Proposals for person‐centred care in the COVID‐19 era. Delphi study

Abstract Background In this COVID‐19 era, we need to rethink the criteria used to measure the results of person‐centred care strategies. Objective To identify priorities, and criteria that health services can use to pursue actually the goal of achieving person‐centred care. Design Three‐phase online qualitative study performed during May–July of 2020 using the Delphi technique. Setting and Participants An online platform was used for a consensus meeting of 114 participants, including health planning experts, health‐care institution managers, clinicians and patients. Main Outcome Measures Criteria and indicators for the achievement of person‐centred care. Main Results The first round began with 125 proposals and 11 dimensions. After the second round, 28 ideas reached a high level of consensus among the participants. Ultimately, the workgroup agreed on 20 criteria for goals in the implementation of person‐centred care during the COVID‐19 era and 21 related indicators to measure goal achievement. Discussion Nine dimensions and 28 priorities were identified. These priorities are also in accordance with the quadruple aim approach, which emphasizes the need for care for health‐care professionals, without whom it is impossible to achieve a better quality of care. Conclusions Person‐centred care continues to be a key objective. However, new metrics are needed to ensure its continued development during the restoration of public health services beyond the control of COVID‐19. Patient or Public Contribution Twelve professionals and patient representatives participated voluntarily in the construction of the baseline questionnaire and in the selection of the criteria and indicators using an online platform for consensus meetings.


| INTRODUC TI ON
Person-centred care (PCC) is defined as being respectful and responsive to patient needs and preferences and allowing the patient's values to guide all clinical decisions. 1 This definition includes respect for the patient's personal rights and active patient participation in the decisions that are made regarding their care. 1,2 PCC is characterized by an integrative approach aimed at preserving dignity, considering the patients' needs and preferences, improving quality of life and wellbeing, and promoting active patient participation to achieve better health outcomes. 2,3 Person-centred goal setting represents a shift from provider-or policy-oriented goals to the inclusion of the patient's personal goals in shared care planning. 4,5 The PCC model includes integrated care that promotes personal well-being, active patient participation and co-planning for better outcomes and considers patient experience as a measurable outcome that can be used to guide changes in resources or procedures at the organisational level. [6][7][8][9][10] Barriers that could hinder the achievement of PCC goals include resistance to change (including the patient's resistance to participate in joint decision making with their health-care professionals), lack of professional facilities and limited access to information, which are usually designed using a paternalistic care approach. 11 Patients and citizens have a lot to say about the scope of PCC; however, directive personnel and staff attitudes are more of a determinant of the paradigm change that is necessary to promote PCC. 4 Moreover, advances in the evaluation of outcomes from the patient's perspective could be made by, for example, analysing both patient and professional attitudes and incorporating measures using the Patient Reported Experience Measure and the Patient Reported Outcome Measure questionnaires. [12][13][14] The COVID-19 pandemic has changed many aspects of the framework for patient-health-care professional relationships. 15 In previous times of crisis, the professional perspective was that the patient experience may need to be sacrificed in the interest of clinical effectiveness. 16,17 COVID-19 has introduced new health-care scenarios and conditions of human interaction and has altered procedures that were established long ago, resulting in unexpected consequences for health-care equity, accessibility, patient participation in the decision-making process and the evaluation of results. 12 These changes in the era of COVID-19 have made it difficult for more PCC and have required the establishment of new priorities to ensure that the efforts made to implement PCC do not stop. Numerous changes can be seen in European and local scenarios 13,14 where primary care consists of universal coverage and is the gateway to the health-care system, with selective attention primarily based on disease type.
The pandemic has caused personal care restrictions, and specifically for chronically ill patients, follow-up that is limited to phone calls.
It has also lead to the breakdown of the multidisciplinary structure of primary care teams, due to the need to prioritize staff based on hospital needs and the high demand for emergency and specialized respond to the health needs of their patients. 18 The design of these recommendations incorporated guaranteed safe access to healthcare centres, gradual face-to-face care for chronic patients, and proposals for the care of institutionalized patients. 18 Locally, efforts to minimize the risk of infection due to the COVID-19 pandemic have interrupted the care and follow-up of chronic patients, as well as scheduled diagnostic tests. Furthermore, advances made to date for more PCC in both national and regional health-care services are converting patients and their caregivers in the principal responsibility of their self-care. 19 The effects of the COVID-19 era require rethinking the current health-care system structure and evaluating the stability of previous advances made in medical care. The lack of stable and significant advances emphasizes the need for more practical guidance for PCC implementation and for specific criteria and indicators to cover all dimensions of PCC. 20 It is important to preserve the care of the patient, to integrate their experiences when processes are redefined and to maintain their participation in decision-making processes. 20,21 This study aimed to identify the priorities of PCC and to establish criteria and indicators with which health services can use to model stable and reliable PCC goals and objectives in both the current and post-COVID-19 era.

