketing

The meeting recognized that WHO needs to identify and utilize advocacy and social marketing strategies in order to promote patient-centred care and ensure that the initiative and movement would be brought forward from concept and abstraction, from the realm of understanding and appreciation, to concrete policy and action in the countries at all levels of the health care system. Governments need to be stimulated to perform their stewardship role, and all stakeholders need to be involved from the start. In addition to the popular book, the international symposium and the website, which have been planned as integral parts of the Initiative, other concrete and practical suggestions included the following: (l)

an advocacy kit that includes the policy framework and other resource materials, including the profiles and work of agencies and organizations engaged in patient-.centred care activities, literature references, Cochrane evidence summarit:s, case studies and country experiences; abridged and academic versions of key documents for publication, even commissioned papers for each of the four domains, possibly as a series of articles in selected journals, e.g. The Lancet; a pre-launch preview of the products of the Initiative at the World Organization of National Colleges and Academies (WONCA) Annual Conference in July 2007; and the proceedings of the symposium as a journal supplement.

(2)

(3)

(4)

- 13 -

In the spirit of sharing and advancing knowledge for advocacy and practice, Dr Alfred Loh brought copies of a guidebook, Improving Health Systems: the Contribution of Family Medicine, the product of a collaborative proj ect of the World Organization of Family Doctors and WHO. Dr Gauden Galea distributed copies of the WHO publication, Preventing chronic diseases: a vital investment, and CD-ROM versions ofthe publications Preparing a Health Workforce for the 21st Century: the Challenge of Chronic Conditions and Innovative Care for Chronic Conditions: Building Blocks for Action. The Regional Office for Jhe Western Pacific displayed reference materials in the meeting room and distributed an initial list, with profiles and activities, of organizations already engaged in activities related to patient-centred care. These resources will be accessible via the Internet once the website is developed. The website will enable individuals and organizations to know what is going on and how to connect and work in synergy. 2.7 Wrap-up and closing session

Before the closing of the meeting, Dr Nesbit rejoined the group and was briefed on the presentations, discussions and recommendations. He noted that the meeting had been productive and that the Initiative could now be pursued more vigorously, having benefited from the collective wisdom and inputs of the reference group and the rich and varied experience outside the confines of WHO. Pointing out the importance of mapping the linkages and capitalizing on the synergy of the overarching patient-centred approach with WHO programmes and activities, he was convinced that when more subs;;lmtial and meaningful work is achieved, the Initiative could make a difference not only in the Asia-Pacific region, but also in other parts of the world. Dr Nesbit considered the first meeting as a significant step forward and an important prelude to the main activities still to be done. He instructed the secretariat to make sure that all the members get copies of the report and the documents of the meeting. In closing, he thanked the members present for their time and invaluable contribution and looked forward to a more complete attendance of the members of the reference group in future meetings. 3. 3.1 3.1.1 General The term "patient-centre" care" connotes a limited focus on direct patient care in the clinical realm for those who are ill and generally have reason to interact with the health system, especially with health care providers. The term "people-centred care" is preferred and recommended. This term encompasses all individuals from the demand-and-supply side of the health care system, and spans personal and population-based health services, including disease prevention and promotion of wellness, in health care institutions and in other care settings. CONCLUSIONS AND RECOMMENDATIONS

-

-

--

-[

- 14 -

3.1.2

Patient- or people-centred "care" includes the following key elements: • • • • culture of care and communication; appropriate services, approaches and models; responsive, responsible and accountable services and institutions; and environmental support through enabling and participatory mechanisms.

The provider-patient relationship should be an active, two-way partnership. This relationship is recognized as the central point of the health system where a positive confluence of provider-side and demand-side factors could be achieved with an optimal mix of policy levers. 3.1.3 Although there is a diversity of cultural, socioeconomic and political contexts of health systems in the Asia-Pacific region, a patient- or people-centred and rights-based approach to-health care is relevant to all forms of health systems at all stages of development. The biregional initiative is a welcome and timely move on the part of WHO and should be carefully planned and relentlessly pursued. It would be useful to identify and capitalize on the strategic roles of health system players, including WHO and the governments of member countries and areas, towards ensuring that patient-centred care becomes a daily reality in every health care system and setting. The Initiative is not a new, top-up programme or project. Patient- or people-centred care elements should be embedded in all health programmes. mature and developmental alike. The links between the Initiative and these health programmes need to be mapped out, especially with respect to the menu of policy options and recommendations. Good strategies and planning documents are already in use, and relevant recommendations should be incorporated in the policy menu. The adoption and implementation of the patient- or people-centred approach to health care ultimately rests in governments and in the various health constituencies and stakeholders. They should be consulted and their contributions incorporated into the policy framework and menu. This participatory process ensures relevance, usefulness and buy-in of the recommended future actions. Policy framework and domains Evidence from western and modem health systems dominate current literature on quality of health care, including patient safety and patient-centred care. The initial list of options for policy reforms and interventions should be expanded to capture a wide range of hard and soft evidence, including country experiences and quality studies, particularly in the Asia-Pacific region. The strength of the evidence base for the menu of policies and interventions could be differentiated to the ex.tent possible so that countries are guided in assessing their potential effectiveness and in deciding on the policy mix and the timing of implementation that fit their unique situations, through incremental changes or through a revolutionary, system-wide reform approach.

