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Patient-Centered Care: More than the Sum of Its Parts Planetrees Patient-Centered Hospital Designation Program.

W hen a nurse at theCelilo Cancer Centerat the Mid-ColumbiaMedical Center in The Dalles,Oregon, found out that his pa-tient was scheduled to receivechemotherapy on her weddinganniversary, he asked the womanand her husband what songtheyd first danced to on theirwedding day. It was Save theLast Dance for Me, and the nextday, when the couple rose fromtheir chairs after the patients six-hour infusion, the song beganplaying. Right there in the infu-sion area, with their arms aroundeach other, they danced.

This story illustrates the kindof care that has become the normat the 10 hospitals in North Amer-ica recognized since 2007 aspatient-centered hospitals byPlanetrees Patient-Centered Hos-pital Designation Program. Atthese hospitals patientcenteredcare is more than a buzzword.Rather, its reflected in their mis-sion statements, strategic plans,models of nursing care, and day-to-day operations.

While many organizations,including the Institute of Medi-cine,1 the Institute for HealthcareImprovement, 2 and Planetree, 3 have endeavored to define pa-tient-centered care, no definition

conveys its essence as well asthe patients at these hospitals

can. This place has a specialcharacter, one patient said in afocus group. Others have said,You can tell the nurses here careabout you as a person, Theyare a special breed of peoplehere, and I dont think its justa job for them; theyre here fora reason.

Over the past year, this se-ries, Putting Patients First , hasexplored several aspects of thepatient-centered approachencouraging patients to reviewtheir medical records, liftingrestrictions on family involve-ment in care, and lowering noise

levels in hospitals, among others.We believe they show that, ulti-mately, patient-centered care ismore than the sum of its parts.

PROVIDING A FRAMEWORK

Planetrees goal for the designa-

tion program is to make patient-centered care less of an ambiguousnotion and more of an attainablegoal (for more information, go tohttp://planetree.org/consultation.html ). Many facilities have as-pired to become more patientcentered as the con cept has gar-nered attention in recent years.The Hospital Consumer Assess-ment of Healthcare Providers andSystems (HCAHPS) survey, forexample, compiles patients as-sessments of hospital care andmakes them available online (seewww.hospitalcompare.hhs.gov ).Also, the major health care re-form legislation passed this year

This is the seventh and last in a series of articles from Planetree, an international non-profit organization founded in 1978 thats committed to improving medical carefrom the patients perspective. For more information, go towww.planetree.org.To register for a free Webinar based on this series that starts on September 21,go to http://bit.ly/aezmEu.

[email protected] A JN t September 2010 t Vol. 110, No. 9 49

By Susan B. Frampton, PhDSara Guastello

Kurt Rohrbacher, RN, plants a pair of Groucho glasses on a chemotherapypatient at Celilo Cancer Center at the Mid-Columbia Medical Center in The

Dalles, Oregon, where hes known for his ability to set cancer patients mindsat ease during their treatment. Photo courtesy of Mid-Columbia Medical Center.
http://planetree.org/consultation.htmlhttp://planetree.org/consultation.htmlhttp://www.hospitalcompare.hhs.gov/http://bit.ly/aezmEuhttp://bit.ly/aezmEuhttp://www.hospitalcompare.hhs.gov/http://planetree.org/consultation.htmlhttp://planetree.org/consultation.html


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criteria for designation in 11 cat-egories (see Table 1).

Criteria include whether hos-pitals balance patients needs withtheir safety, whether transparencyremains a priority even whensomething unexpected occurs,whether the work environmentis supportive of staff, and whetherpatient-centered approaches areapplied to billing and communityoutreach. The designation pro-cess begins with a self-assessmentthat requires hospital leadersto appraise the organizationsculturean appraisal that canbe valuable, regardless of whetherits part of the designation pro-cess. After all, Planetree designa-tion recognizes a job well done,

not a job all done. (Designationlasts for three years.)

After the self-assessment, ahospital provides to Planetreedocumentation of its patient-centered practices. Next, a teamincluding representatives of fa-cilities that have achieved des-ignation make an on-site visit;the written documentation isverified through a facility tourand feedback from patients,family members, and staff. Thisteams assessment is then re-viewed by an independent com-mittee of health care leaders,with representatives from theAmerican Hospital Association,the Insti tute for Healthcare Im-provement, and patient advo-cacy groups, among others. Thisfeedback informs a decision to

designate a hospital as patientcentered.

includes financial incentives tohospitals that meet certain stan-dards of patient-centeredness,such as the use of patient andcaregiver assessments or the useof individualized care plans. 4

Still, theres a gap betweenaspiration and reality at manyorganizations when it comesto patient-centeredness. The de-signation program provides aframework for evaluating a hos-pitals systems and processes, onethats based on Planetrees threedecades of work with hospitalsin the United States and abroad,and especially on data gatheredfrom focus groups conductedwith thousands of patients, fam-ily members, and health care

professionals. Using these per-spectives, Planetree shaped 50

50 A JN t September 2010 t Vol. 110, No. 9 ajnonline.com

Table 1. The Patient-Centered Hospital Designation Program: Categories andSelected Criteria

Category Examples of Criteria

Structures and FunctionsNecessary for Implementation,Development, and Maintenanceof Patient-Centered Concepts

Processes are in place to obtain and use feedback from patients and families on avariety of hospital practices and initiatives.