| ME THODS
A qualitative study was conducted between May and July of 2020. This study was performed in three phases ( Figure 1). In the first phase, a consensus meeting was held to identify health-care professionals' needs in reaching the PCC target after the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the second phase, the Delphi methodology 22 was used to identify the priorities of PCC in the time of COVID-19.

| Participants
The first work group participated in the development of the baseline questionnaire and included 12 professionals and representatives from patient associations.
For the Delphi study, 94 potential participants were identified from various health services through informal contact and the snowball sampling technique. The inclusion criteria were as follows: at least 10 years of experience as a health-care professional (doctors and nurses), health-care institutions and department managers, information systems experts, health quality experts, public health experts, academics and patient representatives. Refusal to participate was the exclusion criterion. Voluntary participation began after receiving information about the study objectives and the methodology to be applied. The first email was sent to inform the participants about the study objectives and scope, the confidentiality of the responses, and included a participation agreement form. After receiving the signed participation agreement, a second email was sent with methodological instructions and a link to the online response register.
In the final consensus meeting, another nine experienced healthcare system management and evaluation professionals established the PCC criteria and indicators. They reviewed their relevance and acceptability, as well as the indicator definitions, the viability of the calculation formula and potential information sources. These professionals adapted the criteria to formulate the indicators using corresponding numerators and denominators. In this phase, there was no patient participation.
In this study, there was a promoter group, or core group, which included eight professional PCC experts. Their role was to synthesize the proposals in the different phases of the study. (see Table 1).

| First consensus meeting
The first consensus meeting was conducted online and consisted of a brainstorming session in which professionals and patients were asked, 'What do healthcare professionals need to implement more person-centred care during and after the SARS-CoV-2 pandemic'?
These online consensuses determined the first pool of priorities related to professionals' needs in achieving PCC after the pandemic.
Each professional or patient provided a group of proposals from different dimensions using a common approach. The first selection round included all the suggested proposals.

| Delphi study
The suggested proposals for PCC priorities were rated using a 0-to-10-point scale; proposals rated between 8 and 10 points were F I G U R E 1 Flowchart of study phases: consensus conference, Delphi study and final workgroup consensus conference considered absolute priorities, proposals rated between 5 and 7 points as medium priorities, and proposals rated between 0 and 4 points as relative priorities. The following aspects determined the acceptance grade of agreement: average proposal score (between 7 and 8 points) and the coefficient variability (higher variability; more significant homogeneity within scores). This method achieved sufficient consensus that allowed for the definitive acceptance or exclusion of the proposal when the average was below or above these scores.
The second round worked to improve the wording of the firstround items and to clarify their meaning and allowed for the inclusion of new proposals. The same rating scale was applied in this round. Nine or ten points indicated a high-grade consensus (achieved in 50% of the proposals); scores between 49% and 40% indicated moderate consensus; and the rest were eliminated. The participants' average scores from the first round were made available for review in the second round.

| RE SULTS
The first panel of experts suggested a group of 125 proposals for priorities categorized among 11 dimensions. The core group analysed these proposals based on productivity terms: the number and   To promote the preventive medicine in the primary care by improving the prevention and information on patient health. To promote the message that the pharmaceutical treatment is not the unique therapy and decision related to patients eating and exercise habits, toxic habits and other habits prevent contagion 73 To build multidisciplinary groups based on hospital, familiar and social approaches in order to address a problem from an integrative vision and adapted to the urgency degree and the information should be available in each level, institution and managers The cooperation between PC and social services through a common 'Centre Plan' in order to detect the person's needs, identifying the community most prevalent health problems, as the social or environmental determinants and establishing strategies to resolve them Health education to empower patients in healthy habits that contribute and maintain a good immunity system, and essential aspects to avoid contagion, at primary and hospital healthcare (hands washing, mask use, home ventilation, social distance and vaccination recommendations) To maintain an active contact of health-care services with the local councils, so that they take responsibility knowing the situation of most vulnerable people by supporting and collaborating decidedly with municipal health structures To support family reconciliation, it was an added stress factor during the pandemic due to the lack of relatives and schools' support  Numerator: number of patients not included in telemedicine programs (expect those that rejected inclusion due to digital analphabetism or other reasons) Denominator: number of patients included in telemedicine programs or use mHealth solutions supervised by health area professionals OP_2 Access to updated maps of social and health resources, specially to address the situations of most vulnerable persons Numerator: number of professional of the health area that accessed or downloaded from the intranet information about social and health resources during the last 6 months Denominator: number of active professionals in the health area during the last 6 months OP_ 3 Availability of multidisciplinary intervention teams (professional teams of different disciplines that act in unexpected situations/situation of force) qualified to assist special collectives or centres in overflowed services Numerator: number of professionals involved in multidisciplinary seminaries/workshops/ work m to address overflowed situations (health crisis) Denominator: number of active professionals in centres of the health area OP_4 To extend equally the use of high-resolution consultation to polymedicated patients as in the case of those with preferential access to consultations and diagnosis tests (preferential health-card access) applying producers to ensure its correct usage Numerator: number of polymedicated chronic patients included in high-resolution consultations procedures Denominator: number of polymedicated patients (with more than 5 drugs per day) attended during the last three months Numerator: number of patients with preferential access attended in less than 10 minutes respect the scheduled time Denominator: number of patients with preferential access attended in the last three months in the centre At the end of the second round, 28 priorities reached a high consensus (see Table 2). None of the proposals included in the healthliteracy dimension had a sufficient level of consensus for inclusion;   (Table 4). Among these criteria, three were not included, considering that they are currently applied systematically in healthcare centres. For further details, see Supplementary Material 2.
In the consultation round, the 20 criteria were included in the following four dimensions: proposals for electronic health records, organization and procedures, patient participation and new goals.
For each of these 20 criteria, clarifying information was added and 12 were revised for further improvement. In addition, the information sources and reference standards were changed in other four criteria, and redundant information was deleted from one criterion.

