001

Table of Contents
 
Title Page
Copyright Page
Dedication
Acknowledgements
THE EDITORS
THE CONTRIBUTORS
PROLOGUE
Introduction
THE PLANETREE MODEL
ESSENTIAL ELEMENTS OF PATIENT-CENTERED CARE
CURRENT TRENDS IN PATIENT-CENTERED CARE
REFERENCES
 
PART 1 - ESSENTIAL ELEMENTS OF PATIENT-CENTERED CARE
 
CHAPTER 1 - HUMAN INTERACTIONS AND RELATIONSHIP-CENTERED CARING
 
INTRODUCTION
RELATIONSHIP-CENTERED CARE/CARING
ROLE OF SOCIAL SUPPORT IN HEALTH AND HEALING
PUTTING CONCEPTS INTO ACTION
REFERENCES
 
CHAPTER 2 - ACCESS TO INFORMATION: INFORMING AND EMPOWERING DIVERSE POPULATIONS
 
ACCESS TO INFORMATION AT THE BEDSIDE
ACCESS TO INFORMATION IN THE COMMUNITY
CONCLUSION
REFERENCES
 
CHAPTER 3 - HEALING PARTNERSHIPS: THE IMPORTANCE OF INVOLVING PATIENTS, ...
 
INTRODUCTION—THE IMPORTANCE OF PARTNERSHIPS
VOLUNTEERS AS PARTNERS
QUO VADIS—THE FUTURE
REFERENCES
 
CHAPTER 4 - NUTRITION: THE NURTURING AND HEALING ASPECTS OF FOOD
 
FOOD, HEALTH, AND THE HEALING ENVIRONMENT
ONE HOSPITAL’S JOURNEY: WINDBER MEDICAL CENTER
FOOD AND HEALING
REFERENCES
ADDITIONAL SOURCES
 
CHAPTER 5 - SPIRITUAL AND CULTURAL DIVERSITY: INNER RESOURCES FOR HEALING
 
RELIGION, SPIRITUALITY, AND MEDICINE
DEFINITIONS OF RELIGION AND SPIRITUALITY
IMPORTANCE OF RELIGION AND SPIRITUALITY IN HEALTH CARE
SPIRITUALITY IN THE CARE OF THE DYING
PLANETREE SPIRITUALITY
ORGANIZATIONS AND THEIR SPIRITUALITY
REFERENCES
 
CHAPTER 6 - INTEGRATING COMPLEMENTARY AND ALTERNATIVE PRACTICES INTO ...
 
DEFINITION OF CAM
EPIDEMIOLOGY AND POPULATION SIGNIFICANCE
INTEGRATIVE MEDICINE
CONCLUSIONS
REFERENCES
 
CHAPTER 7 - EFFECTS OF VIEWING ART ON HEALTH OUTCOMES
 
WHAT ARE HEALTH OUTCOMES?
THEORIES: ART THAT CAN IMPROVE OUTCOMES
PREFERENCES FOR VISUAL IMAGES
STRESS-REDUCING EFFECTS OF VIEWING ART
EFFECTS OF VIEWING NATURE ON PAIN
EFFECTS OF NATURE VERSUS ABSTRACT IMAGES ON OUTCOMES
GUIDELINES FOR SELECTING HEALTH CARE ART
PLANETREE ARTS PROGRAMS
REFERENCES
 
CHAPTER 8 - HEALING ENVIRONMENTS: CREATING A NURTURING AND HEALTHY ENVIRONMENT
 
PRIVACY
PATIENT SAFETY
NOISE CONTROL
VIEWS OF AND ACCESS TO NATURE
LIGHTING
THERAPEUTIC ENHANCEMENTS
GATHERING SPACES
ENVIRONMENTAL CONTROL
GETTING AROUND THE FACILITY: WAYFINDING
SEPARATION OF TRAFFIC TYPES
STAFF SUPPORT AREAS
STAFF WORKSTATIONS
EDUCATION SPACES
CONCLUSION
REFERENCES
 
CHAPTER 9 - HEALTHY COMMUNITIES: EXPANDING THE BOUNDARIES OF HEALTH CARE
 
A BROADER DEFINITION OF HEALTH
COMMUNITY
REFERENCES
ADDITIONAL RESOURCES
 
PART 2 - CURRENT TRENDS IN PATIENT-CENTERED CARE
CHAPTER 10 - BUILDING THE BUSINESS CASE FOR PATIENT-CENTERED CARE
 
DEMONSTRATING PLANETREE’S EFFECTIVENESS
THE INDUSTRY SHIFTS ITS FOCUS
PRODUCT DIFFERENTIATION
FINANCIAL IMPERATIVE
IMPROVED CLINICAL OUTCOMES
HEALTH CARE WORKFORCE SHORTAGE
IN CONCLUSION: A STRONG BUSINESS CASE
REFERENCES
 
CHAPTER 11 - THE PHYSICIAN-PATIENT RELATIONSHIP IN THE PATIENT-CENTERED CARE MODEL
 
THE CHANGING PHYSICIAN PERSPECTIVE
THE PATIENT PERSPECTIVE
THE PAYER PERSPECTIVE
THE ROLE OF PLANETREE
PHYSICIAN INVOLVEMENT IN PLANETREE
REFERENCES
 
