How to practice person‐centred care: A conceptual framework

Abstract Background Globally, health‐care systems and organizations are looking to improve health system performance through the implementation of a person‐centred care (PCC) model. While numerous conceptual frameworks for PCC exist, a gap remains in practical guidance on PCC implementation. Methods Based on a narrative review of the PCC literature, a generic conceptual framework was developed in collaboration with a patient partner, which synthesizes evidence, recommendations and best practice from existing frameworks and implementation case studies. The Donabedian model for health‐care improvement was used to classify PCC domains into the categories of “Structure,” “Process” and “Outcome” for health‐care quality improvement. Discussion The framework emphasizes the structural domain, which relates to the health‐care system or context in which care is delivered, providing the foundation for PCC, and influencing the processes and outcomes of care. Structural domains identified include: the creation of a PCC culture across the continuum of care; co‐designing educational programs, as well as health promotion and prevention programs with patients; providing a supportive and accommodating environment; and developing and integrating structures to support health information technology and to measure and monitor PCC performance. Process domains describe the importance of cultivating communication and respectful and compassionate care; engaging patients in managing their care; and integration of care. Outcome domains identified include: access to care and Patient‐Reported Outcomes. Conclusion This conceptual framework provides a step‐wise roadmap to guide health‐care systems and organizations in the provision PCC across various health‐care sectors.


| INTRODUCTION
In the Institute of Medicine's 2001 seminal report Crossing the Quality Chasm, patient-centred care was identified as an essential foundation for health-care quality and patient safety 1 and ever since has been recognized as a high priority for the delivery of health-care services in many jurisdictions. [2][3][4][5][6] Patient-centred care has been an evolving concept, originally depicted by Edith Balint in 1969 as "understanding the patient as a unique human being." 7 Since then, there have been many other conceptualizations of patient-centred care. 1,[8][9][10][11] Patient-centred care has been described through an array of alternative and more commonly adopted terms, including: patient (and family)-centred care, relationship-centred care, personalized care and user/client-centred care. Various jurisdictions, organizations and health-care systems utilize different terms and concepts. For instance, in the United States, the concept is usually linked to a "patient-centred care medical model," while in the United Kingdom, it is associated with primary care, and in Scotland, PCC is known as "mutuality." 8 Given that the concept of patient-centred care is evolving, it is important to understand how different jurisdictions define and operationalize it. In this article, we have chosen to use the term "person-centred care" (referred to as PCC), as opposed to patient-centred care, in agreement with Ekman et al's distinction between patient-centred care and PCC, by which PCC refrains from reducing the person to just their symptoms and/or disease. 12 We concur that it is important to acknowledge the notion of person, which calls for a more holistic approach to care that incorporates the various dimensions to whole well-being, including a person's context and individual expression, preferences and beliefs. 12 Additionally, PCC is not limited to only the patient, but also includes families and caregivers who are involved, those who are not living with illness, as well as prevention and promotion activities.
PCC has not been traditionally integrated into health-care quality improvement. Recent policies emphasize the value of patient views, which not only complement health-care provider perspectives, but also provide unique information about health-care effectiveness, [13][14][15][16][17][18] including improvement of patient experiences and outcomes and health-care provider satisfaction, while decreasing health-care services utilization and costs. 19,20 Based on this evidence and the need to address sky-rocketing health-care costs, many health-care systems around the world are moving towards a PCC model. [21][22][23] At the global level, the World Health Organization (WHO) has developed policy frameworks for people-centred health care 24 highlighting personcentredness as a core competency of health workers, 25 and as a key component of health-care quality 26 and primary care. 27 Conceptually, PCC is a model in which health-care providers are encouraged to partner with patients to co-design and deliver personalized care that provides people with the high-quality care they need and improve health-care system efficiency and effectiveness.
Despite many efforts to practice PCC, most health-care systems are challenged by effective implementation of PCC across the continuum of care. Shifting to PCC requires services and roles to be redesigned and re-structured to be more conducive to a PCC model. Although numerous conceptual frameworks of PCC have been introduced and discussed in the existing literature, 5,9,11,12,[28][29][30][31][32][33][34][35][36][37][38] practical guidance on the implementation of PCC has not been well described.
To address this gap, we developed a conceptual PCC framework that provides a comprehensive perspective, particularly with respect to the foundations needed to achieve PCC.

| METHODS
The guiding perspective for developing the framework was from a patient (and family caregiver, representative) perspective to ensure that the framework reflects what matters people, not only policy makers and HCPs. This conceptual framework describes and links key PCC domains and best practices to a model of practical implementation, through a narrative overview 39 of theoretical and conceptual works from academic and grey literature, in addition to policy and organizational documents.

| Sources of information
Based on the guidance from Green et al on conducting a narrative review, 39 a preliminary search was conducted. A number of sources included in the review were identified through a scoping review conducted on person-centred quality indicators that revealed rich literature on PCC practice and measurement. Search protocol details, including databases and search terms, have been published. 40 Additional works that were hand-searched and selected included frequently cited PCC literature and key policy documents from reference lists, and those identified by our patient partner (Zelinsky).

| Selection criteria employed
Articles that were selected by the research team were agreed upon by the team members that assessed the following criteria for inclusion: an existing theoretical or conceptual patient/person-centred care framework; importance to patients (as validated by Zelinsky); frequently cited (as verified in Google Scholar); and provides interesting discussion or presents concepts important to patients that tend to be missing from the academic literature, which would allow for a comprehensive perspective in developing the PCC framework. A number of sources were excluded as the research team deemed saturation for developing domains and concepts. Due to the inclusive scope of the review and high variation among sources, critical appraisal was not conducted.

