Creating a Zone of Openness to Increase Patient-Centered Care
Evidence from clinical consultations indicates that patients are frequently not informed by their healthcare providers of the full range of intervention options available and the potential associated outcomes. Decision support interventions can improve the range of information provided to patients and facilitate shared decision making, however these are only available for a small fraction of healthcare decisions made every day. A further barrier to patient centered care are recently identified patient perceptions and beliefs that actively participating in clinical decision making may lead them to being perceived as "difficult" patients by their healthcare providers, and that being labeled as "difficult" could subsequently result in lower quality care. Moreover, medical staff members were perceived as least likely to approve of patients actively participating in clinical decision making. These patient beliefs of fearing repercussions for asserting themselves in clinical decision making suggest that for shared decision making to become routine, providers need to create a "Zone of Openness" that dispels these beliefs.
The proposed project aims to test the implementation of 2 complementary interventions: a simple evidence-based patient activation intervention - "Ask 3 Questions"- augmented by a novel theory-based intervention - the "Zone of Openness" - aimed at healthcare providers. The novel intervention will be developed in collaboration with multiple stakeholders (physicians, clinical support staff and patients) and will be informed by a concurrent micro-systems analysis of 4 primary care practices, to identify the best methods for implementing interventions to promote patient centered communication. Once the "Zone of Openness" intervention is developed, we will conduct a pilot randomized controlled trial using a 2x2 factorial design to collect data to inform a large scale evaluation of the interventions, alone and in combination compared to a control condition. Consistent with a patient-centered approach, outcome measures will be selected in collaboration with a group of patient stakeholders. Findings from self-report measures will be validated with objective measurement of clinical encounters, by audio recording consultations. This proposal responds directly to the PCORI area of interest #3: "Developing, refining, testing, and/or evaluating patient-centered approaches, tools, for translating evidence-based care into healthcare practice in ways that account for individual patient preferences for various outcomes."
RELEVANCE The proposed project is highly relevant to the mission of PCORI. We will develop, implement and test 2 complementary interventions - the "Zone of Openness" and "Ask 3 Questions" - aimed at improving patient centered communication. The purpose of the interventions is to empower patients to ask and encourage healthcare providers to answer the patient-focused questions at the heart of PCORI's mission:
- Given my personal characteristics, conditions and preferences, what should I expect will happen to me?;
- What are my options and what are the benefits and harms of those options?; and
- What can I do to improve the outcomes that are most important to me?
This project will result in 3 key deliverables:
- a new theory based intervention to create a clinical "Zone of Openness";
- rigorous pilot data to inform a large scale effectiveness trial of the intervention, alone and in combination with "Ask 3 Questions"; and
- a tool-kit for implementation of these interventions in primary care.
Findings and products from this project will be disseminated through conferences, publications in peer-reviewed journals and collaborative networks of implementation researchers focused on patient centered care.
^ Dominick Frosch, PhD was the original principal investigator for this project.
Tai-Seale M, Elwyn G, Wilson CJ, Stults C, Dillon EC, Li M, et al. Enhancing Shared Decision Making Through Carefully Designed Interventions That Target Patient And Provider Behavior. HealthAffairs 2016 April 01;35(4):605-612.
Tai-Seale M, Sullivan G, Cheney A, Thomas K, Frosch D. The Language of Engagement: "Aha!" Moments from Engaging Patients and Community Partners in Two Pilot Projects of the Patient-Centered Outcomes Research Institute. Perm J. 2016 Feb 22;20(2). doi: 10.7812/TPP/15-123. [Epub ahead of print] PubMed PMID: 26909777.
Ming Tai-Seale, Patricia K. Foo, and Cheryl D. Stults, "Patients with Mental Health Needs Are Engaged in Asking Questions, but Physicians’ Responses Vary," HealthAffairs 32 (2013): 2259-267.
Creating a “Zone of Openness” at the Doctor’s Office - A narrative about how California researchers develop a tool to eliminate patients' fear of reduced care quality when they disagree with their doctor.
VIDEO: Creating a Zone of Openness
Learn more about this project and how it uses decision-support tools to encourage shared decision making between patients and their clinicians.
VIDEO (below): Improving Patient-Centered Communication
Ming Tai-Seale, PhD, MPH, describes her PCORI-funded research project that looked into whether shared decision making in primary care settings changed the behavior of both patients and providers.