CHAPTER 12 - ADAPTING PATIENT-CENTERED CARE TO DIVERSE HEALTH CARE SETTINGS
 
BEHAVIORAL HEALTH: NEW YORK- PRESBYTERIAN HOSPITAL
CONTINUING CARE: WESLEY VILLAGE
INTEGRATED HEALTH CARE: AURORA HEALTH CARE
CONCLUSION
 
CHAPTER 13 - INTEGRATING QUALITY AND SAFETY WITH PATIENT-CENTERED CARE
 
HUMAN INTERACTIONS AND COMMUNICATION
PATIENT EDUCATION AND ACCESS TO INFORMATION
INVOLVEMENT OF FAMILY AND FRIENDS
NUTRITION
COMMUNITY PARTNERSHIPS
SUPPORTING PATIENT INVOLVEMENT
WHEN THINGS GO WRONG
CONCLUSIONS
REFERENCES
 
CHAPTER 14 - PATIENT-CENTERED CARE AS PUBLIC POLICY: THE ROLE OF GOVERNMENT, ...
 
USING PUBLIC POLICY LEVERS
CHALLENGES, PROSPECTS, AND OPPORTUNITIES
REFERENCES
 
CHAPTER 15 - BREAKING DOWN THE BARRIERS TO PATIENT-CENTERED CARE
 
EXPLORING THE BARRIERS
NEW STRATEGIES TO OVERCOME THE BARRIERS
YOUR ROLE IN OVERCOMING THE BARRIERS
REFERENCES
 
EPILOGUE
NAME INDEX
SUBJECT INDEX

001

This book is dedicated to Laura C. Gilpin (1950-2007),
poet, nurse, and friend, and to the love she inspired
in all who knew her and who were touched by
her kindness, caring, and respect.

ACKNOWLEDGMENTS
We would like to express our deepest gratitude to the true pioneers of patient-centered care, including Planetree’s founder, Angelica Thieriot, whose eloquent Prologue in this second edition chronicles her personal journey as a patient, which led her to advocate for the rights of all patients. A key colleague in that journey of turning vision into reality was Laura C. Gilpin, to whom this book is lovingly dedicated. Laura’s unfailing dedication to patients and to those who care for patients touched everyone she worked with in her early years as a nurse and in her last two decades working with Planetree hospitals around the world. And to the late Harvey Picker (1915-2008), founder of The Picker Institute, an organization, like Planetree, committed to a health care system in which caring, kindness, and respect are believed to be essential elements in the delivery of excellent care.
We continue to be indebted to so many, who, over Planetree’s thirty-year history, have helped to nurture, shape, and guide the vision to become the international organization it is today. We are especially grateful to Planetree’s founding board of directors, to the initial model sites, and to the organizations, including The Henry J. Kaiser Family Foundation and The San Francisco Foundation, whose support made the establishment of the original Planetree model site possible.
We are especially grateful to affiliate members of Planetree. These hospitals, ambulatory centers, clinics, nursing homes, continuing care centers, integrated health systems, as well as the thousands of nurses, physicians, administrators, managers, librarians, volunteers, and others, through their work each day, are advancing the philosophy and principles of patient-centered, family-centered, and relationship-centered care. We continue to be inspired by the innovation and creativity that this diverse group brings to the patient care experience. Special thanks to our Dutch partners, Planetree Nederland, for their leadership in establishing patient-centered care in the Netherlands, and to Heidi Gil and the staff and leadership team of United Methodist Homes for their commitment to transforming the culture of nursing homes and continuing care centers to a more resident-centered model.
Thanks especially to the patients themselves, who throughout the years have so generously shared their stories and perceptions with us, continually inspiring us to expand the vision of what is possible in health care. We would also like to thank those like-minded individuals and organizations, who through their ongoing work are helping to realize our shared vision.
We truly appreciate the contributions made by so many talented writers in the first edition of Putting Patients First, including Bruce Arneill, Susan Edgman-Levitan, Karrie Frasca-Beaulieu, Trevor Hancock, George Handzo, Charlene Honeycutt, Leland Kaiser, Allan Komarek, Kathy Reinke, Carol Ryczek, Phyllis Stoneburner, Dianne Storby, and Jo Clare Wilson. Thank you all for your assistance in making the book a success.
We would also like to acknowledge recent members of the Planetree board of directors for their guidance and support of the organization. Finally, we would like to thank the supportive staff members of Planetree for their work day in, day out, to support our affiliates on their journeys, and in particular to Sara Guastello, without whom this second edition would not have been possible. Her skills, talent, and cheerful diligence were essential to moving this project along and bringing it to successful completion. Thank you, Sara!
Susan B. Frampton and Patrick A. Charmel
The Editors

THE EDITORS
SUSAN B. FRAMPTON, PhD, is president of Planetree, a nonprofit organization. In that capacity, she works with a growing network of hospitals and health centers around the world that have implemented Planetree’s unique patient-centered model of care. Prior to her work with Planetree, she spent over twenty years at several hospitals in the New England area. Her work focused on community education, wellness and prevention, planning, and development of integrative medicine service lines. Frampton received her undergraduate training at Rutgers University and both master’s and doctoral degrees in medical anthropology from the University of Connecticut. She has numerous publications, including the edited collection Putting Patients First (Jossey-Bass, 2003), which won the ACHE Hamilton Book of the Year Award in 2004; chapters in Patient Advocacy for Health Care Quality (Jones & Bartlett, 2007); and articles and interviews in Journal of Alternative and Complementary Medicine, AHA News, Modern Healthcare, and Hospitals and Health Networks. In addition to speaking internationally on culture change, patient-centered design, and health care consumerism, Frampton has presented keynotes on designing patient-centered practices in acute and continuing care and in ambulatory medicine settings for the Medical Group Management Association (MGMA), Healthcare Design Symposium, World Health Organization (WHO) Health Promoting Hospitals group, and Veterans Health Administration.
 