3.1.4

3.1.5

3.2 3.2.1

3.2.2

Knowledge management plays an important role in operationalizing and implementing the frame~ork more effectively. The policy framework should address issues related to ',txperience documentation and sharing, leveraging of lessons from outside the health sector. and dissemination of the evidence base. Health policies and interventions do not operate in isolation, and the policy menu must be presented in a manner that provides guidance on how the recommended options mutually reinforce each other, or otherwise, and what possible application or implementation issues could become barriers to effectiveness and sustainability. Health care in the Asia-Pacific region is less individualistic than western models of care, and heavily involves and revolves around the family and other social support systems. This should be considered in the development of the policy framework. The individual policy domain (Domain 1) needs to be inclusive offamily, community and civil society because they provide the demand-side context, as well as influence individual consumer or patient perspectives, preference~ and behaviour. In addition to the core competencies in knowledge and skills, the formation and reinforcement of positive values and attitudes must be strengthened. The importance of communication and counselling in the curriculum and in continuing professional development must be stressed. While western and modem medicine has become a predominant paradigm of health care in the Asia-Pacific region, traditional and alternative medicine is also widely practised. The individual and organizational policy domains (Domains 2 and 3, respectively) should also incorporate, as appropriate, this important component of health care systems in the region. Patient-centred care results in part from appropriate individual practitioner behaviour and good patient-provider partnerships. The work environment and systems within which practitioners and health care teams operate should be designed and made cond:rcive to the delivery of safe and responsive care, e.g. the organizational values and culture, the organization of the care process, and quality assurance systems. Policy reforms impact all levels and components ofthe health system in various intended and unintended ways and in different orders of magnitude. This should be a major consideration in the development of wide-ranging policies such as: human resource planning; allocation of resources; financial and other incentives such as the recognition and upgrading of primary care services and providers; and the latitude given to professional bodies in terms of their roles and contributions in standards setting and regulation, among others; accountability of the health insurance sector; development of other, alternative safety nets; selection criteria for professional education to improve quality and geographical distribution; demand side interventions to reduce barriers to utilization of appropriate care.

3.2.3

3.2.4

3.2.5

3.2.6

3.2.7

3.2.8

- 16 -

3.3 3.3.1

Country consultations The in-depth stakeholde" consultations in selected Member States constitutes an integral part of the Initiative as it provides important inputs from the field to the process of developing the policy framework and emiching the policy menu, Considering the diversity of the Asia-Pacific countries and the learning benefits from the use of different consultation methodologies, the consultation process may vary across countries, using an appropriate variety or mix of approaches.

3.3.2

It is important to have multisectoral representation and a mix of individuals and organizations from the supply and demand sides of the health care system. Funding agencies and other partners could also be invited. With proper guidance, national governments and relevant active health organizations should be invited to lead in the planning and conduct of the consultations, including the design and methodology, as well as in the determination of stakeholder representation and composition of participants, The in-depth stakeholder consultations at country level could initially be done in Malaysia, the Republic of Korea and Thailand where there have been indications of readiness and relevant experience. As recommended by the representative of the South-East Asia Regional Office, Bhutan could also be considered. It would be beneficial to the policy framework development process if other countries were given the opportunity to comment on and provide input to the framework document. WHO should seriously study and explore the possibility of doing a cost-effective, second wave of consultations for the remaining Member States and areas. The process and timeline should be explored and determined in consultation with the country offices of WHO.

3.3.3

3.3.4

3.4 3.4.1

Advocacy and social marketing In addition to the alread~l planned activities and products - a dedicated website, a popular book, and an international symposium to launch the book and generate support for the Initiative - promotion and advocacy could be undertaken through academic and quality circles, commissioned papers, and supplements or articles in selected journals, e.g. The Lancet, WHO should pro-actively search for opportunities to use regional forums, conferences and similar activities as a platform to promote the Initiative and the patient-centred approach, e.g. the regional conference of the World Organization of National Colleges and Academies (WONCA) in July 2006. It would be helpful to develop a communication plan that will systematically translate the wide range of evidence, experiences and implementation vignettes into appropriate media messages and materials for specific audiences. and ensure that such audiences are reached.

3.4.2

3.4.3

- 17 -

I

OPENING REMARKS First Meeting of the Patient at the Centre o(Care Initiative Reference Group 4-5 July 2006

ANNEX 1

DISTINGUISHED MEMBERS OF THE BIREGIONAL PATIENT AT THE CENTRE OF CARE INITIATIVE REFERENCE GROUP, OUR TWO EXPERTS WHO HAVE SUPPORTED THIS WORK AND COLLEAGUES. Good morning and welcome to the first meeting of the Reference Group. We have much work ahead of us, in this meeting and afterwards, and I am indeed grateful that you have come to join us in taking this very important step, the beginning of a movement towards patient-centred health care in WHO and in the two regions of WPR and SEAR .

• As many of you are aware Dr Omi is a candidate for the post of Director General of WHO. He went on extended leave from 20 June until the election is decided on 8 November 2006. Hence he cannot be here this morning. So I am now Acting RD but the initiative and drive for patient centered care has come from Dr Omi. He has been interested in this area for some time but he is not alone, as we all know, advocates and practitioners of patientcentred care have been growing in numbers and spreading their influence across the globe. Various terms are being used for this new movement - patient centred, consumer-centred, patient-oriented, humanized, patient-focused, and similar others, but it doesn't really matter.

• They share a common goal with the validity and value of this movement being rooted in universally held principles of human dignity and human rights which are enshrined in international law. Why has the quest for patient-centred care become an important element and driving force in the health reform agenda of a growing number of countries, professional organizations, health care institutions, the health academe, and other health-oriented groups, some examples of which

- 18 -

I

we have included in your folders? Why is WHO, particularly SEARO and WPRO, taking the patient-centred and rights-based approach to health care? Why do we see the urgency to chart a new course and develop a road map to reorient healthcare, especially in our regions?

Let me try and provide some answers in this short introduction.

We are all familiar with the wake up call of the publication To Err is Human. In fact. judging from web resources alone, the literature and activity on quality of care, including patient safety and patient-centred care. have increased in quantum proportions since the book came out in 1999. 'To err is human' quantified the problem in the USA and brought home the magnitude of the problem. But quality of health care is an enormous issue globally.

As the book says "It may be part of human nature to err, but it is also part of human nature to create solutions, find better altern8jives and meet the challenges ahead." Since then the attention in trying to find solutions has largely been on health providers and the health system within which they operate. Health providers, because they are often not properly and adequately prepared to provide quality health care that meets the needs and preferences of patients - in what is provided and how it is provided.

Numerous bodies including the Institute of Medicine have come to the conclusion that patient-centredness of health services is an essential key to ensuring that health systems meet patient needs. Care that is safer, more reliable, more responsive, more effective and more integrated.

