Journal of Health Care for the Poor and Underserved

338 Guest editorial PATIENT-CENTERED PATIENT-VALUED CARE PAUL J. BOUMBULIAN, D.P.A., M.P.H.1 MacGREGOR W. DAY, M.B.A.2 THOMAS L. DELBANCO, M.D.3 SUSAN EDGMAN-LEVITAN, P.A.4 DAVID R. SMITH, M.D.5 RON J. ANDERSON, M.D.6 IN today's uncertain health care climate, few things are as inevitable as change. The last quarter-century has seen unprecedented increases in health care costs, mounting concern over the quality of care and access to care, competition among health care providers, and increasingly aggressive federal interventions to stabilize a system that consumers and providers agree is in critical disrepair. Underserved populations, and the hospitals that care for them, are bearing the brunt of a confluence of hostile economic and political factors that in many communities threaten the very existence of meaningful health care. 1 Vice President, Strategic Planning, Parkland Memorial Hospital, 5201 Harry Hines Blvd., Dallas, TX 75235 2 Executive Vice President and Chief Operating Officer, Parkland Memorial Hospital, 5201 Harry Hines Blvd., Dallas, TX 75235 3 Director, Picker/Commonwealth Patient-Centered Care Program; Director, Division of General Medicine and Primary Care, Beth Israel Hospital and Harvard Medical School, 330 Brookline Ave., LY-314, Boston, MA 02215-5491 * Associate Director, Picker/Commonwealth Patient-Centered Care Program, Beth Israel Hospital, 330 Brookline Ave., LY-314, Boston, MA 02215-5491 5 Medical Director and Chief Executive Officer, Community Oriented Primary Care, Parkland Memorial Hospital, 5201 Harry Hines Blvd., Dallas, TX 75235 6 President and Chief Executive Officer, Parkland Memorial Hospital, 5201 Harry Hines Blvd., Dallas, TX 75235 Journal of Health Care for the Poor and Underserved, Vol. 2, No. 3, Winter 1991 ___________________Boumbulian, Day, Delbanco, et al.________________339 But hospitals must not waver in their determination to deliver compassionate , quality health care. Crisis can give rise to opportunity, and despite a difficult working climate, there is still room for innovation. Patient-Centered Patient-Valued Care represents one way to improve the quality of care in an industry that often seems most intent on protecting the bottom line. Patient-Centered Patient-Valued Care is an attempt to reorient the provider /patient relationship—a relationship that, in part, is historically rooted in how hospitals are organized. Background The American hospital has passed through two principal evolutionary eras and has now entered a third. The first took place in the 19th century when hospitals were organized to provide care to immigrant male workers who had no families and could not be cared for at home. At the time, the dominant paradigm for the organization of work involving large numbers of people was the industrial manufacturing model: resources were brought to factories, and workers transformed the resources into new goods.1 This model was borrowed from the military, where soldiers were stripped of their individuality as they became component parts of a fighting unit. Authority flowed down from the top, and men were organized functionally in progressively larger units. The major purpose was to create uniformity and control. Many of these characteristics—functional organization, nursing uniforms , time clocks, 24-hour military time—continue, in part, today. Patients, in turn, are dehumanized. Much like military recruits, they are gowned, labeled, and stripped of their identity. Procedures are performed on them as if they were items on an assembly line. The patient loses almost all autonomy and control.2 3 The second era was marked by Osier and the Flexner Report. Hospitals became places where science "happened." Physicians and other health care providers increasingly learned how to diagnose and treat disease using tools of science.1·4 The focus on biomedical research stimulated the development of extraordinary new technologies. As a result, the disease burden of Americans quickly changed. Many of the acute infectious diseases which had been the scourges of our past were eliminated or controlled. In the late 1960s and 1970s, the diffusion of technology from academic medical centers to community hospitals accelerated, thereby spreading the benefits of scientific medicine. The success of the scientific model has shown it to be essential to medicine, if not its cornerstone. Yet the model has many limitations. Science-based medicine, which grew out of the Cartesian-Newtonian mechanistic concept...