PATRICK A. CHARMEL, MPH, FACHE, is president and chief executive officer of Griffin Hospital and its parent organization, Griffin Health Services Corporation. He has been associated with Griffin since 1979, when he served as a student intern while attending Quinnipiac University. After graduating from Quinnipiac, Charmel received a master’s of public health from Yale University. After serving in a number of administrative positions at Griffin Health Services Corporation, he became president in 1998. He is also the chief executive officer of Planetree, a subsidiary corporation. During his tenure, he has positioned Griffin Hospital as an award-winning, innovative organization, recognized as an industry leader in providing personalized, humanistic, consumer-driven health care in a healing environment. Under his leadership, Griffin has appeared on the Fortune magazine list of the 100 Best Companies to Work for in America for nine consecutive years, was named a 2007 Premier /CareScience National Quality Leader, and has received the 2005 and 2007 Health Grades Distinguished Hospital Award for Clinical Excellence. Griffin was also a recipient of the Total Benchmark Solution’s Top 100 Quality Award in 2006 and was named one of the Solucient 100 Top Performance Improvement Leader Hospitals in 2007. He is coauthor of Putting Patients First (Jossey-Bass, 2003), which received the American College of Healthcare Executives Health Care Book of the Year award in 2004.
In 2005, he was appointed by the U.S. Secretary for Health and Human Services to the twenty-one-member National Advisory Council for Healthcare Research and Quality. He is chairman of the board of directors of the Connecticut Hospital Association and is a member of the board of directors of Qualidigm, a CMS-contracted quality improvement organization. Charmel is vice chair of the board of governors of the Quinnipiac University Alumni Association.
In 2006, Charmel 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. He was inducted into the Junior Achievement Free Enterprise Hall of Fame in 2002, and he is a recipient of the Dean Avery Award, given by the New London Day newspaper, which recognizes individual commitment to the public’s right to know.

THE CONTRIBUTORS
ATHER ALI, ND, MPH, is assistant director of Integrative Medicine at the Yale-Griffin Prevention Research Center, where he supervises research in complementary and alternative medicine (CAM). He is also codirector of the Integrative Medicine Center at Griffin Hospital, where he oversees naturopathic clinical care and residency training. He obtained a bachelor’s degree in psychobiology from UCLA, doctor of naturopathic medicine (ND) from Bastyr University, residency in integrative medicine from Griffin Hospital/University of Bridgeport, and a master’s in public health, focused on chronic disease epidemiology, from Yale University. He completed a National Institutes of Health (NIH) postdoctoral fellowship, focused on integrative medicine research, and is involved in a number of research projects in CAM and preventive medicine. He is a founding director of integrative medicine at Yale and is Yale University’s clinical representative to the Consortium of Academic Health Centers for Integrative Medicine.
 
CARRIE BRADY, MA, JD, is Planetree’s vice president of quality and is responsible for assisting Planetree affiliates in collaborating on patient-centered quality and patient safety strategies and for coordinating the development and implementation of Planetree’s patient-centered designation process. Before joining Planetree, Brady spent several years as a vice president of the Connecticut Hospital Association, where her role included coordinating two statewide pilot tests of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey, developing one of the first patient safety organizations (PSOs) in the nation, and designing a public reporting program for Connecticut hospitals. She has served on several state and national committees, including the National Quality Forum (NQF) Review Committee for Hospital CAHPS, the NQF Serious Reportable Events Maintenance Committee, and the National CAHPS Benchmarking Database Advisory Group. Brady received a JD and a combined MA/BA in sociology from Northwestern University and was a 2005-2006 Patient Safety Leadership Fellow.
RANDALL L. CARTER is Planetree’s senior vice president and has provided consultation and programs on patient-centered care, developing healing environments, service, and leadership for health care organizations and physician groups, in addition to audiences in building and design, retail, software, education, broadcasting, and government. Carter serves as a commissioner on the National Health Council’s Commission on Putting Patients First and as an expert faculty member for the Patient-Centered Care Institute. Prior to joining Planetree, Carter was a member of the Executive Management Team at Mid-Columbia Medical Center in The Dalles, Oregon. Mid-Columbia was the first systemwide implementation of the Planetree philosophy of care in the United States in 1991. During Carter’s tenure at Mid-Columbia, the organization hosted over a thousand organizational site visits and was recognized in numerous publications and health care periodicals, as well as on Bill Moyers’ landmark documentary series Healing and the Mind.
 
