Cover page

Table of Contents

Title page

Copyright page

Tables and Figures



The Editors

Susan B. Frampton, PhD

Patrick A. Charmel, MPH, FACHE

Sara Guastello

The Contributors



Introduction: Patient-Centered Care Goes Global

Patient-Centered Care: A Cresting Wave of Change

Still Much Work to Be Done

The Patient Experience Is the Human Experience

Patient-Centered Care Field Work

About This Field Guide

Part 1: Patient-Centered Care as a Fundamental Strategy for Achieving High-Quality, High-Value Care

1: The Patient-Centered Care Value Equation

The Value Equation

Health Care Consumers Are Challenging Us to Do Better

Improving Efficiency and Freeing Up Time to Care


2: Defining and Measuring Patient-Centered Quality

Defining Patient-Centered Care

The Tie That Binds Quality, Safety, and the Patient Experience

The Big Question

Raising the Bar in Patient-Centered Care Through Designation

Measuring Patient-Centeredness

Conclusion: A Goal That Can Be Set, Measured, and Achieved

Part 2: Challenges and Solutions in Patient-Centered Care

3: Compassion in Action

Quality Outcomes Linked to Compassion and Empathy

Compassion and Empathy in Practice

Embedding Compassionate Care in Education

Practical Tools to Enhance Compassionate Practice

Putting Compassion First

Conclusion: Compassion and Transformation

4: Words That Work: Patient-Centered Physician Communication

Transforming an Organization's Communication Curriculum: Step by Step

How the Change Affected Patient and Staff Experience


5: Activating Patients Through Access to Information

Information Yields Activation

Patient Activation Improves Health Outcomes

“Nothing about Me, without Me”

Shared Medical Records

Using Personal Health Records to Promote Continuity of Care

Redesigning Patient Education

Cultivating a Teaching and Learning Culture

Community Education

Conclusion: Measuring the Impact

6: Healing Partnerships: The Role of Family in Patient-Centered Care

Why Partnering with Family Is Good for Patients

Patient-Directed Family Presence

Turning Concepts into Practice

Beyond Family Presence: Embracing Family Involvement

Supporting the Needs of Family


7: Healing Environment: Architecture and Design Conducive to Health

Setting the Stage for Patient-Centered Care

Planetree Design Principles

Employing a Patient-Centered Design Process


The Auditory Environment

Healing Design Is Safe Design

Balancing Healing Design and Safety in Behavioral Health Settings


Part 3: Activating Stakeholders to Create Organizational Change

8: Creating Lasting Organizational Change: Turning Hopes into Reality

Business as Usual Is No Longer an Option

But How?

Focus on What Really Matters: Where do We Want to Go?

Harnessing the Power Of People to Be the Change

Support Implementation and Execution of Excellence

Staying on Track: Defining, Measuring, and Showing Meaningful Progress

Conclusion: Small Enough to Start, Big Enough to Matter

9: Culture Change and the Employee Experience

Shared Values, Beliefs, and Vision

Quality Human Interaction within a Shared Vision

Wellness Experts


10: Partnering with Patients and Families to Improve Quality and Safety

Creating a Culture of Safety and Quality

Engaging Patients and Families in Transforming Health Care Systems

Conclusion: The Next Horizons in Patient Engagement

11: The Role of Physicians in Patient-Centered Care

Patient-Centered Care: The Work of the Soul

What Matters Most

Deconstructing Resistance to Patient-Centered Care

Tackling the Challenge of the Disrespectful Physician

The Physician Perspective on …

If You're Not Part of the Solution, You're Part of the Problem

Conclusion: Personal Commitments Physicians Can Make to Be More Patient-Centered

12: Creating a Patient-Centered Continuum of Care

Lessons from the Field: The Netherlands

Lessons from The Field: Quebec

Strategies for Improving Continuity

Conclusion: Planetree Designation Promotes an Integrated Approach to Patient-Centered Care


Title page

Tables and Figures


Table 1.1:Sharp Memorial Hospital Patient- and Family-Centered Care Program Enhancements
Table 2.1:Patient-Centered Hospital Designation Readiness Assessment
Table 2.2:Measures to Assess Aspects of Patient-Centered Care
Table 3.1:All About Me: Questions to Elicit Information About the Person to Enable Delivery of Compassion
Table 3.2:Examples of Positive, Neutral, and Negative Interactions
Table 4.1:Short Teaching Pearls to Integrate Communication Teaching into Teaching Encounters
Table 6.1:Examples of Patient-Directed Family Presence Guidelines and Policies
Table 7.1:Auditory Environment Self-Assessment for Health Care Providers
Table 8.1:Responses to Change