Human Interactions A model that embraces continuity, consistency, and accountability in care andpermits staff to personalize care for each patient.

Patient Education and Access toInformation

Educational materials are available for patients and families and accessible tostaff.

Family Involvement Flexible, 24-hour, patient-directed visitation.Nutrition Program 24-hour access to a variety of foods and beverages.Healing Environment:

Architecture and Interior DesignRemoval of barriers at nurses stations, such as high counters and counter-to-ceiling glass partitions, as well as those in family lounges and unit-based kitchens.

Arts Program A therapeutic-distractions program involving music, visual arts, crafts, animalvisitation, and bedside reading.

Spirituality and Diversity Documenting and addressing the needs of diverse cultural groups.Integrative Therapies Assessment of staff and patient interest in and need for alternative,

complementary, and integrative therapies.

Healthy Communities A plan to improve community health.Measurement Satisfaction of inpatients and outpatients assessed using a validated instrument,

with performance exceeding national averages.

A hospital must adhere to 50 criteria in the following 11 categories to be recognized by Planetree as a patient-centeredhospital.


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suggesting a link between patient-centered care and patient satis-faction.

The benefits of designation.Accolades received by the desig-nated hospitals include the 2007Malcolm Baldrige National Qual-ity Award, a presidential awardfor excellence given to the SharpHealthcare System, of whichSharp Coronado Hospital is apart, and Magnet accreditationfrom the American Nurses Cre-dentialing Center in recognition

of nursing excellence at DelnorHospital in Geneva, Illinois. Also,Griffin Hospital appeared onFortune magazines list of 100Best Companies to Work For inthe United States from 2000 to2009, and in 2009 Centre de r-adaptation Estrie, a rehabilitationhospital in Quebec, was recog-nized in Canadas Les Affaires magazines Best Employers Chal-lenge.

On its Quality Check Web site(www.qualitycheck.org ), the JointCommission recognizes hospitalsthat have received the Planetreedesignation. Planetree-designatedhospitals have been featured inthe Washington Post 16 and the

New York Times .17 But the great-est benefits have little to do withpublicity. Marcia Hall, chiefexecutive officer of Sharp Coro-nado Hospital, said: We are ex-tremely proud of becoming oneof the first five nationally notedPlanetree Designated Patient-Centered Hospitals. But its notabout awards. They confirm thatwere on the right track, but itsmostly about progress toward avision to make a dif ference forthe people we work with and the

people we serve.NEXT STEPS

When Planetree launched thedesignation program in 2007, itwas specific to acute care hospi-tals. Since then, advisory coun-cils in behavioral health andcontinuing care have worked torevise the designation criteria sothat theyre applicable to a greaterrange of settings. The new crite-ria establish a consistent set ofstandards for what consumerscan expect from any patient- orresident-centered provider.

Also, an International Des-ignation Advisory Council isshaping a set of international

staff as contributing to the po-tential for medical errors. 9, 10

Given the alarming ratesof turnover, 11 vacancy, 12 andburnout 13-15 among nurses, theexperience of staff is a criticalconsideration in the Planetreedesignation. Giving bedside staffrewards and recognition, retreats,access to minutes of leadershipmeetings and other informationon organizational priorities, a sayin how care is delivered, andservices supporting worklife

balance are among the ways thathospitals uplift staff while puttingpatients first. Griffin Hospital inDerby, Connecticut, for instance,makes an on-site fitness centeravailable to staff, sponsors afarmers market at the facilityduring the summer, and offersprepackaged meals to go in itscafeteria.