CAROLYN M. CLANCY, MD, was appointed director of the Agency for Healthcare Research and Quality (AHRQ) on February 5, 2003. Prior to her appointment, Clancy had served as AHRQ’s acting director since March 2002 and previously was director of the agency’s Center for Outcomes and Effectiveness Research (COER). AHRQ is the lead federal agency for promoting health care quality. Clancy, a general internist and health services researcher, is a graduate of Boston College and the University of Massachusetts Medical School. Following clinical training in internal medicine, she was a Henry J. Kaiser Family Foundation Fellow at the University of Pennsylvania. She was also an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond before joining AHRQ in 1990. Clancy holds an academic appointment at George Washington University School of Medicine, has published widely in peer-reviewed journals, and has edited or contributed to seven books. She is a member of the Institute of Medicine.
 
JAMES B. CONWAY, MS, is senior vice president at the Institute for Healthcare Improvement (IHI), after having served as senior fellow from 2005 to 2006. From 1995 to 2005, he was executive vice president and chief operating officer of Dana-Farber Cancer Institute (DFCI). Prior to joining DFCI, he had a twenty-seven-year career at Children’s Hospital, Boston, in Radiology Administration, Finance, and as assistant hospital director for Patient Care Services. He holds a master of science degree from Lesley College in Cambridge, Massachusetts. An adjunct faculty member at the Harvard School of Public Health, Conway is the 2001 winner of the first Individual Leadership Award in Patient Safety by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA). He is a member of the Institute of Medicine Committee on Identifying and Preventing Medication Errors, a Distinguished Advisor to the National Patient Safety Foundation, and a past member of The Joint Commission Sentinel Event Alert Advisory Group.
 
JANET M. CORRIGAN, PhD, MBA, is president and CEO of the National Quality Forum, a not-for-profit membership organization established to develop and implement a national strategy for health care quality measurement and reporting. From 1998 to 2005, Corrigan was senior board director at the Institute of Medicine, where she provided leadership for their Quality Chasm Series. Prior to joining IOM, Corrigan was executive director of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Corrigan received her doctorate in health services research and master of industrial engineering degrees from the University of Michigan and master’s degrees in business administration and community health from the University of Rochester. In 2002, she was the recipient of the Institute of Medicine Cecil Award for Distinguished Service, and in 2006, she was appointed a fellow in the American College of Medical Informatics. In 2007, she was awarded the Founders’ Award by the American College of Medical Quality, the TRUST Award by the Health Research and Educational Trust, and the Award of Honor by the American Society of Health System Pharmacists.
 
MARGARET CULLIVAN, MEd, RN, began her career in the academic arena, as a language arts and theater arts instructor at the secondary and college level. A sibling’s illness piqued Cullivan’s interest in the medical field, resulting in her pursuit of a nursing degree. Combining her medical and educational background, she eventually became director of education at Williamsburg Community Hospital. Presently, Cullivan serves as Planetree coordinator and director of volunteer services/guest service at Sentara Williamsburg Regional Medical Center and is active on local and national boards promoting volunteerism. As liaison for the hospital’s nationally recognized auxiliary, she champions their fundraising efforts toward the support of patient-centered care initiatives, such as the chapel, healing garden, and free mammogram and bone density programs.
HEIDI GIL, NHA, CCM, was appointed executive director of Wesley Village in Shelton, Connecticut, in December 2004. She has been with United Methodist Homes since September 2000, previously serving as administrator of Bishop Wicke Health Center. Gil has seventeen years of experience in long-term and sub-acute operations in for-profit and not-for-profit settings, successfully improving financial, clinical, and operational performance. Under Gil’s administration, Wesley Village has received several best practices awards, deficiency-free surveys from the State of Connecticut, and a score of 100 percent following the tri-annual JCAHO inspection. Since October 2002, Gil has led the development and implementation of Planetree Continuing Care: Creating Relationship-Centered Caring Environments, making Wesley Village the first leader in adapting the Planetree acute-care model for continuing care. Through the implementation of Planetree, Wesley Village has experienced impressive results in quality measures, employee turnover, net operating income, and overall community satisfaction. As the Planetree continuing care director, she is now leading the expansion of the Planetree Continuing Care network and provides consultation services to affiliates nationally and internationally.
 
CANDACE FORD GRAY, MLIS, has directed the Planetree Health Library in San Jose, California, since its inception in 1987. After earning her MLIS from the University of California Berkeley, she worked in public libraries and managed corporate and hospital libraries. Now executive director of the second-oldest Planetree library affiliate, Gray has given many presentations on health literacy and consumer health information services. She has contributed to revisions of Planetree’s Classification Scheme and Health Resource Center Information and Policy Manual. She consults with Planetree affiliates and other organizations on developing and operating community health libraries. At the national conference in 2006, Gray received the Planetree Lifetime Achievement Award.
 
ALEXANDRA HARRISON, PhD, leads the Calgary Health Region’s Patient Experience team, which is dedicated to enhancing the experience of care as seen “through the eyes of the patient.” The Calgary Health Region is a large, integrated system that provides the full continuum of health care services for more than a million people living in Southern Alberta. Harrison’s health care background includes professional practice, management, teaching, and research. She continues to teach as an adjunct faculty member in the Faculty of Medicine at the University of Calgary. Her PhD research demonstrated the critical role that patients and families play in the coordination of health services from the perspective of those who receive care. Prior to joining the Health Region, Harrison had senior roles in medical education at the University of Calgary and the Canadian Medical Association in Ottawa.
 