| Synthesis
Common domains identified from the literature were reviewed, from which comparable themes and concepts were synthesized and then classified according to the Donabedian model for health care improvement into "Structure," "Process" and "Outcomes." 28,41 Among these three domains, each component is influenced by the previous and each is interdependent on the other. 41 Secondly, the research team engaged in a series of facilitated discussions to develop and refine the framework, including parsing and combining domains, subdomains and components, which also helped the research team to determine the point of saturation with respect to domains and components, and cease further search in the literature. to the results from the interaction between the health-care system, HCPs and patients. The framework is organized like a roadmap, depicting the practical PCC implementation in the order that should be implemented -starting from structural domains that are needed as pre-requisites, to facilitate processes and influence outcomes needed to achieve PCC. Table 1 shows the seven core structural domains that have been identified as foundational components or pre-requisites to promote a PCC model. The literature widely recognizes the importance of creating a PCC culture across the continuum of care (S1), where governments 42 and organizations play a key role in the development of clear and comprehensive polices, processes and structures necessary for health-care systems and health-care providers to deliver PCC. 5,30,43,44 A common set of core values among all parties, as part of a strategic vision (S1a) is essential in the provision and receiving of care that includes patients, health-care providers, communities and organizations within and outside of traditional health-care services. While it is and values and promotes dignity and antidiscriminatory care. 46,47 There is a need to be explicit in ensuring that diversity, including race, ethnicity, gender, sexual identity, religion, age, socio-economic status and disability, is addressed and incorporated. 48 A "rights-approach" to PCC is aligned with the promotion of human dignity for both patients and health-care providers and allows both parties to be aware of their rights and responsibilities. 14,49 Moreover, best practices demonstrate the need to standardize PCC language among patients, health-care providers, policy makers, along with other key stakeholders to effectively foster a PCC culture of care (S1b). 5,31,44 If the focus is in providing high quality of care, the terminology used by health-care systems must change; PCC promotes the value of co-design where health-care providers do things with people, rather than "to" or "for" them. 13 The lack of emphasis on PCC in medical education remains a barrier to its implementation, 5  In implementing these structural components, the balance between health-care providers and patient burden and prioritization of issues must be acknowledged. In addition, quality improvement leaders need to be included in the development of these programs. 6 Having a clear vision on how PCC strategies fit within overall healthcare system, quality improvement is critical in improving PCC processes and outcomes. 5

| Process
Four process domains were identified, each of which builds upon the last during a patient-health-care providers interaction (  82 Providing respectful care fosters relationship building and has been shown to promote healing and better outcomes. 20 To provide respectful and compassionate care, one must acknowledge the patient as an expert in their own health, and through this, develop partnerships that allow for sensitivity to emotional and psychological needs and empathetic responses. 31 It has been shown that compassion decreases in the latter years of medical training, in which by the time the health-care providers completes their training, they have become more desensitized to empathic processing. 84

| Outcomes
Outcomes derived from PCC need to be real and tangible, to show the value of implementing this type of model. Four outcome domains were identified (Table 3). Access to care (O1) is defined as the system's capacity to provide care efficiently after a need is recognized, as well as costs associated with receiving care. 97 A person-centred access model acknowledges the structures that may result in physical or financial barriers, as well as or other determinants of health-care access; 97 it can help patients secure appropriate and preferred health care at the right time to promote improved health outcomes while reducing costs to the health-care system. 84,98 A Timely access to care is often cited as an outcome of PCC (O1a.), which is not only wait times for operations and referrals, or the time needed during a consultation or waiting for test results, but also the availability of health-care providers during and outside working hours (O1b.). Improving timely access to care has the potential to reduce hospital admissions, decrease utilization of health-care services (e.g emergency department visits and hospital length of stay) and also may help to reduce morbidity and mortality for both acute and chronic disease. 99,100 Opportunities for cost savings that are relevant to both patients and the system must also be identified, particularly the lack of affordability of health-care services, which can have a negative impact on patients and families. 97

| Study limitations
A limitation of our study is not conducting a critical appraisal of the sources used. However, it was agreed by the study team that the more inclusive approach to our text selection -including a variation in sources, both from the academic and grey literature (including government documents and patient organizations), it would not be appropriate to assess the quality of the sources in a systematic way. Further, as we were looking to obtain a comprehensive perspective to PCC and were most interested in concepts that were identified as important to patients, but tended to be missing from much of the peer-reviewed lit-

| Strengths of the framework and applicability
The newly developed evidence-based, patient-informed framework captures key factors to comprise a PCC model, including best practices identified by various organizations that ensure the patient perspective is reflected alongside health-care providers and the system. Finally, our proposed framework provides a unique perspective: incorporating international viewpoints, concepts and literature, as well as integrating best practice and patient perspectives, while focusing on implementation and quality improvement. In this way, the framework is highly generalizable and can be adapted to multiple health-care contexts.
It is important to note that while this framework can provide guidance on implementation, it is not meant to be a "blanket approach" to PCC; there is still a need for health-care systems to be responsive to their specific contexts and identified priorities, while encouraging innovation for PCC.

| CONCLUSION
In summary, this framework provides a step-wise roadmap for healthcare systems striving to implement PCC. While people can relate to the PCC concept, health-care providers and policy makers must embark towards this cultural shift in practice, and systems must be willing to adopt and create innovative models that are conducive to providing incentives to support and practice PCC. The adoption of PCC comes with challenges, and entails critical changes, particularly with regard to how care delivered and how patients and their providers interact. However, despite the challenges associated with this shift, the benefits of PCC are evident presenting a major opportunity for improving health outcomes; PCC is our future. To improve health and health care, health-care systems must find a way to effectively implement and measure PCC.