Leaders of the U.S. Depart -

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1 Instructions for Continuing Nursing Education Contact Hours appear on page 363. Service Quality and Patient-Centered Care Beverly Waller Dabney Huey-Ming Tzeng Leaders of the U.S. Depart - ment of Health & Human Services (2011) urge providers to improve the overall quality of health care by making it more patient centered. Patient-centered care (or person-centered care) refers to the therapeutic relationship between health care providers and recipients of health care services, with emphasis on meeting the needs of individual patients. Al - though the term has been used widely in recent years, it remains a poorly defined and conceptualized phenomenon (Hobbs, 2009). Patient-centered care is believed to be holistic nursing care. It provides a mechanism for nurses to engage patients as active participants in every aspect of their health (Scott, 2010). Patient shadowing and care flow mapping were used to create a sense of empathy and urgency among clinicians by clarifying the patient and family experience. These two approaches, which were meant to promote patient-centered care, can improve patient satisfaction scores without increasing costs (DiGioia, Lorenz, Greenhouse, Bertoty, & Rocks, 2010). A better under standing of attributes of patient-centered care and areas for improvement is needed in order to develop nursing policies that in - crease the use of this model in health care settings. The purpose of this discussion is to clarify the concept of patient-centered care for consistency with the common understanding about pa - tient satisfaction and the quality of care delivered from nurses to patients. Attributes from a customer service model, the Gap Model of The Gap Model of Service Quality is used to clarify the concept of patient-centered care. Four possible patient-centered care service quality gaps were identified. Nurse administrators may use these gaps to identify and develop appropriate outcome measures. Service Quality, are used in a focus on the perspective of the patient as the driver and evaluator of service quality. Relevant literature and the Gap Model of Service Quality (Parasuraman, Zeithaml, & Leonard, 1985) are reviewed. Four gaps in patient-centered care are identified, with discussion of nursing implications. Background and Brief Literature Review Patient-Centered Care The Institute of Medicine (IOM, 2001a) and Epstein and Street (2011) identified patient-centeredness as one of the areas for improvement in health care quality. The IOM (2001b) defined patient-centeredness as health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care (p. 7) Charmel and Frampton (2008) defined patient-centered care as a healthcare setting in which patients are encouraged to be actively involved in their care, with a physical environment that promotes patient comfort and staff who are dedicated to meeting the physical, emotional, and spiritual needs of patients (p. 80) In a concept analysis of personcentered care, Morgan and Yoder (2011) defined it as a holistic (bio-psychosocialspiritual) approach to delivering care that is respectful and individualized, allowing negotiation of care, and offering choice through a therapeutic relationship where persons are empowered to be involved in health decisions at whatever level is desired by that individual who is receiving the care. (p. 3) Of significance in various definitions of patient-centered care is the focus on the patient s needs, patient control, and the interaction between the patient and health care provider. Being patient-centered suggests health care providers adapt their Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University, Keene, TX. Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic Programs, College of Nursing, Washington State University, Spokane, WA. November-December 2013 Vol. 22/No

2 services to reflect the goals, needs, and values of the individual patient. The Joint Commission (2010) expected hospital leaders to develop standards to advance effective communication, cultural competence, and patient- and family-centered care. Gerteis, Edgman-Levitan, Daley, and Delbanco (1993) identified seven dimensions of patient-centered care needed to improve health care quality: (a) respect for patients values, preferences, and expectations; (b) coordination and integration of care; (c) information, communication, and education; (d) physical comfort; (e) emotional support and alleviation of fear and anxiety; (f) involvement of family and friends; and (g) transition and continuity. Communication with pa - tients, which is essential to the application of patient-centered care, facilitates patient involvement in the planning of treatment (Hunt, 2009). Patient-centered care can influence patient satisfaction, the quality of health care, and possibly a patient s desire to return to a health care provider for future services (Andrews, 2009; Charmel & Frampton, 2008). Patients are ex pected to accept more financial responsibility for their health care, and they expect value in their health care purchases as they would with any other major purchase (Charmel & Frampton, 2008). McCormack, Manley, and Walsh (2008) emphasized the significant role played by health care policy in developing systems and processes in health care institutions that are person-centered. The recommendations of the IOM (2001b) and the Agency for Healthcare Research and Quality (2009) to adopt a philosophy of patient-centeredness have encouraged many institutions across the United States to implement patientcentered models. A comprehensive report on patient-centered care was developed by the Institute for Family-Centered Care and the Institute for Health Care Im prove - ment, from which four key concepts emerged: (a) respect and dignity, (b) information sharing, (c) participation, and (d) collaboration (Johnson et al., 2008). Charmel and Frampton (2008) indicated the attributes of patient-centered care need to be clarified to facilitate understanding of their inter-relatedness. As