STEVEN F. HOROWITZ, MD, served as medical director of the Samuels Planetree Model Unit at Beth Israel Medical Center in New York City, where he was chief of cardiology from 1988 to 2002. He is currently chief of cardiology at the Stamford Hospital in Connecticut and a clinical professor of medicine at New York’s Albert Einstein College of Medicine. Horowitz championed the establishment of one of the original Planetree model sites more than fifteen years ago and was instrumental in bringing Planetree to Stamford Hospital. He speaks internationally on his experiences as a physician and cardiologist working to personalize and demystify the hospital experience. Horowitz serves as a national Planetree board member and consultant, and he has worked with the medical staffs of many Planetree affiliates to achieve greater understanding and physician support for patient-centered care. In 2007, Horowitz received Planetree’s Lifetime Achievement Award.
 
F. NICHOLAS JACOBS, MA, is president and CEO of Windber Medical Center and the Windber Research Institute. He holds a master’s from Carnegie Mellon University and both master’s and bachelor’s degrees from Indiana University of Pennsylvania. He has a certificate in health systems management from the Harvard School of Public Health and is also a fellow in the American College of Health Care Executives. He has received several awards, including the Community Rural Health Leader of the Year by the Pennsylvania Rural Health Association. He serves on the boards of the Pennsylvania Mountains Healthcare Alliance and the Hospital Council of Western Pennsylvania. He is the chairman of the Keystone Chapter of the American Red Cross Disaster Relief Services. His writings have been published nationally, and he has been prominently featured in the Wall Street Journal, Forbes, Fortune, USA Today, Health Leaders, and Modern Healthcare. Jacobs is widely acknowledged as the first health care CEO to create and maintain a blog.
 
STEVEN L. JEFFERS, PhD, is founder and director of the Institute for Spirituality in Health at Shawnee Mission Medical Center (SMMC), a regional medical center in the suburbs of Kansas City. Jeffers received a BA in religion from Palm Beach Atlantic College, an MDiv from Midwestern Baptist Theological Seminary with a concentration in Greek and New Testament, and a PhD in the Program in the Humanities from Florida State University, where he studied the Greco-Roman classics, the Bible, and world religions. Prior to his current work, Jeffers was a seminary professor with extensive experience in faith congregational ministry. In his role with the institute, he works with physicians, with other health care providers, and with civic, business, and religious leaders of various faith traditions to advocate for the effective, compassionate care of patients and families and the integration of spirituality into the practice of medicine.
 
H. LEE KANTER, MD, is a practicing cardiologist and electrophysiologist in a twenty-member cardiology practice in Virginia Beach, Virginia. Kanter graduated from the University of Virginia School of Medicine and pursued postgraduate medicine and cardiology training at the University of Michigan and Washington University, respectively. He has been active at Sentara Virginia Beach General Hospital as a physician champion for Planetree and co-chair of the patient-centered care committee. Kanter’s current leadership roles include being an active board member of Medical Society of Virginia, president of Virginia Beach Medical Society, and vice president of medical staff, Sentara Virginia Beach General Hospital.
 
DAVID L. KATZ, MD, MPH, is a board-certified specialist in both internal medicine and preventive medicine/public health and is a fellow of the American College of Physicians and the American College of Preventive Medicine. He is an associate professor (adjunct) at the Yale School of Public Health, director of Yale University’s Prevention Research Center, and founder and director of the Integrative Medicine Center at Griffin Hospital in Derby, Connecticut. Katz contributes a monthly nutrition column to O, the Oprah Magazine; a weekly health column to the New York Times Syndicate; a daily blog to Prevention Magazine; and medical consulting to ABC News. He has twice been recognized as a Top Physician in Preventive Medicine by the Consumers’ Research Council of America. He has consulted on obesity control and the prevention of chronic disease to the secretary of health, the commissioner of the U.S. Food and Drug Administration, the National Governors Association, and the World Health Organization. He has authored over a hundred scientific articles; numerous chapters, abstracts, essays, and commentaries; and eleven books.
 
REV. DR. DENNIS KENNY is a psychologist, theologian, and spiritual caregiver. He was the founding director of the prestigious Institute for Health and Healing of the California Pacific Medical Center, which was chosen by Natural Health magazine as the leading holistic hospital in the United States. He is the author of Promise of the Soul (Wiley), rated the best new self-help book by Body and Soul magazine. He has been the spirituality consultant for the Planetree organization. He is currently the director of pastoral care and the director of the Disease Reversal Program at Cleveland Clinic.
 
GAIL MACKEAN, MPA, PhD, has a long-standing commitment to patient and family-centered care, which has come from her varied and lifelong experiences with health, illness, and the health care system, initially as a daughter of a mother living with a chronic, disabling condition and then as a practicing physiotherapist and administrator working in the Canadian health care system; as a parent of two children, one born with complex medical problems requiring ongoing, intense interactions with the health care system; as a parent member of a children’s hospital parent advisory committee; and finally as a health services researcher. MacKean currently works as a research and evaluation consultant. She is a member of SEARCH Canada’s lead faculty team, has an adjunct appointment with the Department of Community Health Sciences at the University of Calgary, and has close ties to the Calgary Health Region. Her research interests lie primarily in patient and family-centered care and in public participation in health services and policy development.
 