WHO has put quality of care, especially patient safety, among its priorities. In 2004 the Global Alliance for Patient Safety was launched. Since then much has been done in the area of patient safety. But traditionally, our focus is on the supply side of the health equation - the biomedical, technological, provider and delivery system side of health care. It is high time that we pay more attention to the demand side - the health consumer and patient. Although we see

- 19 -

evidence of change, for example PAHO held in May of this year a regional workshop on Patients for Patient Safety. In our part of the world, SEARO and WPRO are expanding their current work on patient safety towards patient-centred care, giving due consideration to patients', their families and the communities where they live, their expectations and preferences and to their participation in decision making and implementation of care, because they add a new dimension to what biomedicine and health technology have to offer. I should also mention that several Regional Committee resolutions provided the basis and springboard for the Initiative, by calling on WHO, among other things, to develop a policy framework taking account of such issues as human dignity, patients' rights and needs, and the role of the family, the community and the larger society. The end goal is to improve health and health outcomes by ensuring that health policies lead to improvements in the quality of health care. WHO will take the lead and organize a movement that consolidates and builds on the groundswell of ongoing efforts by various stakeholders in different parts of the globe. Through the Initiative, WHO can champion these efforts so that they are taken to scale, more strategically and more widely, and adopted by governments as a matter of policy. WHO can also ensure the linkages to other related areas. The patient centered care is a way to achieve patient safety. It is also an integral part of improved care for chronic conditions. It is intimately related to responsiveness a fundamental objective of health systems, championed in the WHO's World Health Report of2000. And more broadly to a rights based approach to health which WHO advocates for. We believe that it is time to go beyond rhetoric and take action. Good intentions are no longer good enough. There is demand for more to be done and there is an evidence base to justify a framework of strategic actions.

- 20 -

I expect that by the end of this meeting, we should have a clearer understanding of where we are and what strategies and actions we could do to promote patient-centred care and to mobilize all health stakeholders and constituents to take concrete steps to push the agenda forward.

Once again I thank you for giving up your valuable time to join us here on this important work.

Thank you and I wish you a fruitful meeting.

- 21 ANNEX 2

LIST OF TEMPORARY ADVISERS, AND SECRETARIAT

1. TEMPORARY ADVISERS

Dr Maimunah bte Hamid, Director, WHO Collaborating Centre, for Health Systems Research, lalan Rumah Sakit Bangsar, 59000 Kuala Lumpur,_Malaysia. Tel.: (603)22825921. Fax: (603)22825172or22971513. E-mail: maimunah.ah@ihsr.gov.my Dr Alfred Loh, Secretary General and Chief Executive Officer, World Organization of Family Doctors (Wonca), #01-02 College of Medicine Building, 16 College Road, Singapore 169854, Singapore. Tel.: 6562242886. Fax: 6563242029. E-mail: ceo@wonca.com.sg Dr Phua Kai Hong, Associate Professor of Health Policy and Management, The Lee Kuan Yew School of Public Policy #10-00, National University of Singapore, 29 Heng Mui Keng Terrace, Singapore 119620, ::'ingapore. Tel.: (65) 6516 6134. Fax: (65) 6778 1020. E-mail: cofpkh@nus.edu.sg Dr Alberto Romualdez, Director, Health and Human Values Program, M-Tech Hospital 379 Sen. Gil Puyat Avenue, Bel Air Village, Makati City 1209, Philippines. Tel.: (632) 896 6711, 896 675l. Fax: (632) 8961473. E-mail: quasirC(i!mozcom.com Dr Anuwat Supachutikul, Director, Institute of Hospital Quality Improvement and Accreditation, Nonthanburi Province 11000, Thailand. Tel.: 6602951 0102. Fax: 6602951 0138. E-mail: anuwat@ha.oLth

2. SECRETARIAT

Dr Linda Milan (Responsible Officer), Director, Building Healthy Communities and Populations, World Health Organization, United Nations Ave., P.O. Box 2932, 1000 Manila, Philippines. Tel.: (632) 528 9981. Fax: (632) 526 0279. E-mail: milanl@wpro.who.int

- 22 -

Dr Wang Xiangdong. Regional Adviser. Mental Health and Control of Substance Abuse. World Health Organization. United Nations Ave .• P.O. Box 2932, 1000 Manila, Philippines. Tel.: (632) 528 9858. Fax: (632) 526 0279. E-mail: wangx@wpro.who.int Mrs Remedios Paulino (Focal Point), Short-term Professional, Mental Health and Control of Substance Abuse, World Health Organization. United Nations Ave., P.O. Box 2932. 1000 Manila, Philippines. Tel.: (632) 528 9851. Fax: (632) 526 0279. E-mail: paulinor@wpro.who.int Dr Reijo Salmela, Acting Director, Health Sector Development, World Health Organization, United Nations Ave., P.O. Box 2932, 1000 Manila, Philippines. Tel.: (632) 528 9835. Fax: (632) 526 0279. E-mail: salmelar@wpro.who.int Mr Dorjsuren Bayarsaikhan, Regional Adviser, Health Care Financing, World Health Organization, United ]\iations Ave., P.O. Box 2932, 1000 Manila, Philippines. Tel.: (632) 528 9808. Fax: (632) 526 0279. E-mail: bayarsaikhand@wpro.who.int Dr Gauden Galea, Regional Adviser. NonCommunicable Diseases, World Health Organization, Western Pacific Regional Office, United Nations Ave .. P.O. Box 2932, 1000 Manila, Philippines. Tel.: (632) 5289860. Fax: (632) 526 0279. E-mail: galeag@wpro.who.int Dr Ezekiel Nukuro, Regional Adviser, Human Resources Development, World Health Organization, United Nations Ave., P.O. Box 2932. 1000 Manila, Philippines. Tel.: (632) 528 9816. Fax: (632) 5260279. E-mail: nukuroe@wpro.who.int Dr Sultana Khanum, Director, Health Systems Development, and Focal Point for Patient Safety. World Health Organization, World Health House, Indraprastha Estate, Mahatma Gandhi, New Delhi 110002, India. Tel.: 91-11-23370804. Fax: 91-11-23370197. E-mail:khanums@whosea.org Ms Vivian Lin. Professor. School of Public Health, Bundoora VIC 3086, Australia. Tel.: 6139479-1717. Fax: 6139479-1783. E-mail: V.Lin@latrobe.edu.au Ms Carolyn Poljsh Research Fellow, School of Public Health. Bundoora VIC 3086 Australia. Tel.: 61 39479-3354. Fax: 61 39479-1783. E-mail: C.Poljski@latrobe.edu.au