Figure 1.1:SMH Employee and Physician Satisfaction Percentile Rank (FY2008–FY2011)
Figure 1.2:SMH Overall Patient Satisfaction Percentile Rank (FY2008–FY2011)
Figure 1.3:SMH Overall Percentage Perfect Care Compliance Composite (FY2008–FY2011)
Figures 1.4 and 1.5:HCAHPS Patient Experience Survey Comparison of U.S. Designated Patient-Centered Hospitals and the National Average. Reporting Time Period: 04/01/2011–3/31/2012
Figure 1.6:Percent of Patients Who Would Definitely Recommend This Hospital to Friends and Family, Rates of Improvement
Figure 1.7:Percentage of Patients Highly Satisfied, Rates of Improvement
Figure 7.1:Maasziekenhuis Pantein
Figure 7.2:Hospital Israelita Albert Einstein Garden and Labyrinth
Figure 7.3:Tane Hospital Roof Garden
Figure 7.4:Tane Hospital Interior
Figure 7.5:Elmhurst Memorial Hospital Patient Room
Figure 8.1:Excellerator Tool: Creating the Right Movement Ability
Figure 8.2:Do Want Matrix: Right Action
Figure 9.1:Living in Coherence with Our Foundations

This book is dedicated to the continuing inspiration provided to caregivers around the world by the life and work of Laura C. Gilpin (1950–2007).


THIS IS THE third edition of the Putting Patients First series, the first published a decade ago. The success of this series is a testament to the forward-thinking ideas of Planetree's early leaders, led with quiet grace and a strong vision by Angelica Thieriot, who contributed the prologue to this book. These visionaries were defining what it meant to be patient-centered before there was even a term to define. They established a firm foundation for patient-centered care and the Planetree model and philosophy to flourish.

Where it flourishes is in hospitals, medical centers, nursing homes, clinics, physician practices, assisted living communities, behavioral health centers, rehabilitation hospitals, and other care settings where, day in and day out, caregivers devote themselves to the care of others. In putting together this book, we have been humbled by those who have taken on this tremendous responsibility and privilege—often doing so as they try to make the most of scarce resources in the face of many external demands that exert additional pressures. It could be very easy for these caregivers to dismiss patient-centered care as one more thing to do, but they don't. Instead, they have approached it as THE thing to do. The ideas and innovations captured throughout these pages originated with them. This book is a testament to their attitudes of compassion and empathy, their resourcefulness, and their creativity.

Our dear friends Laura Gilpin and Harvey Picker embodied these attributes of compassion, empathy, resourcefulness, and creativity. Their spirits and influence are present throughout this book.

Many of the innovations in these pages have originated with health care professionals. Others are examples of codevelopment where patients have gone beyond sharing their experiences with us to guide improvement, and have fully partnered with health care providers to develop and implement practices that improve the health care experience for all involved.

In each edition of this series, it has been a pleasure to invite a diverse group of patient-centered care champions to share their expertise and unique perspectives on what it takes to create and sustain an organizational culture that puts patients first. For this book, as in years past, these requests were consistently met with eager desire to impart knowledge and an enthusiastic willingness to share, despite busy schedules and heavy responsibilities. We are immensely grateful for the time, energy, and effort each contributor dedicated to this project. You will find them listed after The Editors.

In every aspect of creating this book, we have drawn heavily on the experiences of our colleagues around the world from whom we have learned so much. Their support and guidance in this process have been invaluable. We do not have the space to list all of their names, but we wanted to especially thank some key global leaders, including Jim van den Beuken and Marcel Snijders of Planetree Nederland; Lucie Dumas of Réseau Planetree Quebec; Henrique Sutton de Sousa Neves, CEO of Sociedade Beneficente Israelita Brasileira and the staff of Planetree Brazil; Lucile Hanscom of the Picker Institute and Sir Donald Irvine of Picker Europe; Karen Luxford of the Clinical Excellence Commission in Australia; Antonello Zangrandi and Federico Zangrandi of Progea in Italy; Ana Augusta Blumer Salotti; kz Morihiro; Dr. Dorothea Wild; Dr. Etel Veringa; Marie Fuglsang and Karin Jay for being international ambassadors for Planetree, helping to expand patient-centered care around the world and facilitate global sharing of best practices and innovations.