DWIGHT N. MCNEILL, PhD, MPH, is a vice president of education and research at the National Quality Forum in Washington, D.C., where he is responsible for promoting the attainment of national health care quality improvement priorities through educational forums, publications, and research. Previously, he worked in the federal government on national and state quality reporting and implementing community-wide improvement programs in diabetes, disparities, and asthma. Prior to that, he was involved in the development of Healthcare Effectiveness Data and Information Set (HEDIS), was cofounder and first chairman of the Foundation for Accountability (FACCT), and was director of health care information and planning at Verizon Corporation, where he worked with 140 health plans to measure and improve quality. He received his MPH in psychiatric epidemiology from the Yale University Medical School and his PhD in social policy from Brandeis University.
 
KIMBERLY NELSON MONTAGUE, MA, AIA, NCARB, is the director of design consultation services for Planetree, where she works with a growing network of hospitals and health centers around the world to help improve their environments in terms of the components for the Planetree Model of Care. Prior to her work with Planetree, she spent over twenty years working as an architect, most recently as a principal with the Albert Kahn Family of Companies. Her portfolio of work includes health care projects ranging from small community-based clinics to large, urban, and teaching hospitals. Her duties ranged from design to development and project management. Montague received a bachelor of science and a master’s degree in architecture from the University of Michigan.
 
WENDY W. PECHE, MA, is a member of the Employee and Organization Development team at Aurora Health Care, Milwaukee, Wisconsin. Peche’s role includes the coordination of the system implementation strategy of transforming the culture to patient-centered care. Peche has been passionate about Planetree since 2001, when Aurora’s first hospital joined the Planetree membership network. She has been in health care for over thirty years and was at the bedside for the first half of her career. She has a master’s degree in administrative leadership and is coauthor of the book Legendary Team Leadership (Spring Book Press).
 
ROBERT F. SHARROW, AIA, ACHA, NCARB, is a health care facility architect in Detroit, Michigan, where he is vice president and director of health care planning at the Albert Kahn Family of Companies, a leading architectural-engineering firm that has designed numerous Planetree facilities. His portfolio of projects includes three completed hospitals and many ambulatory care centers for Aurora Health Care in Wisconsin. He is currently principal for a new replacement hospital project for Elmhurst Memorial Hospital, a Planetree affiliate in Elmhurst, Illinois. Sharrow has a passion for the design of patient-centered care environments and is committed to the development of building designs that embody human-focused care amenities. He has used his profession to develop therapeutic healing spaces that meet the needs of those in the medical profession, patients, and their families.
 
MICHELE A. SPATZ, MS, earned her master’s degree at the University of Illinois Graduate School of Library and Information Science, where she was inducted into Beta Phi Mu, the International Library Science Honor Society. After receiving her degree, Spatz was the first librarian to earn tenure at the University of Illinois College of Medicine in Peoria, working there as reference librarian and then branch library director.
While there, she chaired a regional consumer health information project for central Illinois in the early 1980s. In the fall of 1991, she moved to The Dalles, Oregon, to establish the Planetree Health Resource Center, a community-based consumer health library, for Mid-Columbia Medical Center. She has served as the resource center’s director since it opened in June 1992. Spatz is the author of the recently published book Answering Consumer Health Questions: The Medical Library Association Guide for Reference Librarians (Neal-Schuman Publishers). She is active locally, regionally, and nationally as a writer, teacher, committee member, and consultant.
 
ROGER S. ULRICH, PhD, conducts research on the effects of health care architecture, art, and gardens on medical outcomes. He has published widely in both scientific and design journals and is the most cited researcher in the area of evidence-based health care design. His work has influenced internationally the architecture, interior design, and selection of art for major hospitals. Ulrich has worked extensively in the United Kingdom and Scandinavia, especially Sweden, where he has carried out research at the Karolinska Institute of Medicine and other institutions. He has also been visiting research professor in healthcare architecture at the University of Florence, Italy; visiting professor to the Bartlett School of Architecture at the University College London; and Invitation Research Fellow of the Japan Society for the Promotion of Science. Ulrich has also served as senior adviser to the United Kingdom National Health Service for its program to create scores of new hospitals. He is a member of the board of directors of The Center for Health Design, California.
 
JEAN WATSON, PhD, RN, AHN-BC, FAAN, is Distinguished Professor of Nursing and holds an endowed Chair in Caring Science at the University of Colorado Denver and Anschutz Medical Center Campus. She is founder of the original Center for Human Caring in Colorado and is a fellow of the American Academy of Nursing. She previously served as dean of nursing at the University Health Sciences Center and is a past president of the National League for Nursing. Watson has earned undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and holds her PhD in educational psychology and counseling. She is a widely published author and recipient of several awards and honors, including an international Kellogg Fellowship in Australia and a Fulbright Research Award in Sweden. She holds six honorary doctoral degrees, including three international honorary doctorates from Sweden, United Kingdom, and Quebec, Canada. Her most recent book is Caring Science as Sacred Science (F. A. Davis, 2005).
 
CATHERINE WHALEN is the director of Community Initiatives at Mid-Columbia Medical Center in The Dalles, Oregon. In this capacity, she is the primary community liaison for the medical center, representing organizational resources for local initiatives and guiding strategic priorities for community involvement. She has played a key role in facilitating the awareness and adoption of the healthy communities concept at the organizational, city, and county levels. Whalen has been a speaker on the subject of healthy communities and the five-component definition of health at the Oregon Association of Hospital and Health Systems, the Arkansas Rural Health Forum, and Allina Medical Systems. She copresented with Trevor Hancock at the annual Planetree Conference in Rhinebeck, New York. She is currently a member of the Association for Community Health Improvement, an examiner for the Washington State Quality Award, and a past examiner for the Malcolm Baldrige National Quality Award.
 