FIRST MEETING OF THE PATIENT AT THE CENTRE OF CARE INITIATIVE REFERENCE GROUP MANILA, PHILIPPINES 4 to 5 JULY 2006 TENTATIVE TIMETABLE 4 July 2006, Tuesday 5 July 2006, Wednesday

Opening Ceremony

0830 - 0900

Welcome

I Ulscusslon on related matters

nS30 - 0930 0900 - 0930 0930 -1000 1000 - 1100 1100 -1130 1130 Scoping paper Continuation of discussion Next steps Closing Ceremony

W

tv

1300 - 1530

Policy Framework Country consultations Project information for group endorsement

1800 - 2000

Welcome Dinner

tTJ

~ w

X

- 25 -

ANNEX 4

OUTLINE PATIENT AT THE CENTRE: REORIENTING HEALTHCARE PRACTICE FOR THE 21st CENTURY Vn'ian Lin

\V'ho wants 'patient at the centre!?

Why IS theI< a problem' What is 'patient-focused health care" Importance for Asia-PacIfic Region? \XIhat can be done? - Propm;ed policy matrix

"ext step (in-country consultation) and some u;sues

For

th~

La Trobe Univenmy School of Public Health team

PATIENT-CENTREDNESS - A CONVERGENCE Pr:imary care and j\lrna-Ata Declaration

WHY IS THERE A PROBLEM? Medica! education - concentrate un body systems and ..I!seast: conditions; dcx:s not Iflcorporate ~oclal cGn"text, psychosocml issues, ethics and communications Patient information -limited availability, mappropriate fonns, pOD1 communication Service courdinallon- fragmentation due to speclalizahon. lack of team \....ork and program Silos, onenred toward~ speCialties rather rhiln the needs of tht whole p1;i"SOn (.,'!uality system~ - need to focus on both teChnical ,-)uality and expenentJal elemc:nts of care; need for feedback on o..,)uaht)' of cart: process Financing ince~tive~ - push physician behavior .tc:'\vards ~hort consuitanon, high-throughput, over/under servICing In relation te, profit margm, non-referrals, no case management Ocadmg to discontinUity of care) Healthcare.g<.wemanct: - few opportunities fO.r consurnn IOput and feedback; little reporting back to the commumty

Consumer health movement, mon:mt:f1t

\Vomen'~

health

Health promotlO11 (particularly health promotmghO:iiptta!s)

Health and human rights Health sy:,rem rel'ponsi,'eness (WHO 2000 Report) Evidence-based medicine Healthcare quality and safety Complementary and aitemati,'c health care

PUTTING PATIENT AT THE CENTRE - MANY ADVOCATES • Multiple defiruuom of 'patienr-centred care' mostly focused on the experience of clinical encounter (and patient satisfaction) Somt: common notions - partnership, sociotechnical sy~tems Business case - safety, 'adherence', satisfaction, health outcomes, quality of life

PUTTING PATIENT AT THE CENTRE - CARE IN CONTEXT

1

- 26 -

CHARACTERISTICS OF PATIENTFOCUSED HEALTHCARE? lnformatmn - the health condition, likely course, chOIces of treatment, hkely consc"luences ~cce~~ - appropriate:: and reSpOnSl\'1; care Com: and cummunicatlon - being mformcJ, n;spect, 000dlscnrrunattOn, Inyoh-tment In deCJslon-makmg-, ChUICt::, pn\'acy Profe~Sionl'Ll teams - coordmated care and (oUpcratlOn between health profeSSIOnals, worklng in partnership with patients and families CommItment to "l~ali(y. safe, and ethical ore - b~ prote '. on:&.ls and healthcare Iflsntubons Safe, functional and \velcummg phYSIcal em'irunmenl Affordablt: and accountable health servICes - confidence In standards of health care, \l.;th avenues for redress where gnevances antic )I,

IMPORTANCE FOR ASIA-PACIFIC? Changing health care m:eds - ~CDs, mental health, disabling injuries mt:an need for continuIng conract

\"'I[h ht"fllrh sy. . tem I ncrea . . lng commumty expeC[ations and knowledgt: ICT-t.'nabled, pressure to deli"er preferred forms of care ~t'\\" .... C1eflttftc

knowledge -links berween p . . ychosoClal

states and pathophystnlohry; effecri"enes~ of p~ycho!,ocial ~df-management); social Prcs~ure

intefyentioos (includmg ~ocial suppOf"( and dererminants of healrh

Orgamsa~onal

and health system policy that surrort aboH

i\rran~'t:mems/ mcentives

for health st:CfOr reform

DEMAND SIDE OPPORTUNITIES Con:;umer information, communication, and

SUPPLY SIDE OPPORTUNITIES Cunsumn partlClpanun - ,u;;;I.:{)untabiht~ n:porttng, inclu~t\·!.: gO\ t:rnaoc<: Law and dhiCo.; - it:).,'l~latl.: IC, prult:Cl tor rattt:nt aut, )numl anJ IOforrm:J consent, Impw\,t:d handllOg f) fy.Htt:nt complrunts Pnmary ht:alth can.: - pattcnI/ pnman cart: pw\·jdn n:\auoo-;hIP ,\" ct!ntrallO ht:alth syste;:m Ht:alth cart: organization - build in performanct: monltonng systt:m for t.]ualtry·, safety, patient satisfactIOn, care coon.lmattun Wurkforce: dt:\'dopmt:m - problt:m-based learning, curncula chao).,rt: to lOc1ude ethICS, cultural competency, commUniCatl(Jn ~kJll~, and p~"chu~ucla\ tnttrH:n(tOn~

health education - deCISIon aids, risk communication interve:ntions, counselling support Increasing personal control - self-management Increase social support and social integrati~n

-

peer support, self-help groups Increase: social cohesion - community develc)pment ..."-ttentioo to spintual factors - pastoral care

U>()rk[(lrCe;: rtgulatton - IOcf;rporak code of eth1C~, plac!.: rehcul<lt')f\ nble;:ctl\"e;: ,t": protect1On of pubhc ht:alth and saf!:t) hnanctng - sucial he;:alth InSUr,IOCI..., bkm.kd raJ mCllts tint b;li~IllCl· lOo,:n11\·\:: bct\veen on:r/ undtr SCr.·1Ct:, rft:\ tlltJ()fl;' curr..:, ~\r1d ,\~~un: contlou1t'· ot cart

WHAT CAN BE DONE? Establish shared values (in development)empowerment, participation, people-centred development, noo-discrinUnatlOo .Articulate a vision for transforming healthcare -

ACTION IN FOUR POLICY DOMAINS Comiumer - better informed ano more c::mpowered patients, familie~, and commurur\" leaders

2.

