This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Globally, health‐care systems and organizations are looking to improve health system performance through the implementation of a person‐centred care ( PCC ) model. While numerous conceptual frameworks for PCC exist, a gap remains in practical guidance on PCC implementation.
Based on a narrative review of the PCC literature, a generic conceptual framework was developed in collaboration with a patient partner, which synthesizes evidence, recommendations and best practice from existing frameworks and implementation case studies. The Donabedian model for health‐care improvement was used to classify PCC domains into the categories of “Structure,” “Process” and “Outcome” for health‐care quality improvement.
The framework emphasizes the structural domain, which relates to the health‐care system or context in which care is delivered, providing the foundation for PCC , and influencing the processes and outcomes of care. Structural domains identified include: the creation of a PCC culture across the continuum of care; co‐designing educational programs, as well as health promotion and prevention programs with patients; providing a supportive and accommodating environment; and developing and integrating structures to support health information technology and to measure and monitor PCC performance. Process domains describe the importance of cultivating communication and respectful and compassionate care; engaging patients in managing their care; and integration of care. Outcome domains identified include: access to care and Patient‐Reported Outcomes.
This conceptual framework provides a step‐wise roadmap to guide health‐care systems and organizations in the provision PCC across various health‐care sectors.
Keywords: conceptual framework, healthcare quality, implementation, person‐centred careIn the Institute of Medicine's 2001 seminal report Crossing the Quality Chasm, patient‐centred care was identified as an essential foundation for health‐care quality and patient safety 1 and ever since has been recognized as a high priority for the delivery of health‐care services in many jurisdictions. 2 , 3 , 4 , 5 , 6
Patient‐centred care has been an evolving concept, originally depicted by Edith Balint in 1969 as “understanding the patient as a unique human being.” 7 Since then, there have been many other conceptualizations of patient‐centred care. 1 , 8 , 9 , 10 , 11 Patient‐centred care has been described through an array of alternative and more commonly adopted terms, including: patient (and family)–centred care, relationship‐centred care, personalized care and user/client‐centred care. Various jurisdictions, organizations and health‐care systems utilize different terms and concepts. For instance, in the United States, the concept is usually linked to a “patient‐centred care medical model,” while in the United Kingdom, it is associated with primary care, and in Scotland, PCC is known as “mutuality.” 8 Given that the concept of patient‐centred care is evolving, it is important to understand how different jurisdictions define and operationalize it. In this article, we have chosen to use the term “person‐centred care” (referred to as PCC), as opposed to patient‐centred care, in agreement with Ekman et al's distinction between patient‐centred care and PCC, by which PCC refrains from reducing the person to just their symptoms and/or disease. 12 We concur that it is important to acknowledge the notion of person, which calls for a more holistic approach to care that incorporates the various dimensions to whole well‐being, including a person's context and individual expression, preferences and beliefs. 12 Additionally, PCC is not limited to only the patient, but also includes families and caregivers who are involved, those who are not living with illness, as well as prevention and promotion activities.
PCC has not been traditionally integrated into health‐care quality improvement. Recent policies emphasize the value of patient views, which not only complement health‐care provider perspectives, but also provide unique information about health‐care effectiveness, 13 , 14 , 15 , 16 , 17 , 18 including improvement of patient experiences and outcomes and health‐care provider satisfaction, while decreasing health‐care services utilization and costs. 19 , 20 Based on this evidence and the need to address sky‐rocketing health‐care costs, many health‐care systems around the world are moving towards a PCC model. 21 , 22 , 23 At the global level, the World Health Organization (WHO) has developed policy frameworks for people‐centred health care 24 highlighting person‐centredness as a core competency of health workers, 25 and as a key component of health‐care quality 26 and primary care. 27
Conceptually, PCC is a model in which health‐care providers are encouraged to partner with patients to co‐design and deliver personalized care that provides people with the high‐quality care they need and improve health‐care system efficiency and effectiveness.
Despite many efforts to practice PCC, most health‐care systems are challenged by effective implementation of PCC across the continuum of care. Shifting to PCC requires services and roles to be re‐designed and re‐structured to be more conducive to a PCC model. Although numerous conceptual frameworks of PCC have been introduced and discussed in the existing literature, 5 , 9 , 11 , 12 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 practical guidance on the implementation of PCC has not been well described. To address this gap, we developed a conceptual PCC framework that provides a comprehensive perspective, particularly with respect to the foundations needed to achieve PCC.
The guiding perspective for developing the framework was from a patient (and family caregiver, representative) perspective to ensure that the framework reflects what matters people, not only policy makers and HCPs. This conceptual framework describes and links key PCC domains and best practices to a model of practical implementation, through a narrative overview 39 of theoretical and conceptual works from academic and grey literature, in addition to policy and organizational documents.
Based on the guidance from Green et al on conducting a narrative review, 39 a preliminary search was conducted. A number of sources included in the review were identified through a scoping review conducted on person‐centred quality indicators that revealed rich literature on PCC practice and measurement. Search protocol details, including databases and search terms, have been published. 40 Additional works that were hand‐searched and selected included frequently cited PCC literature and key policy documents from reference lists, and those identified by our patient partner (Zelinsky).