CONNECTING PATIENT-CENTEREDNESSAND QUALITY

Care safety and quality go handin hand in any patient-centeredapproach. Accordingly, Planetreeevaluates outcomes as a part ofthe designation process by com-paring a hospitals scores withnational benchmarks. Wevefound that collectively the 10designated hospitals exceed theCenters for Medicare and Medi-caid Services (CMS) national av-erages on several core measures(see Figure 1). This conforms tothe Institute of Medicines con-clusion that patient-centered careis a part of the foundation ofhigh-quality care. 1 Also, as agroup, the nine U.S. designatedhospitals perform above the CMSnational average in nine of the10 publicly reported HCAHPScategories and at the nationalaverage in the quiet at nightcategory (see Figure 2). The mostsignificant differences appear in

the overall rating and in likeli-hood to recommend the facility,

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93% 89%86%

92%96%

93% 91%96%

Overall PneumoniaCare

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National average Designated hospital average

Figure 1. Comparison of U.S. Planetree-DesignatedHospitals and CMS Hospitals on CMS Core Measures,Third Quarter 2007 through Second Quarter 2009

The Commonwealth Fund.http://whynotthebest.org .
http://www.qualitycheck.org/http://www.qualitycheck.org/


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[email protected] A JN t September 2010 t Vol. 110, No. 9 53

criteria that are globally appli-cable. Designation programs areunder way in Canada and theNetherlands and in developmentin Brazil and Japan. t

Susan B. Frampton is president of Plane-tree in Derby, CT, where Sara Guastellois manager of designation and resourcedevelopment. Frampton coordinatesPutting Patients First: sframpton@

planetree.org.

REFERENCES

1. Institute of Medicine. Committee onQuality of Health Care in America.Crossing the quality chasm: a newhealth system for the 21st century .Washington, DC: National AcademyPress; 2001. http://www.nap.edu/ books/0309072808/html.

2. Institute for Healthcare Improvement.Patient-centered care: general. n.d.http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral.

3. Frampton SB, Charmel PA, editors.Putting patients first: best practicesin patient-centered care . 2nd ed. SanFrancisco: Jossey-Bass; 2008.

4. The Patient Protection and AffordableCare Act. 111th Congress, 1st sessioned. 2010.

5. Centers for Medicare and MedicaidServices. Hospital compare . 2010.http://www.hospitalcompare.hhs.gov.

6. Watson J, Frampton SB. Humaninteraction and relationship-centeredcaring. In: Frampton SB, CharmelPA, editors. Putting patients first:best practices in patient-centeredcare. San Francisco: Jossey-Bass; 2008.p. 3-26.

7. Stone S. A retrospective evaluation ofthe impact of the Planetree patient-centered model of care on inpatientquality outcomes. HERD : Health en-vironments research and design jour-nal 2008;1(4):55-69.

8. Frampton SB, et al. Patient-centeredcare improvement guide . Derby, CT;Camden, ME: Planetree, Inc.; PickerInstitute; 2008 Oct. http://www.planetree.org/Patient-Centered%20Care%20Improvement%20Guide%2010.10.08.pdf.

9. Buerhaus PI, et al. Is the shortage ofhospital registered nurses getting bet-ter or worse? Findings from two re-cent national surveys of RNs. NursEcon 2005;23(2):61-71, 96, 55.

10. Kaiser Family Foundation, Agencyfor Healthcare Research and Quality,Harvard School of Public Health.National survey on consumers expe-riences with patient safety and qualityinformation . Washington, DC; 2004Nov. http://www.kff.org/kaiserpolls/ pomr111704pkg.cfm.

11. Kovner CT, et al. Newly licensedRNs characteristics, work attitudes,and intentions to work. Am J Nurs 2007;107(9):58-70.

12. American Hospital Association. The2007 state of Americas hospitalstaking the pulse. Findings from the2007 AHA survey of hospital leaders[PowerPoint presentation]. Washing-ton, DC. http://www.aha.org/aha/ content/2007/PowerPoint/StateofHospitalsChartPack2007.ppt.

13. Erickson RJ, Grove WJC. Why emo-tions matter: age, agitation, andburnout among registered nurses.Online journal of issues in nursing 2008;13(1).

14. Vahey DC, et al. Nurse burnout andpatient satisfaction. Med Care 2004;42(2 Suppl):II57-II66.

15. Aiken LH, et al. Hospital nurse staff-ing and patient mortality, nurse burn-out, and job dissatisfaction. JAMA 2002;288(16):1987-93.

16. McAteer MJ. Virginia hospital treatsthe whole person. Washington Post 2009 Mar 24. http://www.washingtonpost.com/wp-dyn/content/article/2009/03/23/AR2009032301806.html.

17. Lombardi, KS. For patients, morecomfort and a bigger dose of respect.New York Times 2008 Feb 17. http:// www.nytimes.com/2008/02/17/nyregion/nyregionspecial2/17hospitalswe.html.

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Overall Ratingof 9 or 10

Likelihood toRecommend

Responsiveness PainManagement

DischargeInformation

Quiet at Night Cleanliness

75%

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National average Designated hospital average

Figure 2. Comparison of U.S. Planetree-Designated Hospitals and CMS Hospitals on HCAHPSMeasures, July 2008 through June 20095

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