Health professionals - more responsI .... e and

partnership between patients! families and health care professi(mais Operacionalize values and "i.sion throughout the health system and society

skilled health professlOnals 3. 4. Healthcare institutions - more effective and supporrive health services and faciliuc:::-. Health systems - better system desihTfl, ruJe~, and Incentives to suppurt pauem-focust'd

yualitv care

2

-27-

DOMAIN 1: Consumers OBJECTIVES Particlpation in healthcare decisioomaking through enhanced awareness and incn:ased health ll(t'rac~ Particlpatlon in health

DOMAIN 2: Health professionals OBI ECTIVES More responsive care through better communication and recognition of

MEASURES Multifaceted approach to consumer and patient

MEi\SURES Basic and contmuing education to incorporate

education (media campaign, decisio~ aids, self-help and self- . managetm:nt)

psychosocial issues ·\dherence [0

standards

sen'icc:-; planning and policy-makmg

Support for consumer orgamsatlons

for quality, safe and ethical care

additional competencie:; and knowledge base, a:-; well as experiential and reflective training methods Open disclosure standards, clinical

pathways, and peer reView

DOMAIN 3: Healthcare institutions OBJEcnvES Appropriate physical environment

DOMAIN 4: Health system ()BJECllVES \{I'-ASCRES In\'t~st in primary can: services and workforct: development

Effective healthcan: teams \\'ith dear rolt:s lmprmed patient tlows Intt:g;ratl:: educatIOn and counselling IOtu C<lfe More supportive modds of cart: Continuous quaht) Improvement systems Committed health services managers

MEAse RES PhYSical design that are functional and comfortable Coordmated team care: l;uod signagc:: and serVlCe: scheduling Appropriate financmv lt1centln:s for holisti{~:are Models of care that provide for continuity of care Audit and feedback systems Leadership development

Strengthen primary care Monitor professional standards (~U1ck ft:s()lution of complaints and {,.nevances Gn:ater public accountabiht) for services Rational technology use :'\pp~riatt: financing mcentlves Recognition of social and cultural d1\!crstty

Establish profi.:ssi{Jnal re~.,s(ration

ami education

smndanls Comphltnt~ investigation and conclitabon mcchamsms Public reporting uf performana: Appwpriate purchasing of

Targeted st:rV1ct:s and serviCl.: h'lJiddmes

NEXT STEP In-c{>unrf)" (()flsuitatit)os: 1) Understand 'framing' of issues in different health sy~tt::m~

ISSUES Large \'olume of literature - more advocacy and less evidence about mix of inren'L'"fItions Limited c\'idencc base about: 1) Asia-Pacific countnes, 2) system-level ~trategies (and context-specific nature of policy solutions) Applicability of experiences of developed countnes Vision - should countries in the region 'catch up' (with focus on improving quality, safety, satisfaction, and rc:::ponsl\'eness) or 'leap frog' (and consider new paradi!-,'ffis for health systems)?

2) Gather experiences with policy imern:nrions 3) Test rdevance ilnd feasibility of policy matrix

4) Obtain sense of prioritie~ for action 5) lmtigate stakeholder support for the initiative, and for process to be undertaken to progress the initiative

3

POLICY FRAMEWORK FOR THE ASIA-PACIFIC REGION (DRAFT) Vision: Patients are served by a health sy?tem that is designed around the holistic needs of the patient

Mission:

To enable the public, private and not-for-profit sectors, including health providers and consumers, to work together to drive improvements in the quality of the health care experience so that patients are placed at the centre of the health system

The guiding principles of the framework are: 1. Patient-focused health care results in better outcomes for the individual and for the health system. 2. Patients deserve to receive care appropriate to need and should be supported in making informed choice. 3. Patient needs are anticipF'Jed and services are customized based on ~atient

needs, values and preferences.

4. Patients are encouraged to be full and active participants in decision-making in accordance to their wishes about their care, and knowledge is shared fully and freely. 5. Health care decision-making is evidence-based, ethical, and sensitive to the cultural and psychosocial aspects of care needs. 6. Services are provided in a setting that most naturally fits the patient's unique situation and makes him/her receptive to new information and instruction. 7. Investment in capacity building is required to support health professionals and institutions to work in teams, be effective communicators, and be responsive to patient needs. 8. Education at the community and facility levels is needed to support people to adopt positive care-seeking behaviour and become effective users of health services. 9. Quality of care and better health outcomes are the governance drivers of health care institutions. 10. Health policy development incorporates the voices of consumers and leaders in the health professions. 1.0

N

tTl

~

'-"

><

Patient at the Centre _Policy framework_draft Page 1 of 10

Indicative Checklist of Policy Measures At the national level, a range of policy measures is likely to be needed, and reforms will be required at several levels: health consumers, health providers, health facilities/institutions, and health systems. The following indicative checklist is surely non-exhaustive and prescriptive, and in fact, will further be expanded/elaborated on to include specific good examples during the consultation process. The current thinking is that this will form the core of a comprehensive, but not necessarily exhaustive and prescriptive, policy menu from which Member States could eventually adopt/adapt their own reforms and interventions based on their unique needs and circumstances. The policy framework features four domains:

>>y

>-

Consumers, patients and their families, community leaders Health professionals and providers Health services, facilities and institutions (organization level) Health systems

0,

WI

Patient at the Centre_Policy framework_draft Page 2 of 10

DOMAIN ONE:

Consumers "-_ -

,OUTCOMES Better informed and more empowered consumers, patients and their families, and community leaders who actively participate in health systems

..