Articles that were selected by the research team were agreed upon by the team members that assessed the following criteria for inclusion: an existing theoretical or conceptual patient/person‐centred care framework; importance to patients (as validated by Zelinsky); frequently cited (as verified in Google Scholar); and provides interesting discussion or presents concepts important to patients that tend to be missing from the academic literature, which would allow for a comprehensive perspective in developing the PCC framework. A number of sources were excluded as the research team deemed saturation for developing domains and concepts. Due to the inclusive scope of the review and high variation among sources, critical appraisal was not conducted.
Common domains identified from the literature were reviewed, from which comparable themes and concepts were synthesized and then classified according to the Donabedian model for health care improvement into “Structure,” “Process” and “Outcomes.” 28 , 41 Among these three domains, each component is influenced by the previous and each is interdependent on the other. 41 Secondly, the research team engaged in a series of facilitated discussions to develop and refine the framework, including parsing and combining domains, subdomains and components, which also helped the research team to determine the point of saturation with respect to domains and components, and cease further search in the literature.
Figure 1 presents the conceptual framework for implementing PCC. Structure includes PCC domains related to the health‐care system or the context in which care is delivered and provides the foundation for PCC – the necessary materials, health‐care resources and organizational characteristics. Process includes domains associated with the interaction between patients and health‐care providers. Outcomes show the value of implementing the PCC model, with domains relating to the results from the interaction between the health‐care system, HCPs and patients. The framework is organized like a roadmap, depicting the practical PCC implementation in the order that should be implemented – starting from structural domains that are needed as pre‐requisites, to facilitate processes and influence outcomes needed to achieve PCC.
Framework for person‐centred care
Table 1 shows the seven core structural domains that have been identified as foundational components or pre‐requisites to promote a PCC model. The literature widely recognizes the importance of creating a PCC culture across the continuum of care (S1), where governments 42 and organizations play a key role in the development of clear and comprehensive polices, processes and structures necessary for health‐care systems and health‐care providers to deliver PCC. 5 , 30 , 43 , 44 A common set of core values among all parties, as part of a strategic vision (S1a) is essential in the provision and receiving of care that includes patients, health‐care providers, communities and organizations within and outside of traditional health‐care services. While it is agreed that a key guiding principle in implementing PCC is to incorporate the patient perspective, 5 there is a need to ensure that care is also patient‐directed, whereby patients are provided with sufficient and appropriate information to make decisions about their care and level of engagement. 5 , 45 Further, PCC respects individual patient beliefs and values and promotes dignity and antidiscriminatory care. 46 , 47 There is a need to be explicit in ensuring that diversity, including race, ethnicity, gender, sexual identity, religion, age, socio‐economic status and disability, is addressed and incorporated. 48 A “rights‐approach” to PCC is aligned with the promotion of human dignity for both patients and health‐care providers and allows both parties to be aware of their rights and responsibilities. 14 , 49 Moreover, best practices demonstrate the need to standardize PCC language among patients, health‐care providers, policy makers, along with other key stakeholders to effectively foster a PCC culture of care (S1b). 5 , 31 , 44 If the focus is in providing high quality of care, the terminology used by health‐care systems must change; PCC promotes the value of co‐design where health‐care providers do things with people, rather than “to” or “for” them. 13
Structure domains and components
Vision, Mission Patient‐directed: integrating patient experience and expertise Addressing and incorporating diversity in care, health promotion and patient engagement Patient and health‐care provider rights Consistent operational definitions Common language around PCC Integration of all health‐care sectors and professionals Professional education and accrediting bodies Translating into practice through continued professional education and mentorship Identify resources Creating partnerships with community organizations Create patient advisory groups Provide adequate incentives in payment programs; celebrate small wins and victories Encourage teamwork and teambuilding Collaborate with and empower patients and staff in designing health‐care facilities Environments that are welcoming, comfortable and respectful Spaces that provide privacy Spiritual and religious spaces Facility that prioritize the safety and security of its patients and staff Areas/rooms that will support the accommodation of patients Provide interpretation and language services Patient‐directed visiting hoursElectronic Health Record systems with capacity to coordinate and share health‐care interactions across the continuum of care
Health information privacy and security E‐health adoption support through strategic funding and educationCo‐design and development of innovative programs to collect patients and caregiver experiences about care received and providing timely feedback to improve the quality of health care (including complaints and compliments, wins and lessons learned)
Reporting and feedback for accountability and to improve quality of health careThe lack of emphasis on PCC in medical education remains a barrier to its implementation, 5 resulting in practices gaps. Specifically, current education tends to focus on the biomedical model, is not standardized across health‐care sectors and professionals, and is not co‐developed with patients and health‐care providers, (S2) despite successful models that incorporate both perspectives in the development and implementation of training. 43 With the rapid emergence and evolution of PCC, there is a need for innovative education programs that are endorsed by key stakeholders and champions in medical education, including medical faculty, deans, administrative directors and accrediting bodies. 43 , 50 Educational programs should also include administrative staff, volunteers and allied professionals involved in health care, who are needed to support the cultural change. 24 As integrating PCC into the health‐care curriculum does not necessarily translate into practice, PCC education programs should be designed to continue through informal training, continued leadership development and training through mentors and role‐models, eventually leading to a greater impact on culture change. 5 , 24