The progress documented in this book builds on the work of many organizations, among them Joint Commission International, the International Society for Quality in Health Care, the National Quality Forum and the National Priorities Partnership, the Picker Institute, the World Health Organization, the Institute for Healthcare Improvement, Health Consumers' Alliance of South Australia, the Saskatchewan Union of Nurses, the Danish Unit of Patient-Perceived Quality, the Arnold P. Gold Foundation, and the African Patient-Centered Care Initiative led by Peter Arimi of USAID, Fred Wabwire-Magnen of the Regional Centre for Quality in Healthcare and Stephen Kinoti of Fio Corporation.

The Putting Patients First series would not be possible were it not for Andy Pasternack and Seth Schwartz at Jossey-Bass who have been valuable partners on this project. They have guided us through the publishing process, and have worked hard to ensure that the manuscripts we have so painstakingly developed ultimately make it into the hands of readers so that the concepts can be put into practice.

To our draft manuscript reviewers, Karen Adams, Sir Donald Irvine, Jerod M. Loeb, Debra Ness, and Jennifer Sweeney, we thank you for your thoughtful and constructive comments.

We would finally like to acknowledge our colleagues and friends within Planetree—the members of the board of directors and the Planetree International Advisory Council, and an enormously talented staff for whom patient-centered care is nothing less than a personal mission. It is an honor to work with this brilliant group of people as we turn the page to Planetree's next chapter.

Susan B. Frampton, Patrick A. Charmel, and Sara Guastello

The Editors

The Editors

Susan B. Frampton, PhD

For over a decade, Dr. Susan Frampton has been the president of Planetree, a nonprofit advocacy, consultation, and membership organization that works with a growing network of hospitals and continuing care communities around the world to implement Planetree's comprehensive patient- and person-centered model of care. Dr. Frampton has authored numerous publications, the most recent including a series on patient-centered care in the American Journal of Nursing, International Health Federation Journal, Patient-Centered Care Improvement Guide, Long-Term Care Improvement Guide, and the edited collection Putting Patients First, Second Edition (Jossey-Bass, 2008). The first edition of Putting Patients First (Jossey-Bass, 2003) won the ACHE Hamilton Book of the Year Award in 2004.

In 2013, Dr. Frampton was appointed cochair of the National Priorities Partnership (NPP), a collaborative of fifty-two major national organizations working to identify strategies for improving safety, quality, and patient-centered outcomes for the U.S. health care system. Her work with the National Priorities Partnership extends back to 2009, when she was first named a member. In 2011, she served on NPP's Better Care Subcommittee, which helped to shape a set of comprehensive national goals to improve the quality of health and health care. She also was cochair of the NPP (Re)admissions Action Team, which developed and executed strategies to safely reduce avoidable readmissions and increase the uptake of patient-centered team-based care delivery models. In addition to this work with NPP, Dr. Frampton has participated on the Joint Commission's Expert Advisory Panel on culturally competent patient-centered care standards, the National Quality Forum's Care Coordination Steering Team and the Institute of Medicine's review panel for their 2009 publication on integrative medicine.

In addition to speaking internationally on culture change, quality and safety, and the patient experience, she has presented keynotes on designing patient-centered practices in acute care, continuing care, and ambulatory medicine settings for various hospital associations, Veterans Health Administration, and the World Health Organization. In addition, Dr. Frampton was honored in 2009, when she was named one of “20 People Who Make Healthcare Better” by Health Leaders Magazine.

Patrick A. Charmel, MPH, FACHE

Patrick A. Charmel, president and chief executive officer of Griffin Hospital and its parent organization, Griffin Health Services Corporation, has been associated with Griffin since 1979, when he served as a student intern while attending Quinnipiac University. He became president in 1998. As president of Griffin Health Services Corporation, he is also the chief executive officer of Planetree Inc., a subsidiary corporation. Under his leadership, Griffin has appeared on the Fortune magazine list of the 100 Best Companies to Work for in America for ten consecutive years. The Griffin Hospital management team was selected as the 2008 Top Leadership Team in Healthcare in the nation for community and mid-size hospitals by HealthLeaders Media. Griffin has been the recipient of numerous quality, value, and patient experience awards from various national organizations that measure and monitor hospital performance. Griffin is the only Connecticut hospital named a Top Quality Performer by The Joint Commission, the leading accreditor of health care organizations in America. Griffin Hospital was also recognized by the Premier healthcare alliance as a winner of the 2010 Premier Award for Quality, putting it in the top 1 percent of the nation's hospitals. Griffin also received this award in 2007.