PHILIP J. WILNER, MD, MBA, is vice president and medical director for Behavioral Health at Weill Cornell Medical Center of New York-Presbyterian Hospital. He is executive vice chair of the Department of Psychiatry and associate professor at Weill Medical College of Cornell University. Wilner received his bachelor’s degree, summa cum laude, from Columbia College and his MD from the College of Physicians and Surgeons, both of Columbia University. He completed his psychiatry internship, residency, chief residency, and research fellowship training at the New York Hospital Cornell Medical Center and his MBA in health care administration at the Zicklin Business School of Baruch College. Since the early 1990s, Wilner has assumed positions of increasing responsibility in clinical management and leadership for the renowned Payne Whitney Manhattan and Westchester Divisions of the Weill Cornell Medical Center of New York-Presbyterian Hospital. Wilner was the recipient of a Reader’s Digest Fellowship in 1988 and conducted studies in the biological bases of psychiatric illness. He is a fellow of the American Psychiatric Association and member of the American College of Healthcare Executives and the American College of Physician Executives.

PROLOGUE
WHAT PATIENTS CAN TEACH US ABOUT IMPROVING THE QUALITY OF HEALTH CARE
The genesis for the idea of Planetree came out of a hospital experience I had in the late 1970s. I became seriously ill with an unidentified virus and spent two weeks in a leading hospital in the San Francisco Bay Area. I survived with a fervent intention to change the way hospitals treat patients.
The following year was spent trying to parse out which elements of my hospital experience had been the most negative and figure out how they could be improved. I also set out to speak with anyone who had experience in changing institutions, especially in health care: dreamers, innovators, and paradigm changers.
From those conversations came the members of the original board of Planetree and a specific philosophy of care, an apparently obvious—but in fact forgotten—point of view: hospitals exist to make people better, to help them heal. All the other motives—profit, employment, training, efficiency, and so forth—are ancillary to the main purpose and will only be well served if the principal objective, healing, is kept in focus.
Alienation, fear, hopelessness, loneliness, and dehumanization were the emotions that overwhelmed me during my hospital stay and led me to feel that I would never get out alive.
The first impression came at reception, where seemingly uncaring clerical personnel put my husband and me through endless questionnaires and forms as I fought against nausea and the fear that I would pass out. I was then led to a room that faced an air well, furnished only with a mechanical contraption that served as a bed and a metal chair. I felt that I had arrived at a Gulag.
During the two weeks that I was there, I never saw the same nurse twice. Other than my doctor, who came early in the morning to shake his head and talk about me as if I weren’t there (once saying to my husband, “I’m afraid we’re losing her”), anonymous people came and went, giving me pills, drawing blood, and answering my fearful questions with “I don’t know, you’ll have to ask your doctor.”
My mother-in-law sent me an orchid, which became the center of my attention. It was the only refuge from the bleak and sterile ugliness that surrounded me. I stared at it as if to save my life.
My fever and general discomfort kept me awake most of the night, but often, overcome by exhaustion, I would fall asleep at dawn only to be awakened an hour later and served a totally unhealthy, inappropriate, and inedible breakfast.
What would I have needed? What would have been truly healing? These thoughts occupied my mind over the next fifteen years as many wiser, more experienced minds than mine joined the effort to continue to evolve the philosophy of care that is Planetree.
During the period of gestation that followed my hospitalization, I spent many hours in the library researching the history of hospitals. The paths we took to arrive at the current state of affairs became clear. From the hospices of the Middle Ages to the horrifyingly septic institutions of the nineteenth century, through largely well-intentioned and useful changes, we had arrived at the modern, efficient, dehumanized institutions that prevailed in the 1970s. As in many other aspects of life, however, the most inspirational hospitals were the original ones, the ancient Greek Aesculapian hospitals.
In sharp contrast to the barren environments of modern hospitals, ancient hospitals were set in sacred groves, on spectacular sites. Their stated purpose was to awaken the vital healing energies with beauty, art, music, theater, and poetry. Through herbal potions and ritual, they connected their patients to their inner wisdom, and after one night of dreaming in the Abaton (as records meticulously carved in stone say), many patients were either healed or understood how to heal themselves and were discharged. For those who needed more care, a regimen of exposure to the arts, appropriate physical therapies, and herbal potions had a notable rate of success. One of the crucial elements, I imagine, was hope and the positive support of the Aesculapian priests, whose vocation it was to heal.
As I reflected on my experience, some of the issues that came up as needing urgent attention were
• The need for an aesthetic environment, especially one that has elements of nature
• The importance of quality human contact, continuity of care, and family involvement
• The crucial need for empowerment, human dignity, and control
All of these are aspects of the physical, human, and psychological environment.
Out of the six hundred or so people I met with in that early period were people who became the founding board. Among them was Dr. John Gamble, then chief of medicine at Pacific Presbyterian Hospital. He had been involved in an earlier attempt to humanize health care, called the Patients Involved and Responsible (PIR) node. His wisdom, leadership, and political expertise were essential to the success of Planetree.
Roslyn Lindheim was a professor of architecture at the University of California at Berkeley. She had a lifelong interest in healing environments and had designed a number of innovative hospital units. As part of her research for Planetree, she checked herself into a hospital for two days, an experience she found terrifying and demoralizing even though she was in perfect health.
Stewart Brand, futurist and publisher of the Whole Earth Catalogue, brought his boundless intelligence to bear every time the flow of ideas got snagged on some less-relevant point and put us back on track. His lifetime of thinking outside the box created a matrix for the group’s creativity. He also brought us our founding director, the brilliant and effective Ryan Phelan, without whom none of our ideas would have become realities.
Jill Goffstein had founded a very successful alternative school, and Suzanne Arms had single-handedly started the alternative birth movement with her book Immaculate Deception. Their boldness was based on experience in making change, and it proved to be invaluable.
Dr. Don Creevy, in his obstetrical practice, modeled the ideal Planetree doctor: one who takes time to thoroughly inform his patients, who grants women their right to have the birth experience they want, who makes it safe for them to do so, and who generally expresses the caring and attention that healing requires.
Victoria Fay brought her impeccable taste and sense of color and design to the first Planetree interiors.
Phelps Dewey knew about business and the financial aspects of institutions—an element of crucial importance to our success.
Dr. Fred Hudson brought us more medical expertise and many powerful contacts in the community.
Dr. Aileen Aicardi, beloved pediatrician, provided her professional viewpoint and wisdom.
Joan Barbour shared her knowledge as a health educator and came up with the name, Planetree, in honor of the tree on the island of Cos under which Hippocrates taught the first medical students.
Mary Crowley, Gretchen de Witt, and Betsy Everdell were of immeasurable help in providing us the community support and fundraising capabilities without which the project would not have succeeded.
Lee and Adrian Gruhn and Cyril Magnin were our very first donor board members, our very own angels.
The experience in humanistic care and health education provided by Drs. Jordan R. Wilbur and David Sobel were indispensable for our envisioning of Planetree.
Together, we attempted to address the question of how to create healing environments, a discussion that I am happy to report continues to this day in the many splendid Planetree sites and in the spirit of this book.
 