Patients and communities can also play a key role in co‐designing the development and implementation of health promotion and prevention programs (S3). By collaborating with and empowering patients, patient advisory groups, 5 , 43 communities and organizations, health‐care systems will be able to develop appropriate programs that meet the needs of all people. 51 , 52 , 53 , 54 , 55 Building capacity of communities and organizations can also enhance integration, coordination and continuity of care, by supporting patients, and identifying resources that address barriers to accessing care and determinants of health (e.g housing, nutrition, education, etc.). 24
Another major structural component is providing a supportive PCC work environment that ensures adequate resources for staff to practice PCC (S4). Current reimbursement models are one of the main obstacles for promoting and practicing PCC. Physician reimbursement is not typically linked to the importance placed on building and maintaining relationships and level of care quality provided as perceived by patients. Most current primary care payment systems encourage physicians to increase the number of patients seen and reduce time spent with individual patients. 56 Policy makers need to consider alternative provider payment methods and incentives to reward practicing PCC. 5 , 43 , 56 Additionally, to promote a supportive PCC work environment, Epstein et al suggest creating “communities of care,” which work to promote teamwork, collaboration and communication among HCPs to collectively meet the needs of their patients. 48
A supportive and accommodating built environment is an essential aspect of PCC (S5) where co‐design with patients is crucial to ensure that patients feel comfortable, welcomed and have their needs met. 5 , 24 , 28 , 43 Healing environments that support choice, dignity and respect have a positive impact on health‐care outcomes (S5a). The physical design of the health‐care environment influences patient safety (reducing errors, patient falls, infections, etc.) and patient experience (supporting privacy and comfort). 57 , 58 Further, environments should integrate services to accommodate patients, such as language support and, appropriate and flexible visiting hours. 24 Several well‐established patient‐centred organizations (i.e Planetree 59 ) provide consultation services to HCPs to develop PCC environments and support implementation.
Developing a common e‐health platform for health information exchange across providers and patients with the capacity to link all health‐care electronic data across the continuum of care must also be implemented (S6). Such structures include Electronic Medical Records, which have proven to support access, coordination and safety in care delivery, through enhancing health‐care processes (information access, patient‐health‐care provider communication, patient and family involvement, etc.). E‐health technologies should provide secure and private platforms and its integration involves both building and updating existing health‐care facilities, and effectively connecting patients and caregivers with practitioners throughout the continuum of care. 5 , 43
Finally, patients, health‐care providers and policy makers should co‐develop structures to measure and monitor PCC performance based on feedback from patients, to promote PCC practice (S7). Measurement approaches include the use of patient experience surveys, patient‐reported outcome measures in clinical care, patient complaints and complements, alongside reported wins and lessons learned. 30 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 Utilizing existing public reporting systems present an ideal platform for PCC measuring, reporting and providing accountability. 43 Feedback should also be tailored to the audience. For instance, while patients may be concerned with access to care and relationships with health‐care providers, policy makers may utilize the information in assessing health‐care utilization and costs. Health‐care systems are developing innovative programs to collect data from patients and report this information back to patients and health‐care providers in an accurate and timely manner during clinical encounters to support patient self‐management via visual dashboards. 63
In implementing these structural components, the balance between health‐care providers and patient burden and prioritization of issues must be acknowledged. In addition, quality improvement leaders need to be included in the development of these programs. 6 Having a clear vision on how PCC strategies fit within overall health‐care system, quality improvement is critical in improving PCC processes and outcomes. 5
Four process domains were identified, each of which builds upon the last during a patient‐health‐care providers interaction (Table 2 ). Beginning with cultivating communication (P1), evidence has shown that when a patient's values, needs and preferences are incorporated into health‐care practice, communication better enables patients to be active participants in their own care. 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 Positive associations between physician communication skills have been associated with positive patient outcomes such as increased patient satisfaction, recall, understanding and adherence to therapy. 35 , 81 , 82 Components of communication include listening to patients (i.e gathering information through active listening and seeking patient's informational needs) (P1a.), sharing information (P1b.) and discussing care plans with patients (P1c). When combined, this would facilitate PCC and enhance patient care. Enabling physician competency in practicing person‐centred communication through teaching has been shown to be an effective way to implement this style of communication. 83 Techniques such as using open‐ended questions to invite patients to reflect on their condition, pain, symptoms and other areas of life that may be linked to this, and eliciting the patient's reactions to the information given should be practiced to initiate and continue engaging in PCC dialogue.
Process domains and components