part of the promotion of patient-centeredness for quality improvement, clarification of the concept of patient-centered care is needed (McCormack et al., 2008). Communication The interaction between nurses and patients is central for the effective application of patient-centered care (Hobbs, 2009). Levinson, Lesser, and Epstein (2010) noted communication is fundamental to the delivery of patient-centered care. Nursepatient communication seeks to increase the nurse s understanding of the patient s needs, perspectives, and values. Nurse-patient communication also provides patients with information needed to participate in their care and assists in correcting unrealistic expectations. Patient-centered communication is not simply agreeing to provide information per patients requests, nor is it throwing information at patients and leaving them to sort it out (Epstein, Fiscella, Lesser, & Stange, 2010). Skillful communication with patients helps to build trust and understanding, and may require the clinician to engage in further questioning to explore fully what the patient hopes to achieve. The Joint Commission (2010) emphasized identification of patient communication needs as an issue to be addressed by health care leaders. Patient communication needs may include not only language or hearing barriers, but also emotional or fatigue barriers. In a qualitative study of patients with cancer, Montgomery and Little (2011) found some patients may be unable or even unwilling to express their preferences in regard to treatment during the debilitating stages of health. They suggested patients be assessed individually for their ability to engage in such communication; some individuals may need the health professional to assume a greater facilitative role. The quality of relationships and interactions between patients and nurses is of great importance to the achievement of patient-centered care. In addition to adequate information sharing, structures and processes are needed to enhance the delivery of patient-centered care. Delivery of Patient-Centered Care Luxford, Safran, and Delbanco (2011) interviewed senior staff and patient representatives in a qualitative study. Several organizational attributes and processes that facilitate patient-centered care emerged, including the following: (a) strong, committed senior leaders; (b) clear communication of strategic vision; (c) active engagement of patients and families; (d) sustained focus on staff satisfaction; (e) active measurement and feedback reporting of patient experiences; (f) adequate resourcing of care delivery redesign; (g) staff capacity building; (h) accountability and incentives; and (i) a culture supportive of change and learning. Barriers included the need to change the organizational culture from a provider-focus orientation to a patient-focus one, and the length of time needed for the transition to take place. Patient-centered care delivery can appear superficial and unconvincing if confusion exists about the meaning of patient-centered care (Epstein & Street, 2011). Patient-centered behaviors, such as respecting pa - tients preferences, should be justifiable on moral grounds alone and independent of their relationship to health outcomes. Berwick (2009) claimed health system design may affirm patient-centered care as a dimension of quality in its own right. Patient-centered care should not be confirmed just through its effect on patient or organizational outcomes. Evidence-base literature about identifying interventions for improved outcomes in patient-centered care is lacking, partially due to unclear conceptual models and goldstandard measures (Groene, 2011). Brief Overview of the Gap Model of Service Quality The Gap Model of Service Quality (Parasuraman et al., 1985) (the Model) is a widely used business model that focuses on the perspectives of cus- 360 November-December 2013 Vol. 22/No. 6

3 Service Quality and Patient-Centered Care tomers to determine quality and provides an integrated view of the customer-company relationship. The Model is useful for evaluating patient-centeredness in nursing care because of its focus on the customer s perspective as a measurement of service quality. In addition, it facilitates the derivation of statements of patient-centered care as an indicator of quality health care. The Model included five unique gaps in service quality that can influence quality as experienced by the customer. Based on earlier reports (Charmel & Frampton, 2008; IOM, 2001a), gaps number 1, 2, 3, and 5 in the Gap Model of Service Quality had similarities to the concept of patient-centered care. A brief description of these four gaps follows. Gap 1. Customer expectation vs. management perception gap. This gap, also identified as the knowledge gap, reveals discrepancies between managers perceptions of customer expectations and the actual expectations of the customers. This gap in service quality occurs because managers fail to identify customer expectations accurately. The size of the gap depends on upward communication from customer to top management (Parasuraman et al., 1985). Gap 2. Management perceptions vs. service standards gap. This gap, also known as the design gap, measures how well the managers perceptions of customer expectations are translated into service design standards. Service design standards are policies and expectations of the way service is to be provided. This gap depends on managers belief service quality is important and possibly dependent on the resources available for the provision of the service. However, if managers initial understanding of customer expectations is flawed, inefficient service standards inevitably will be produced (Parasuraman et al., 1985). Gap 3. Service standards vs. service delivery gap. This gap, also referred to as the performance gap, represents discrepancies between service design and service delivery. This gap occurs when the specified policies are not followed in service delivery. The quality of delivered service can be affected by numerous factors, such as skill level, type of