OBJECTIVES -

POSSIBLE MEASURES/STRATEGIES

INTERVENTION EXAMPLES ---

• To enhance awareness of health issues • To increase health literacy • To provide skills that enable participation and decision making in clinical encounters

•

Informational and educational resources for use in consumer/patient education programmes Decision-making aids, expanded opportunities to choose

•

A multi-faceted approach to consumer and patient education is required to generate positive changes in health knowledge and behaviour and to develop skills that allow patients to participate in the clinical consultation. Education programs could include:

•

,

• •

•

Mass-media campaigns directed at the wider consumer population to encourage health services utilization; Decision-making aid::'!~hich are personalized and provide detailed and comprehensive information about risks and benefits of medical interventions; Interventions that promote patient adherence to medication regimes through the provision of explicit instructions about taking prescribed medicines; Multi-media interventions to facilitate communication between patients and health professionals, including tape recordings, written summaries of consultations, and computer-assisted educational programs. **

>-

w

• To ensure social infrastructure supports consumer participation in health reform processes

•

<:-----

Support for consumer organizations; processes/mechanisms which enable consumers to participate in policy development and ·health services 2!anning

There is limited documentation about how health organisations best support community/consumer groups and the effectiveness of any strategies. ~--.

Evidence from Cochrane revIews EVIdence from quality studies/literature

--- ---

-

Patient at the Centre_Policy framework_draft Page 3 of 10

DOMAIN TWO: OUTCOMES Skilled health professionals and providers who deliver health care responsive to patient values and needs

Health professionals OBJECTIVES • To increase awareness and appreciation for psychosocial issues and the social determinants of health • To provide communication skills which enable ability to engage with patients • To provide skills for the development of interventions tai!:·red to the values and needs of each individual patient

POSSIBLE MEASURESISTRATEGIES

INTERVENTION EXAMPLES The ability of health professionals to practice patient-centred medicine and to be responsive to patient values and needs should be cultivated during undergraduate training. Undergraduate education needs to:

•

Adoption of comprehensive medical/allied health curriculum, problem-based learning and communitybased training which are skills-oriented, covering communication and development of tailor-made interventions

• • •

• •

focus on competencies and capabilities; be guided by learning goals; to be based in community settings where trainees have regular ongoing contact with patients which allows the development of ·jkills in patient-centred interviewing and assessment; adhere to the biopsychosocial model; teach and reinforce reflective practice via trainee presentations to other students and teachers and through maintaining patient log books."

w N

Professional development for health profeSSionals needs to

• •

• •

~-

.-""~------

-----

•

be evidence-based and reinforce evidence-based practice; be interactive' and experiential allOWing health professionals to participate in role-plays and interviews with simulated patients; encourage critical reflection of clinical practice; improve patient-centred communication skills including establishing rapport, biopsychosocial interviewing and assessment, negotiation, and providing patient information; provide health professionals With patient

Patient at the Centre_Policy framework_draft Page 4 of 10

---.

. -

booklets which educate patients to participate in clinical consultations.'*

-

-

• To enhance commitment to quality, safe and ethical services • To increase adoption of reflective practice

•

Open disclosure requirements and standards

This is a relatively new area of development in developed countries. - - - - - - ..

--

•

Ongoing peer review for health professionals across all disciples -

Skills in reflective practice need to be incorporated in undergraduate education. ** -

*

*.

Evidence from Cochrane reviews Evidence from quality studieslliterature

::{-

•

~I ,

Patient at the Centre_Policy framework_draft Page 5 of 10

DOMAIN THREE: OUTCOMES More effective health services, facilities and institutions

Health care institutions OBJECTIVES POSSIBLE MEASURES/STRATEGIES INTERVENTION EXAMPLES Health care environments need to promote patient health and recovery. Designs need to: • be welcoming, calm, relaxing and accessible; • represent the home environment; • support patient lifestyle and family life; • respect patient need for privacy; • encourage patient ownership of environment; • assist with movement between spaces. ** VJ

•

To develop a physical environment which is appropriate, accessible and safe for patients, and performance-enhancing for health professionals

•

Facility design for comfort, safety and functionality

.>

. • • To delineate the roles and responsibilities of all health professionals To support team work and partnersh ips across all specialties

, • Detailed job descriptions, communication protocols, documents flow, clinical records standards, continuous practice improvement schemes

Team work processes need to: • establish clear objectives, composition and tasks for the team; • promote high level participation by all members; • encourage team problem-solving; • promote respect and communication even where opinions differ. ** -_. _. -

.j:>..

-

_.

Patient at the Centre_Policy framework_draft Page G of 10

~~

~-~

----~

---

-

---~

~-

--_.---

-

----

~-----

----------

To improve patient flow and 0 ensure transparent and accessible service flow/protocols

• •

Methods and systems that give priority to patient needs and ensure efficient use of patient and staff time Appropriate scheduling of appointments

Information systems and patient information needs to be shared amongst health professionals and patients. * Reminder notices encouraging patients to attend health services for specific interventions such as immunisation can increase patient patronagePublic announcements and loose/wallmounted printed materials and signages to guide the public/consumers to naVigate the health service (ie which services are available when, who to see, where to go, what to bring, and when, expected turn around time)

#

.. • To improve the integration of patient education, family involvement, selfmanagement and counselling into health care

-

• • •

Communication and counselling protocols for health professionals Patient education guides which promote self-care Financial and other rewards for exemplary performance (ie public acknowledgment of model staff) Public accountability mechanisms, including community participation in governance (ie exit interviews to determine patient satisfaction)

Validated functional assessments of patients can improve patient-centred practice and increase doctor-patient communication. **

VI

w

•

To provide incentives for quality and ethical care

A recent review of empirical literature found that financial incentives for medical practitioners and hospitals do not result in quality health care"*

•

• To invest in capacity-building for health services managers

•

HRD schemes and advisory services to enhance leadership and managerial skills and to support organizational development

The effect of health care leadership on health systems performance has been studied widely, but few quantitative studies have been undertaken.

-

Patient at the Centre_Policy framework_draft Page 7 of 10

•

To engage in continuous quality improvement through evaluation and feedback

•

Monitoring individual and team performance and its impact on health outcomes Providing feedback and discussion forums, individually and in teams

• • •

Audit and feedback processes can improve clinical practice. Health professionals need to be actively involved and have specific and formal responsibilities for implementing change!