Angelica Thieriot

INTRODUCTION
PATIENT-CENTERED CARE MOVES INTO THE MAINSTREAM
In the approximately six years since the first edition of Putting Patients First was written, patient-centered care has moved from an emerging trend in the health care delivery systems of countries including the United States, Canada, and the Netherlands to a defining characteristic of quality patient care in an ever-expanding number of countries around the world. This move into the mainstream after decades on the fringe is largely the result of the convergence of several evolving social and economic realities:
1. The aging of baby boomers and the associated rise in consumer expectations around the health care experience
2. Unprecedented access to health information fueled by the Internet
3. The demand for greater transparency in reporting of outcomes and new governmental incentives to report these results for widespread dissemination to the public
4. Increased demand for timely and convenient access to costly medical technologies and pharmaceuticals that continue to drive health care costs—including both out-of-pocket costs for patients and employer contributions—increasingly skyward
As we struggle to balance these pressures within what many patients and providers describe as an understaffed, overwhelmed system, providing caring, kind, and respectful service has become even more of a challenge. What began eons ago as a personal calling to provide care to the ill, distressed, and injured has become a trillion-dollar business in the United States alone, with third-party payers in many cases now determining the nature of the patient-caregiver relationship and the extent of their contact with each other. The healing partnership between patient and physician has been reduced to seven-minute office encounters in many settings, and the majority of nurses in hospitals spend more time on documentation than in actually providing care at the bedside (Advisory Board Company, 2003).
Despite these challenges, a growing number of hospitals, clinics, continuing care facilities, and physician practices have found ways to create exemplary patient and resident-centered cultures. They have transformed the experience of care to include what so many other industries have mastered: choice, convenience, personalization, quality, and service. These aspects of a consumer-centric approach mirror the six core elements that the Institute of Medicine declared to be necessary to the delivery of quality patient care—that it be safe, timely, efficient, effective, equitable, and patient-centered (Institute of Medicine, 2001).
Truly patient-centered organizations have figured out how to address the very human needs of patients who come to us when they are most vulnerable, looking for support, comfort, and hope. These organizations see the big picture and attend to the smallest, and yet often the most meaningful, details of the patient experience. They find ways to decrease emergency room wait times and to provide comfortable, attractive furniture in areas where waiting occurs. They offer twenty-four-hour visitation throughout their facilities and support the active involvement of the patient’s family, providing adequate space for them as well as meaningful roles and responsibilities as valued members of the care team. They openly share information with patients and their designated caregivers, encouraging them to review their medical charts and contribute their own progress notes, respecting the fact that we can never know another person as well as we know ourselves. These organizations are converting to electronic medical records and are developing interactive systems that connect information between departments so that patients no longer have to respond to the same requests for personal information over and over again. They have taken down the physical barriers in facilities between patients, families, and staff, while attending to individual privacy, realizing that the needs of patients come first and that addressing those needs in a timely fashion is not a disturbance of our work. It IS our work. These organizations have found creative and successful ways to have staff spend more time interacting with patients and less time in isolated documentation activities and endless and inefficient walking back and forth between patient rooms and the locations of needed supplies. These improvements to the patient care experience have resulted in a slight increase in overall ratings in patient satisfaction in American hospitals between 2002 and 2006 (Press Ganey, 2007).