training received, deficiencies of human resource policies, failure to match supply and demand, degree of role congruity or conflict, and job fit (Parasuraman et al., 1985). Gap 5. Perceived service vs. expected service gap. This is the gap between customers service expectations and their perceptions of the service received. According to Parasuraman and colleagues (1985), customer expectations are based on word-ofmouth communications, personal needs, and past experiences. These four gaps described three key provider abilities and one customer ability: (a) the ability of managers to identify the expectations of their customers correctly, (b) the ability to transfer the identified expectations of their customers into the standards of service, (c) the ability to transform these standards of service into the actual service delivery, and (d) customers perception of how the delivered service met their expectations (Parasuraman et al., 1985). Gaps in Patient-Centered Care Based on the Gap Model of Service Quality (Parasuraman et al., 1985), four gaps in patient-centered care were identified (see Figure 1). Each gap depicted in the model of patient-centered care quality in nursing practice is described below. Gap A. Patient expectation vs. nurse perception gap was derived from Gap 1 in the Gap Model of Service Quality. This gap occurs when discrepancies arise between nurses and nursing administrators perceptions of what the patient expects and the patient s actual expectations. The health care provider fails to identify the patient s expectations accurately. Lack of communication with the patient and an insufficient relationship focus are key contributors to this gap. To close this gap, nurses must communicate with the patient in a way that gathers his or her expectations and needs. Epstein and co-authors (2010) noted the communication goes beyond facts and figures. The clinician must frame and tailor information in response to an understanding of the patient s concerns, beliefs, and experiences. Aspects of the patient s culture, past experiences, his or her perceptions from comments made by others, and immediate personal needs all shape what the patient desires and expects from health care services. The key to closing this gap is to reach consensus about an approach to care which is achieved through shared deliberation. Gap B. Nurse and nursing administrator perceptions vs. patient-centered care standards gap was derived from Gap 2 in the Gap Model of Service Quality. This gap depends on the health care provider s and administrator s beliefs that patient-centered care is important to quality of care and it is possible to provide patientcentered care. This gap is measured by how well the health care delivery design matches the health care provider s perceptions of the pa - tient s expectations or needs. Indi - vidual nurses have their own sets of values and service standards based on their backgrounds and what they perceive the patient s expectations to be. This gap is measured by how well the health care delivery design matches the health care provider s perceptions of the patient s expectations or needs. To close this gap, nurse administrators must decide that meeting the needs of individual patients is a priority, set organizational standards, and provide resources necessary to meet those standards. Individual nurses must decide if the provision of patient-centered care is a priority. The infrastructure of patient-centered care is supported through the senior nursing team s commitment to the principles of patient-centered care. How - ever, development of appropriate standards is contingent on identifying patient needs correctly. Gap C. Patient-centered care standards vs. delivery of patient-centered care gap was derived from Gap 3 in the Gap Model of Service Quality. This gap represents variations in service design and service delivery. The service standards are to be derived from the perceived expectations of patients. Service standards are based on the principles of November-December 2013 Vol. 22/No

4 FIGURE 1. The Four-Gap Model of Patient-Centered Care Quality in Nursing Practice Patient perceived service Gap D: Patient expectation of health care service vs. patient perception of actual health care service received gap Gap C: Patient-centered care standards vs. delivery of patientcentered care gap Delivery of patient-centered standards Quality of Patient-Centered Care in Nursing Practice Patient expectation Gap A: Patient expectation vs. nurse perception gap Nurse and nursing administrator translation of perceptions into patient-centered care standards Nurse and nursing administrator perception of patient expectation Gap B: Nurse and nursing administrator perceptions vs. patient-centered care standards gap patient-centered care, and need to be translated to actual delivery of care. Nurses can have great impact on closing this gap. In practice, patient-centered care is not offered consistently due to nursing factors, such as poor staffing, fatigue, burnout, and lack of education on the delivery of patient-centered care. A qualitative meta-synthesis of four studies found evidence of sustained high commitment necessary to the development of personcentered cultures in clinical settings (McCormack, Karlsson, Dewing, & Lerdal, 2010). However, other cultural characteristics (e.g., the level of staff support) may determine the extent to which that commitment could be sustained. Gap D. Patient expectation of health care service vs. patient perception of actual health care service received gap was derived from Gap 4 in the Gap Model of Service Quality. This gap occurs when the patient s expectations, which are molded by past experiences, culture, personal needs, and word of mouth, are not met or are lacking in some way (Hunt, 2009; Parasuraman et al., 1985). In other words, when care is not patient-centered, patient expectations cannot be met because they are not identified. McCormack and coauthors (2008) suggested a direct relationship between patients experiences of daily care and their perceptions of service effectiveness. To close this gap and understand patient preferences, nursing administrators need to promote an interactive feedback loop that provides health care providers with a mechanism to view care through the eyes of patients and families as well as to link the patients and nursing staff together (DiGioia et al., 2010). A collaborative relationship between health care providers and patients can assist in shaping realistic patient expectations 362 November-December 2013 Vol. 22/No. 6