More and better approaches to, and models, of care

Pilot, evaluate and disseminate models of care across all service areas

New models of care need to include:

• • •

.

.

specialist outreach clinics especially to rural areas; increased collaboration between medical practitioners and nurses; improved discharge planning to reduce the length of stay ;,'1 hospital to free up capacity for subsequent admissions. * W 0\

Educational outreach visits combined with social marketing, appear to be a promising approach to modifying health professional behaviour, especially prescribing. * .__ ..0_-

*

*.

Evidence from Cochrane reviews Evidence from quality studies/literature

Patient at the Centre_Policy framework_draft Page 8 of 10

DOMAIN FOUR:

Health systems

OUTCOMES More supportive health systems, including systemlevel incentives

OBJECTIVES To develop and strengthen the primary care workforce

POSSIBLE MEASURES/STRATEGIES Human resource planning that places emphasis on primary care

INTERVENTION EXAMPLES

• •

• • To ensure transparent regulation and monitoring of p{ofessional standards Standards for education; professional registration and renewal of registration/license (including consumer involvement); skills maintenance

Management education programs Staff scholarships Processes which improve interaction between primary care workforce and management HR policies and practices which are responsive to employee needs !

,

•

Professional registration dependent on accrual of a set number of ~uints for participation in professional development activities

,

To ensure quicker resolution of complaints and grievances

Complaints investigation and conciliation mechanisms (Legal assistance, if needed

Evidence/literature to be located

W -...J

To ensure greater public accountability for service or practice

Public reporting of performance (ie published ranking of local government units, health facilities, and/or specific services in health facilities)

The evidence base in developed countries is evolving on this relatively recent practice

To ensure optimal mix of incentives for rational technology use (RTU) and early intervention

Financing incentives, including for primary care gate keeping and/or demand-side financing Purchasing arrangements that incorporate quality and responsiveness (ie minimizing provider-induced demand) Performance evaluation tools/~stems

Financial incentives need to include:

•

•

fee for service payments to provide a greater quantity of primary care services; target payments for specific clinical services such as immunisation.' .-

~

and

Patient at the Centre_Policy framework_draft Page 9 of 10

performance-based subsidies or grants

Stronger evidence base on how to achieve better health outcomes/impact

Advocating/supporting the mainstreaming of innovative approaches and interventions that are appropriate to the cultural and social context

Evidence/literature to be located.

* **

Evidence from Cochrane reviews Evidence from quality studieslliterature

w

00

Patient at the Centre_Policy framework_draft Pa~e

10 of 10

- 39 -

ANNEX 6

VISION 2020 By the year 2020, Malaysia is to be a united nation, with a confident Malaysian Society, infused by strong moral and ethical values, living in a society that is democratic, liberal and tolerant, cari!j9, economically just and equitable, " progressive and prosperous, and in full possession of an economy that is competitive, dynamic, robust and resilient

VISION FOR HEALTH .. To develop a nation of healthy individuals, families and communities, through a health system that is equitable, affordable, effiCient, technologically appropriate, environmentally adaptable and consumer friendly, with emphasis on quality, innovation, health promotion and resp,,'h'iJ for human dignity, which promotes individual responsibility and community participation towards an enhance quality of life".

MISSION FOR HEALTH The Mission of the Ministry of Health is to build partnerships for health to facilitate and support the people to: , Attain fully their potential in health , Motivate them to appreciate health as a valuable asset . Take positive action to improve further and sustain their health status to enjoy a better quality of life.

CORPORATE CULTURE

Caring Service 2. Teamwork 3. Professionalism 1.

CORPORATE CULTURE

CORPORATE CULTURE United in purpose Sense of belonging Leadership Gaining task Teamwork Accountability Skills & knowledge Creativity Innovation Team Cooperation & Collaboration

• Respectful • Responsive

Caring Service

1

- 40 -

MOH - COMMITTEES

CORPORATE CUL TUF\~ Ethical Committed Professionalism Discipline Best possible way Work Standard

1. Vision, Mission And Corporate Culture

2. Healthcare System Of The Future 3. Medicine In The Future In Malaysia 4. Continuous Professional Development 5. The New Public Hearth And Health Promotion 6. Measurement And Accountability in Healthcare 7. Hospital Efficiency And Physician Accountability 8. Service Standards 9. Patient Centered Medicine

10. Self Help, Self Care, Self Medication 11. Critical Pathway I Clinical Pathway

8 HEALTH SERVICES GOALS • Wellness Focus • Person Focus • Informed Person • Self Help • Care Provided at Home or Close to Home • Seamless, Continuous Care • Services Tailored to Individual or Group Need • Effective, Efficient and Affordable Services

HEALTH SYSTEM OF THE FUTURE • Personal & community responsibility • Individuals and community to make right lifestyle choices • Right information at right time • A state of health as long as possible • Information & education

HEALTH SYSTEM OF THE FUTURE (contd.) • • • • Access to promotive and preventive activities Consultation to maintain health and early treatment of illness Seamless provision of care Access to patient's longitudinal health record by any care provider

HEALTH SYSTEM OF THE FUTURE (contd.) Continuity of care across settings & episodes of care Evidence-based approach Clinical Practice Guidelines (CPG), consensus statements & clinical protocols Patients involved in own care Outcome assessment

2

- 41 -

HEALTH SYSTEM OF THE FUTURE (contd.) • Management of quality • Greater health care provider accountability • Proactive management of weliness • Early detection of disease • Closer links between healthcare providers of individuals with management of community health • • •

HEALTH SYSTEM OF THE FUTURE (contd.) Pooled management of health risks of individuals Lifeti me Health Plan care provided close to home & to the home

HOSPITAL OF THE FUTURE ,fJ Seamless & borderless but links to primary through contracts & network alliances ,fJ Network of services between adjacent hospital localities ,fJ Home away from home concept

HOSPITAL OF THE FUTURE Specialist acute care Higher proportion of lCU within hospitals OT concentrating on laparoscopic or minimally invasive Day Care surgeries

,fJ Comprehensive. integrated & holistic care Smaller specialised physical structures ,fJ Patient focused Decentralised hospital locations

HOSPITAL OF THE FUTURE Strong post acute care services Quality reporting. evidenced based reporting Clinical reparting Ibenchmarks for access & services

Professionals (Health Care providers & Doctor) partner ~

advisors

----

promote weUness

Upkeep world standards

Newly established governing boards with multi hospital responsibilities Greater concentration of lCT

provide acute care Skilled & knowledgeable practice evidence based medicine

3

- 42 -

Clients' Perspective Patient/clie.nt c~ntere.d services Information in health r"Ccords ~ linked, integrated,shared & enables health plan to be prepared & followed Timely, accurate information allows: good decision to be made how to minimise risk from Q disease how to do self risk assessment Prtvate

CONCLUSION Patient ~ ____ Public

... ",iIMt!fiI!f¥"4!rtiUH!l4'. Muttiskllled _

know how to live with the condition

Service level of similar _ standards and quality

Well trained

to know where to obtain help or ser-vice how to do self care & monitoring condition Facilitates interaction &. sharing of experience .1. knowledge .