Charmel is a coeditor of the book Putting Patients First, which received the American College of Healthcare Executive's Health Care Book of the Year award in 2004. A second edition of the book was released in October 2008.

In 2008, he completed a three-year term as a member of the National Advisory Council for Healthcare Research and Quality, to which he was appointed by the U.S. Secretary for Health and Human Services. He also serves as immediate past chairman of the board of directors of the Connecticut Hospital Association, formerly served as chairman of the Greater Valley Chamber of Commerce board of directors, and currently serves as chairman of the board of Diversified Network Service (DNS), the Connecticut Hospital Association's for-profit subsidiary.

Charmel is the immediate past chairman of the board of governors of the Quinnipiac University Alumni Association and a former university trustee. Quinnipiac University honored him with the Distinguished Alumni Award in 2008. In 2011, he received the Distinguished Alumni Award from the Yale School of Public Health. In 2006 he was the recipient of the John D. Thompson Distinguished Visiting Fellow Award at Yale University. He is a recipient of the James E. West Fellow Award from the Boy Scouts of America and the 2009 Planetree Lifetime Achievement Award.

Sara Guastello

Sara Guastello is director of Knowledge Management for Planetree. In this role, she oversees the Patient-Centered Hospital Designation Program and the associated Patient-Centered Merit Recognition Program, the only such program to recognize excellence in person-centered care across the continuum of care and around the world. Sara collaborates and consults with Planetree members and other partners to heighten awareness and understanding of patient- and person-centered approaches to care. She has authored numerous publications, including articles in the American Journal of Nursing Patients First Series, the International Hospital Federation World Hospitals and Health Services Journal, Provider magazine, The Patient journal, and Food Studies: An Interdisciplinary Journal. She has authored white papers on integrating the patient and family voice into hospital operations and advancing person-centered care across the contin­uum, and developed a series of toolkits spotlighting field-tested strategies for HCAHPS improvement. With support from The Picker Institute, she led the efforts to create the Patient-Centered Care Improvement Guide and the companion Long-Term Care Improvement Guide, comprehensive compendiums of premier patient- and resident-centered practices in place at health care organizations around the world.

The Contributors

Róisín Boland, RGN, MBA, former chief executive officer, International Society for Quality in Health Care


Michelle Bowman, BSN, RN, LAc, nursing director, Longmont United Hospital, Longmont, Colorado


Randall L. Carter, senior vice president, Planetree


Catherine Crock, MD, executive director, Australian Institute for Patient and Family Centred Care; physician, Royal Children's Hospital, Melbourne, Australia


Belinda Dewar, PhD, MSc, RGN, RCNT, professor of practice improvement, Institute of Care and Practice Improvement, University of West Scotland, Hamilton, Scotland, UK


Sylvie Doiron, clinical services director, Centre de réadaptation Estrie, Sherbrooke, Quebec


Sir Liam Donaldson, chair in health policy, Imperial College, London; World Health Organization Patient Safety Envoy


Lucie Dumas, CEO, Centre de réadaptation Estrie, Sherbrooke, Quebec; CEO and founder, Réseau Planetree Quebec


Deborah Felsenthal, manager of patients, families and consumers center, Patient-Centered Primary Care Collaborative


John T. Findley, MD, Planetree physician consultant, Valley View Hospital, Glenwood Springs, Colorado


José Henrique Germann Ferreira, MD, CEO, Management Consultancy, Albert Einstein Hospital, São Paulo, Brazil


Richard E. Hanke, EdD, SPHR, leadership development & coaching consultant; founding co-chair, Patient Partnership Council, Delnor Hospital, Geneva, Illinois


Steven F. Horowitz, MD, FACC, medical director, Planetree and Cardiac Care Management, Stamford Hospital, Stamford, Connecticut; professor of clinical medicine, Columbia University College of Physicians and Surgeons, New York; Physician Liaison, Planetree


