Last week I wrote a blog sharing my thoughts on the problematic nature of measuring the person-centredness of our health services. In our collective efforts to improve care quality, we need to be able not only to overcome the technical challenges of designing measures, but also the usual challenges associated with implementing a new system into routine practice.
I argued that rather that directing all our efforts to finding a single silver bullet measure, for now we need to think about how best to use baskets of measures that give a ‘feel’ for how person-centred our care is. A keystone for such an exercise would be a coherent framework, but what would it look like?
The table below describes two frameworks both with differing underpinning characteristics. Which option feels like the right place to start when thinking about a framework for assessing person-centred care?
|Context dependent||One size fits all|
|Self determined; the system chooses
what to notice
|Imposed; criteria are established internally|
|Information accepted from anywhere||Information in fixed categories only|
|System creates own meaning||Meaning is pre-determined|
|Newness, surprise are essential||Prediction, routine are valued|
|Focus on adaptability and growth||Focus on stability and control|
|Meaning evolves||Meaning remains static|
|System co-adapts||System adapts to the measures|
If you are like me, you’ll feel that option 1 describes an appropriate value-base from which to start building a measurement framework for person-centred care. But rather like I was, you may be surprised to know that option 1 is not actually describing measurement at all. Rather, it is describing a system of feedback – something critical for efforts garnered around quality improvement in healthcare.
This important distinction (and indeed the table above) is presented in Margaret Wheatley and Myron Kellner-Rogers’ thought provoking paper What Do We Measure and Why? Questions About The Uses of Measurement.
Their train of thinking starts with a question: what are the problems in organisations for which it is assumed that measures and measurement are the solution? The authors suggest that what organisations really want is reliable, high quality work, and that requires commitment, focus, teamwork, learning, and quality.
Is any of this sounding familiar?
The authors go on to challenge the reader to think, ‘in your experience, [when have] you have been able to find measures that sustain these strong and important behaviours over time?’ I can honestly say that in my 20 years of working I can’t think of a measure that has fundamentally affected my behaviour or way of working.
In thinking about a measurement framework for person-centred care, we need to be acutely aware that our efforts do not lead us down a path where what we measure becomes dangerously detached from the organisational qualities and behaviours that we need to make person-centred care a reality all day, every day.
So, for example, it is vital that future frameworks work to promote behaviours such as compassion, dignity and respect, while also acknowledging the impact that honesty and openness – particularly around safety – contribute towards person-centeredness. Sustaining such behaviours will ensure that the focus of care remains locked on to the person and, consequently, should result in improvements to their quality of life.
A framework would also need to recognise shifts in the dynamic of existing healthcare relationships, for example, movement towards a more collaborative and supportive relationship. By taking care to properly consider the distinction between feedback and measurement, it should be possible to develop and operationalise processes that support the behaviours and capacities required by health services and their staff.
The human desire to measure, and to record what we measure, will go on forever. Similarly, the reasons why we choose to measure and how we choose to do it will remain varied. But in healthcare we face an unprecedented challenge: we need to be doing more for less. This is going to require the NHS to embed an ethos of improvement at every level in the system. If anything, it is likely to be the cumulative efforts of everyone that will see the NHS through the current choppy waters rather than a one off remedy that will emerge from evidence.
So, in our quest for an all-singing, all-dancing measure of person-centre care, let’s not forget that successful quality improvement probably needs more feedback and less measurement. This, I feel, is probably the best starting point for future conversations on how to improve the person-centeredness of the care that we give and receive.
Darshan is a Research Manager at the Health Foundation.