5 Service Quality and Patient-Centered Care related to patients individual health care needs, and minimize false perceptions due to lack of understanding. A complex series of interactions between nurses and patients elicit trust and understanding. Nurses need to use the knowledge gathered from these interactions to adapt a plan of care that reflects individual patient needs. Nursing Implications Nurses may use the four-gap model of patient-centered care quality (see Figure 1) to examine their practice. This approach will provide opportunity to identify gaps as well as develop nursing practice interventions to close the gaps indicated in this new model. For example, nurse executives and managers may develop appropriate outcome measures to monitor the closeness of each corresponding gap (e.g., patient satisfaction measures; patient-centered outcomes such as survival, function, symptoms, and health-related quality of life; clinical outcomes such as injurious fall occurrences, nurses job satisfaction measures, and intention to quit) (DiGioia et al., 2010, Patient- Centered Outcomes Research, 2013). Future Research The four-gap model of patient-centered care quality in nursing practice needs to be tested. Understanding the nurse-patient relationship and the aspects of communication needed for successful outcomes is essential. A focus on patient perspectives assists in capturing cultural, spiritual, and emotional needs that otherwise may be missed or overlooked. Future research that captures the degrees of similarity or difference between patient perspectives and provider perspectives will help identify areas of strengths and weaknesses for improvement. Future research also may explore the links between system issues, such as the effects of nurse staffing on the ability to deliver patient-centered care, and the developmental process of standards and policy for delivery of patient-centered care. Conclusion Four patient-centered care service quality gaps were identified. Individual patient needs influence expectations, and accurate nurse perceptions of these needs require communication with the patient. Collaboration between nurses and patients is essential to provide better understanding of patient needs and helps patients understand what to expect realistically from their health care experience. Once pa tient needs have been assessed accurately and understood, policies relevant to the characteristics of the clinical settings can be established to promote patient-centered care. McClelland (2010) claimed understanding the patient perspective of health care services is pivotal to the development of patientcentered, quality services. The shift of health care from a clinician-centric orientation to a patient-centric one can be challenging to the entire health care team. However, to realize fully the benefits of patient-centered care, nurses must focus on achieving gains in the quality of relationships and interactions with patients (Epstein et al., 2010). REFERENCES Agency for Healthcare Research and Quality. (2009). National healthcare quality report. Retrieved from qual/qrdr09.htm Andrews, S.M. (2009). Patient family-centered care in ambulatory surgery setting. Journal of PeriAnesthesia Nursing, 24(4), doi: /j.jopan Berwick, D. (2009). What patient-centered should mean: Confessions of an extremist. Health Affairs, 28(4), w555-w565. Charmel, P.A., & Frampton, S.B. (2008). Building the business case for patientcentered care. Healthcare Financial Management, 62(3), DiGioia, A., III, Lorenz, H., Greenhouse, P.K., Bertoty, D.A., & Rocks, S.D. (2010). A patient-centered model to improve metrics without cost increase: Viewing all care through the eyes of patients and families. Journal of Nursing Admini - stration, 40(12), Epstein, R.M., & Street, R.L. (2011). The values and value of patient-centered care. Annals of Family Medicine, 9(2), Epstein, R., Fiscella, L., Lesser, C., & Stange, K. (2010). Why the nation needs a policy push on patient-centered health care. Health Affairs, 29(8), Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T.L. (1993). Introduction: Instructions For Continuing Nursing Education Contact Hours Service Quality and Patient- Centered Care Deadline for Submission: December 31, 2015 MSN J1322 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through AMSN s Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to 2. Evaluations must be completed online by December 31, Upon completion of the evaluation, a certificate for 1.3 contact hour(s) may be printed. Fees Member: FREE Regular: $20 Objectives This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who are interested in service quality and patient-centered care. After studying the information presented in this article, the nurse will be able to: 1. Describe patient-centered care. 2. Discuss gaps in patient-centered care. 3. Explain the nursing implications of using the Gap Model of Service Quality to clarify patient-centered care. Note: The authors, editor, and education direc tor reported no actual or potential conflict of interest in relation to this continuing nursing education article. This educational activity has been co-provided by AMSN and Anthony J. Jannetti, Inc. Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP Licensees in the state of CA must retain this certificate for four years after the CNE activity is completed. Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. Accreditation status does not imply endorsement by the provider or ANCC of any commercial product. 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