Edward Kelley, PhD, executive coordinator, WHO Patient Safety Programme


Joep P. Koch, MBA-Health Care, Sector Manager Treatment, Planetree coordinator, Rivas Zorggroep, Gorinchem, The Netherlands


Anna Lee, programme officer, Patients for Patient Safety, WHO


K. J. Lee, MD, FACS, associate clinical professor, Yale University; emeritus chief of otolaryngology, Hospital of St. Raphael, New Haven, Connecticut


Claudio Luiz Lottenberg, president, Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein, São Paulo, Brazil


Karen Luxford, PhD, FAIM, FAAQHC, director, Patient Based Care, Clinical Excellence Commission, Sydney, Australia


Jeanette Michalak, RN, MSN, vice president, Clinical Services, Planetree


Marci Nielsen, PhD, MPH, chief executive officer, Patient-Centered Primary Care Collaborative


Dennis S. O'Leary, MD, president emeritus, The Joint Commission


Anna W. J. Omtzigt, MD, PhD, chairman, medical board, Flevo Hospital, Almere, The Netherlands; medical director, Vrouw & Klinieken, The Netherlands


Dan Otero, BSHA, CLP, LSSBB senior coach, Patient-Centered Lean


Lisa Platt, RID, LEED AP BD+C, EDAC, Planetree consultation service specialist


Marie-Claude Poulin, Planetree coordinator and communications officer, Centre de réadaptation Estrie, Sherbrooke, Quebec; consultant, Réseau Planetree Quebec


Nittita Prasopa-Plaizier, MPH, MHSc, programme manager and technical lead, Patients for Patient Safety Programme, World Health Organization


Heidi Ruis, area manager integrated care, Rivas Zorggroep, Gorinchem, The Netherlands


Marcel Snijders, founder/board member; Designation Specialist, Planetree Nederland


Susan Stone, PhD, RN, NEA-BC, senior vice president and CEO, Sharp Coronado Hospital and Healthcare Center, Coronado, California


Angelica Thieriot, founder, Planetree


Jim van den Beuken, founder and chairman, Planetree Nederland; managing partner, Creative Power


Dorothea Wild, MD, MPH, dr. med., president, Griffin Faculty Practice Plan; associate program director, Combined Internal Medicine and Preventive Medicine Residency Program, Griffin Hospital, Derby, Connecticut


Paula Wilson, president and chief executive officer, Joint Commission Resources/Joint Commission International


THIRTY-FIVE YEARS AGO I was hospitalized with a mysterious virus. What I encountered at the hospital was both surprising and devastating.

Soon after arriving I, in essence, lost my citizenship to the human race. I was no longer an adult with rights and privileges.

My privacy, my modesty, my autonomy, and my identity were taken from me when I was most vulnerable—desperately ill and afraid.

As I slumped in a wheelchair behind six or seven other patients (an accurate if unfortunate word to describe a person in a hospital) also slumping in a badly lit basement hallway awaiting X-rays, I became certain that I wouldn't make it out of that place alive.

The window in my room faced a light well. It was impossible to tell in that penumbra if it was sunny or cloudy, or what time of day it was. There were medical artifacts in my room and all manner of things beeping. The only recognizable object in the room was a chair in the corner.

Every morning I was awakened at dawn (having just fallen asleep a couple of hours before) with an extravagantly unsuitable breakfast.

Each nurse was a new, rushed face, nobody could answer my questions, nobody knew my name. I was prodded and poked with no explanation. “Ask your doctor” was all I was ever told.

The doctor talked to my husband about me as if I wasn't there, at one point saying, “I'm afraid we are losing her.”

Six years before I had moved up to California from Buenos Aires, Argentina, where I was born. While I lived there I gave birth to two children in local hospitals. Those hospitals had normal furniture, curtains, rugs, wall art, and flowers. The nurses were warm and attentive, the food was good, and I felt cared for and safe. Granted I was not ill, but the same hospital was caring for all kinds of patients in the same way. Perhaps the technology was not up to U.S. standards but the experience was much more humane and healing. We knew then, as now, that stress and fear are obstacles to healing. What could be more stressful than to lose your identity and all control over your life and your person?

My virus was self-limiting and after three weeks in the hospital I went home determined to either change the way American hospitals worked, or return to South America—making sure that if I should fall ill again I would never have to endure that experience again.