CONCLUSION

Policies

IT

-!i.• '. -~t:;;

·2

If -

CPG, CME, CPO & qUI/lty governance

-'-HMIS

\~ Referral Process

of.ervices~_ Restructure 'Information ' '" ~E~ff'-e-ct-'-iv-e---'I purcilase through " , '_single__~yst!':!!J I fln8 .. Clng

r- Seamless care ----' health~are 'I

4

- 43 -

ANNEX 7

Hospital Accreditation (HA) Quality & Safety

l.e4rning &. ImPl"Ovement MINQAITQ'" fro_ork

S.lfJpro~ ( Learning Extemel Survey _~r~ess ) -0-

Recognition

S.lfAaaer~

Core Values S. Concepts Key Systems of Hospital

Crcatlvtty &. Innovation Management by Foet

Corrt. Prouss Impro'f'IIlMnt FOC\JS CII'I Ruutts Evidence-based .... pproach

Integrate HA & HPH

In

Every Domalll of Improvement

Health Promotion in every where, every time, every o~e

lnnovalion HP In ROUline /

Holi51lcCare HP In Routine

,

\,

I

I \

\Org Strategic Objective

~

Work System

Environment Management Patienfs right Medical Record Drug SYSlemlLab System )nfectl()n Control

__

MSOlNurse Adm - - - - - - - - - - - - - Etc

1

- 44 -

Integrate HA & HPH In Every Patient Care Review & Continuity or Care 11110 the Community

Find Opportunity For Health Promotion I Bed Side Review ' Ri~k

Oth... RevIews I Cunomer Complaint Review Ad"uSlt EvenClRilk Man.lenlent System Compeleaey ManaEement System In'tclion Coatrol Drul Man.,emen. System Medieal Record Review Resource Utilization Review KPJ Review

C'THER

& Care

Cllmmu.ic.llioR Cunlinuil,. & ole JlI... Tellm wnrk

HRP

En"jrl?nll'lCilI &: EquiJlrnc:nl Holi,tlc Empowermenl

Holistic Empowerment Lifeslyle Prevention

~~~~~on

Use of Clinical Tracer To Learn & Improve All Components S stems

In

the

Thai Patient Safety Goals 2006 Patient Identlfic.tlon

2

- 45 -

ANNEX 8

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

The Patient at the Centre of Care Initiative (PCI)

In-Country Consultation The main purpose of the in-country consultation is to review and consolidate the policy framework. The key consultation questions are as follows: • • • • • • • • • Is patient-focused health care ~ concern within your health system? How prepared is the health system in this countr'l to become patient-focused? What are the key priorities of the health system? How is patient-focused health care understood by stakeholders? Who are the main advocates for patient-focused health care? Is there a commitment to promoting patient-focused health care, and by whom? What is currently being done (by governments and other institutions within the health system) to forward patient-focused health care? What patient-focused health care initiatives have been implemented? Do they work? What patient-focused health care initiatives are being planned for the future? What have been the barriers to the implementation of patient-focused health care, and how have these barriers been resolved or addressed? Does the policy framework cover the right domains? What other domains need to be considered?

DOMAIN ONE:

Better informed and more empowered consumers, patients and their families, and community leaders to actively participate in health systems

• • • • • • • • •

What are the key issues from the perspective of consumers, patients and their families, community leaders in being able to receive patient-focused healthcare? Does the domain fully capture these issues? What other issues need to be considered in this domain? Are the domain strategies useful? Which ones would be a priority? Are the domain strategies feasible? Which ones are most feasible? What are the potential barriers in implementing the domain strategies? How might these be addressed? What might be the main facilitators for implementing these strategies? How might they be harnessed? What are you already doing? Examples of good practice/case studies.

- 46 -

DOMAIN TWO:

Skilled health professionals and providers who deliver health care responsive to patient values and needs

• • • • • • • • •

What are the key issues that prevent health professionals and other health providers from providing patient-focused healthcare? Does the domain fully capture these issues? What other issues need to be considered in this domain? Are the domain strategies useful? Which ones would be a priority? Are the domain strategies feasible? Which ones are most feasible? What are the potential barriers in implementing the domain strategies? How might these be addressed? What might be the main facilitators for implementing these strategies? How might they be harnessed? What are you already dOing? Examples of good practice/case studies.

DOMAIN THREE:

More effective health services, facilities and institutions

• • • • • • • • •

What are the key issues that prevent your health services, facilities and institutions from providing patient-focused healthcare? Does the domain fully capture these issues? What other issues need to be included in this domain? Are the domain strategies useful? Which ones would be a priority? Are the domain strategies feasible? Which ones are most feasible? What are the potential barriers in implementing the domain strategies? How might these be addressed? What might be the main facilitators for implementing these strategies? How might they be harnessed? What are you already doing? Examples of good practice/case studies.

DOMAIN FOUR:

More supportive health systems, including system-level incentives

• • • • • • • • •

What are the key issues affecting your health system that is a barrier for patient-focused health care? Does the domain fully capture these issues? What other issues need to be considered in this domain? Are the domain strategies useful? Which ones would be a priority? Are the domain strategies feasible? Which ones are most feasible? What are the potential barriers in implementing the domain strategies? How might these be addressed? What might be the main facilitators for implemenling these strategies? How might they be harnessed? What are you already doing? Examples of good practice/case studies.