| D ISCUSS I ON
The COVID-19 pandemic has significantly modified the priorities for the achievement of PCC in the Spanish health system, specifically access to primary care while preserving patient and community safety. Public and scientific institutions have proposed a new organizational model to restore public health services beyond the control of COVID-19. 18,19 However, if there are no metrics or measurement criteria, these initiatives will remain as good intentions. These results showed proposals for PCC in nine work dimensions and 28 identified priorities that would improve the capabilities of the health-care system to improve health outcomes while respecting patient values.
In addition, these proposals support the quadruple aim approach, which considers the need for care for health-care professionals, without whom it is impossible to achieve a better quality of care. [23][24][25] Lastly, these proposals are in accordance with the value-based health-care approach. 1,2 The pandemic caused by SARS-CoV-2 has had a devastating impact on Spain. 26 The incidence of cases, the burden of patient care, the number of deceased patients and the number of infected (and also deceased) professionals were all higher in Spain than in neighbouring and less developed countries. 15,27 In this health crisis, the quality of the health-care system has now been questioned and positive opinions of it have diminished. [28][29][30] It is predicted that there will be an increased demand for the review of current approaches, procedures and goals in the coming months. 31 The path undertaken to implement PCC should not be obstructed, and it may be necessary to re-launch the interventions aimed at this objective throughout the health system. Measuring the degree of achievement of the relevant objectives is one way of contributing to this objective.
On an institutional basis, the first step towards post-pandemic recovery was the National Commission's decision for social and economic reconstruction (the so-called Cajal project, which is in progress). Among the recommendations approved in a plenary session by the Spanish Congress of Deputies were the need to strengthen support for professionals, the aim to achieve a higher level of patient participation in making decisions, and the promotion of patient wellbeing, safety and autonomy. It was also approved to promote the digitalization and permanent incorporation of primary care medical records in primary care centres, to use telemedicine and to provide telephonic assistance. 17,21,32 These goals are included among the priorities of this study.
To our knowledge, this is the first study to analyse the priorities necessary to achieve PCC implementation goals in the COVID-19 era. Scientific societies, such as the Spanish Society of Public Health These proposals could be utilized by managers and health authorities to assess the viability and adaptation of the policies that are currently in practice. A shared effort from all stakeholders, such as policymakers, patient representatives, physicians and clinical staff, and public health researchers, is necessary to move these ideas from proposals to actions in the development of the PCC approach. Focusing on the operative adjustments to electronic health records, self-care promotion, procedural redesign and the wellbeing of health-care professionals will serve as tools in the achievement of better health-care outcomes.

| Limitations
No analysis was conducted as to how these recommendations can be put into practice. This study considered the professionals' perspectives, and not just the organizational and management experience, which usually do not represent the clinician's or other health-care professional's point of view. Due to the particularity of the differences between the territorial health services, the information collected and used to calculate some of the proposed indicators may require structural modifications.
This study was conducted in Spain in the context of a national health model. Although the pandemic's overall impact on health systems may have varying intensities, the changes made in response to its effects have been similar. In this sense, although the data should not be extrapolated to other health models, the results can offer clues on how to proceed in the short and medium terms.
In this study, the feasibility of these proposals served to evaluate their priority. The proposals are accompanied by criteria that indicate the direction of progress and indicators to determine if the progress is moving in the correct direction. This study is moving in this direction.
The changes to be implemented should be accepted by the workgroups (those responsible for putting them into practice) and accompanied by tools and metrics that can monitor the levels of achievement. Otherwise, these proposals will be viewed solely as good intentions.

ACK N OWLED G EM ENTS
We would like to thank for their contribution to 'Sociedad Española de Atención al Usuario de la Sanidad-SEAUS' (Spanish Society of assistance to health-care system user) and Patient's Representative Platform to this study.

This study has been funded by Merck, Sharp and Dohme Research
Laboratories, Spain. Design, analysis and interpretation of data were conducted exclusively by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.