The next six months were spent thinking about what I would have wanted during my illness—what I NEEDED to get better.

During that period I researched the history of hospitals, and found out that, in the West, the only glorious period for hospitals was the Hellenic. The asclepian hospitals (dedicated to the god of healing, Asclepius) were set in the most beautiful places, by sacred groves. They used art, theater, music, and poetry to revitalize the patient's healing energies and acceded to their subconscious with ritual acts and dream incubation. Patients were given herbal potions and instructed to go to the “abaton” and dream of their healing, which they did to good effect. They used nutrition and herbal medicines and kept really good records which we have to this day. Guess what: it worked!

Thankfully, we now also have extraordinary medicines and miraculous surgeries. So why not have them be administered in the best healing environments possible?

As I dreamed of my ideal healing place I thought first about the human environment, and how I would have loved a calm focused presence to reassure me.

Nurses go into their profession from a deep desire to heal, to make people feel better, safe, comfortable, and free of pain. It is too demanding and selfless a career to embark upon without a deep altruistic calling.

The difference between the Argentine and American nurses of the 1980s was that the systems that the United States had developed to adapt to high volume and technology had not taken human values into account. I fear that as hospitals modernize around the world they are replicating some of these efficiencies that are so dehumanizing and eventually inefficient.

Wards had (have?) acuity ratings within which nurses were deployed, like widgets, according to a score determined by how ill the patients were. That's why I never saw the same nurse twice. What was needed, I realized, was primary care nursing, each nurse getting a number of patients for whom he or she is responsible. That's how nursing worked in less technologically advanced parts of the world. And that's how nurses get to feel they are truly healing people, how they see the outcome of their care.

Also I thought that nurses needed to be reminded of their calling periodically—and be nurtured and supported to allow them to encounter so much suffering without losing themselves. The person who developed deep ways to do this was Laura Gilpin, our “First Nurse.” When we first interviewed her she said, “I like making it safe for my patients to sleep.” That's the nurse I was looking for!

What I needed most of all was to feel seen and respected, to have the sense that someone cared about my well-being and that my needs would be met. I needed to retain some control, to be informed, in ways I could understand, about what tests were going to be performed, which procedures and why.

One of the first members of the original Planetree board, prominent San Francisco doctor John Gamble, had started a project called PIIR node—patients informed, involved, and responsible. Although this project succumbed to internal hospital politics, it nevertheless provided many useful examples of ways to educate and inform.

Our first director, Ryan Phelan, came from a public resource and information background. In addition to her brilliant ability to turn ideas into working programs, her particular interest in empowering patients by providing them with access to high-quality information was key to the success of our first resource centers and the development of educational materials for hospitalized patients. In the days before the Internet this was an even more unique and valuable resource.

It struck me as odd that we put enormous amounts of effort and money into beautifying airports, hotel lobbies, restaurants, offices, not to mention our own homes, while neglecting the environments within which we spend some of the most important moments of our lives—our own birth, life-changing illnesses, surgeries, and our death as well as these events in the lives of our loved ones—moments of openness, when all our assumptions about our life are up for review; these are eminently teachable moments.

Many studies have shown the impact of the physical environment on healing. From the need for pain medications to length of stay, just being able to look at a tree from the window has an important, measurable impact.

When I went from the daydreaming phase to talking to real people in the field I met architect Roslyn Lindheim, who had dedicated a large part of her career to creating humanized hospital settings. Before we opened our first model unit, she had herself admitted as a patient for two days to see what was needed. The effect of light, color, clutter, sound, beauty, art, doorways, hallways, privacy, the accessibility of the nursing staff—she encountered all of these issues, and with the help of designer Victoria Fay came up with creative and beautiful environments that support healing.

To this day I feel Planetree is evolving new solutions, new ways of adapting to different cultural cues and changing perceptions of beauty and comfort. Wonderful designers and architects have found new ways of improving the environments of hospitals.

I wanted my family and my close friends around me, mainly for support and companionship, but also to bring me food I could eat. I learned that many elderly patients were suffering from malnutrition because they couldn't eat hospital food. It became obvious that with the variety of cultures represented in any patient population, the only way to deal with food preferences and needs was to provide a kitchenette for families to prepare meals.

Also the rising costs of care make it hard to improve the quality of the food provided by the hospital, although I still dream of the hospital as a place to teach patients and families about nutrition and healthy eating. (Years after the beginning of Planetree, I sat with my husband, who was having a heart attack in a cardiac intensive care ward, and watched a breakfast of scrambled eggs, bacon, and coffee delivered to his bedside. (Fortunately he survived.)

The wonderful thing about the modern world is that (possibly thanks to the Internet) people are now empowered to make informed decisions in all aspects of life. We should all claim that right and that privilege, especially when it comes to our health and survival.

Many cultures from around the world have developed ancient modes of healing that work every bit as well as ours. (I myself have seen the symptoms of my Parkinson's disease hugely improved by Chinese mushroom supplements.) Traditional practices should be made available to hospital patients in their own countries as well as in the United States. Modernizing should not exclude traditional modalities that are safe and healing.

Because Planetree has a life of its own and draws the right people to further its goals, it continues to grow and evolve and incorporate new research into the nature of healing environments.

As the retired grandmother of Planetree, I am always thrilled and delighted to see all the new ways in which Planetree has developed.

As a patient I rebelled against being denied my humanity, and that rebellion led to the beginnings of Planetree. We should all demand to be treated as competent adults, and take an active part in our healing. And we should insist on hospitals meeting our human need for respect, control, warm and supportive care, a harmonious environment, and good, healthy food. A truly healing environment.

Angelica Thieriot


DIGNITY, RESPECT, COMPASSION, answering difficult questions, asking someone to say back what they have heard, smiling, expressing empathy without losing objectivity. Traditionally, these and other profound human skills have been little taught or discussed at medical and nursing schools. Indeed, there are many senior doctors who believe that they cannot be taught. Even worse, some view them as peripheral concerns when the real business is understanding why the body-machine is malfunctioning and finding ways to correct it.

It is not that patients do not want the science, technology, and rational clinical assessment and intervention, but they also want the deep connection to them as a person. People with cancer surely want the best chance of survival that modern medicine can offer them, but they also need someone to listen, understand, and explain. They want someone to show solidarity with a fellow human being who is suffering. They want to be the owner of their care, not just a by-product of it.

This challenge is not only for practitioners; it is for those who manage health organizations and for those who lead health care systems. To know that your system is as safe as it can be and to be sure that every single episode of care is truly patient-centered is a formidable task. Yet this should not be the stuff of aspirations; it must be the very fabric of concrete, measurable delivery of care.

What is particularly inspiring about this book is the wealth of practical examples, experiences, and stories from the front line of care by patients, family members, and practitioners.

For anyone who has experienced care personally or through a loved one, there are many things in the chapters that resonate powerfully. Among a telling list of negative interactions with older people in one example in the book is “using childlike language or elder-speak.” How many times has a baby boomer son or daughter felt anger, disbelief, and despair at hearing their elderly mother or father spoken to that way in a hospital, particularly if their communication is impaired (say, through a stroke)?

The Berlin Wall of traditional health care, where it remains, must come down. The philosophy of care set out in this book is not a technocratic matter to sit in a health system's strategic plan. It is the foundation on which a modern health system should be built. Without it, the morality and humanity of care will crumble.

Planetree is an organization that has pioneered the modern movement of patient-centered care. Their work is a touchstone for a new world when the vision becomes a reality, not just in islands of excellence but in the whole land-mass of health care.

This book opens the door of opportunity for all health care providers to be inspired to transform their organizations.

Sir Liam Donaldson

chair in health policy, Imperial College, London

World Health Organization Patient Safety Envoy

Introduction: Patient-Centered Care Goes Global

LISTENING AND CARING. Compassion and comfort. Humanity and respect. Partnership and engagement. The themes at the heart of patient-centered care date back to the origins of modern medicine. Hippocrates is quoted as teaching the earliest medical students, “Treat often, cure sometimes, comfort always.” About the significance of the role of nurses, nursing pioneer Florence Nightingale wrote, “[Nursing] has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet—all at the least expense of vital power to the patient” (1860). Nearly seventy years later Francis Peabody, MD, a renowned physician who fell terminally ill, shared his insights on caregiving: “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal” and “The secret of the care of the patient is in caring for the patient” (1927).

Patient-Centered Care: A Cresting Wave of Change

There is nothing about patient-centered care (or patient-based, person-centered, client-centered, or relationship-centered care) that is cutting edge. And yet, while the concept is truly timeless, it is also especially timely. This book is the third installment of the Putting Patients First series. The first was published a decade ago. At that time, patient-centered care was just beginning to gain traction as the optimal way to deliver care, fueled in large part by a landmark Institute of Medicine study that identified patient-centeredness as one of six primary determinants of health care quality and defined it as: “Health care that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care” (Institute of Medicine, 2001).

In the wake of this high-profile endorsement, efforts to expand patient-centered care have been slow but steady, propelled largely by individual champions and their powerful stories of person-centeredness in action. Today, though, in countries around the world, there is a cresting wave of interest in patient-centered care, driven by powerful industry forces, a growing evidence base, and the demands of increasingly discerning health care consumers.

A Changing Global Health Care Landscape

Since the publication of the first Putting Patients First book, the global health care landscape has shifted. Consumers have ready access to an unprecedented amount of data on diseases, treatments, and health care providers. They are connecting on blogs and social media sites with others who share similar conditions, logging on to online personal health portals, using search engines to guide self-directed health research, and downloading apps for their smartphones to help manage their health. Unquestionably, patients as a whole are more informed than ever before when they meet with their care providers. As a result, they increasingly expect to be engaged in a dialogue about their diagnosis, treatment options, and personal health goals, and to contribute in a meaningful way to the care planning process.

Consumers today not only have access to more information about medical conditions and treatment options, but also about providers. Public ratings and rank-ordered lists of health centers along with quality accreditations are becoming common in many countries. Greater transparency in the sharing of quality and patient experience outcomes and new governmental incentives to publicly report them equip today's consumers with an array of qualitative and quantitative data to inform their decisions of where to go for care.

Consumers have come to expect an abundance of choices in virtually every major (and not-so-major) purchase that they make. Why would health care be an exception—especially now when out-of-pocket health care expenses continue to rise? To remain competitive, health care organizations must be responsive to the full range of patient needs, preferences, and values, and be prepared to withstand the scrutiny and informed decision making of today's health care purchasers, be they individuals, employers, or governments.

The medical tourism industry takes the concept of choice to a new level and is compelling health care providers around the world to seek out ways to differentiate themselves in order to attract patients and revenue from outside their local regions.

At the same time, we are experiencing a global demographic shift. An aging population requires already overburdened, underfunded health care systems to meet the demands of increasingly vulnerable patients contending with chronic diseases, multiple morbidities, and cognitive impairments. Efficient and effective use of resources to optimize outcomes requires that care be coordinated across the full continuum of services and be organized around the person, versus around a discrete episode of care or a specific care setting.

Global Health Care Reform Efforts Promote Patient-Centered Care

All of these factors have created conditions in which patient-centered care stands to flourish. Indeed, around the world, health care delivery systems are undergoing reforms to improve outcomes and maximize value. Field experience and research corroborate that engaging with patients and their family members, welcoming their involvement as integral members of the care team, and supporting health care professionals to forge these partnerships establishes the foundation for superior outcomes, fewer errors, lower readmissions, and high patient and family satisfaction. As a result, patient-centered care is consistently being identified as a fundamental strategy of these reform efforts for achieving high-quality, high-value care. Gone are the days when patient-centered care could be dismissed as something that is “nice” to do should resources allow. Today, patient-centered care is nothing less than a quality and business imperative.

A quick scan of reform efforts currently under way around the world reveals that there are numerous avenues for advancing the adoption of patient-centered care, and many levers for promoting this change.

More broadly, the creation of patient rights charters and the rise in prominence and influence of patient advocacy groups are amplifying the voices of health care consumers to ensure that international, regional, and national health care policies reflect patients' priorities.

The good news is that in industrialized and developing nations, the efforts to advance patient-centered care are growing stronger and more diversified. Numerous policy, funding, accreditation, public reporting, and business levers are shifting the orientation of health care delivery systems from being provider-centered and setting-centered to being person-centered.

At a national and state level, there has been an increasing recognition of patient-centred approaches in the safety and quality agenda as a key domain of quality care. This is typified by the establishment of my own role as Director of Patient Based Care at the Clinical Excellence Commission (a safety and quality agency) in New South Wales. … The only way is up! When you get contacted by specialist doctors wanting to start Facebook pages for their patients to post direct feedback you know things are starting to move!

—Karen Luxford, director, Patient Based Care, Clinical Excellence Commission, Australia