Service Quality and Patient-Centered Care

November-December 2013 • Vol. 22/No. 6 359

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.

Service Quality and Patient-Centered Care

L eaders of the U.S. Depart -ment of Health & HumanServices (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 pro- vides a mechanism for nurses to engage patients as active partici- pants 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 clarify- ing the patient and family experi- ence. These two approaches, which were meant to promote patient-cen- tered care, can improve patient sat- isfaction 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-cen- tered 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

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 implica- tions.

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 practition- ers, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the edu- cation and support they require to make decisions and partici- pate 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, emotion- al, and spiritual needs of patients… (p. 80)

In a concept analysis of person- centered care, Morgan and Yoder (2011) defined it as

…a holistic (bio-psychosocial- spiritual) approach to delivering care that is respectful and indi- vidualized, allowing negotiation of care, and offering choice through a therapeutic relation- ship where persons are empow- ered 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 defini- tions 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 Huey-Ming Tzeng

The Gap Model of Service Quality is used to clarify the concept of patient-centered care. Four possible patient-centered care service qual- ity gaps were identified. Nurse administrators may use these gaps to identify and develop appropriate outcome measures.

Instructions for Continuing Nursing Education Contact Hours appear on page 363.

 

 

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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 com- munication, cultural competence, and patient- and family-centered care. Gerteis, Edgman-Levitan, Daley, and Delbanco (1993) identified seven dimensions of patient-cen- tered care needed to improve health care quality: (a) respect for patients’ values, preferences, and expecta- tions; (b) coordination and integra- tion of care; (c) information, com- munication, and education; (d) physical comfort; (e) emotional sup- port and alleviation of fear and anx- iety; (f) involvement of family and friends; and (g) transition and conti- nuity. Communication with pa – tients, which is essential to the appli- cation of patient-centered care, facil- itates patient involvement in the planning of treatment (Hunt, 2009).

Patient-centered care can influ- ence 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 pur- chase (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 per- son-centered. The recommendations of the IOM (2001b) and the Agency for Healthcare Research and Quality (2009) to adopt a philosophy of patient-centeredness have encour- aged many institutions across the United States to implement patient- centered 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) participa- tion, and (d) collaboration (Johnson et al., 2008). Charmel and Frampton (2008) indicated the attributes of

patient-centered care need to be clar- ified to facilitate understanding of their inter-relatedness. As part of the promotion of patient-centeredness for quality improvement, clarifica- tion of the concept of patient-cen- tered care is needed (McCormack et al., 2008).

Communication The interaction between nurses

and patients is central for the effec- tive application of patient-centered care (Hobbs, 2009). Levinson, Lesser, and Epstein (2010) noted communi- cation is fundamental to the delivery of patient-centered care. Nurse- patient communication seeks to increase the nurse’s understanding of the patient’s needs, perspectives, and values. Nurse-patient communi- cation also provides patients with information needed to participate in their care and assists in correcting unrealistic expectations. Patient-cen- tered 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 com- munication 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 indi- vidually for their ability to engage in such communication; some individ- uals may need the health profession- al 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 infor- mation 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 qualita- tive study. Several organizational attributes and processes that facili- tate 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 measure- ment 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 orien- tation to a patient-focus one, and the length of time needed for the transi- tion to take place.

Patient-centered care delivery can appear superficial and unconvincing if confusion exists about the mean- ing of patient-centered care (Epstein & Street, 2011). Patient-centered behaviors, such as respecting pa – tients’ preferences, should be justifi- able 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-cen- tered care is lacking, partially due to unclear conceptual models and gold- standard 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-

 

 

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tomers to determine quality and pro- vides an integrated view of the cus- tomer-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 serv- ice 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 similar- ities to the concept of patient-cen- tered 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 man- agers’ perceptions of customer expectations and the actual expecta- tions of the customers. This gap in service quality occurs because man- agers fail to identify customer expec- tations 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 translat- ed 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 pro- vision of the service. However, if managers’ initial understanding of customer expectations is flawed, inef- ficient 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-of- mouth communications, personal needs, and past experiences.

These four gaps described three key provider abilities and one cus- tomer ability: (a) the ability of man- agers to identify the expectations of their customers correctly, (b) the abil- ity to transfer the identified expecta- tions of their customers into the stan- dards 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 expecta- tions (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 nurs- ing 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 dis- crepancies 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 relation- ship focus are key contributors to this gap.

To close this gap, nurses must com- municate 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 cli- nician must frame and tailor informa-

tion 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 adminis- trator 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 adminis- trator’s beliefs that patient-centered care is important to quality of care and it is possible to provide patient- centered 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 expecta- tions or needs.

To close this gap, nurse administra- tors must decide that meeting the needs of individual patients is a prior- ity, 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 nurs- ing team’s commitment to the princi- ples of patient-centered care. How – ever, development of appropriate standards is contingent on identify- ing patient needs correctly.

Gap C. Patient-centered care stan- dards 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 expecta- tions of patients. Service standards are based on the principles of

Service Quality and Patient-Centered Care

 

 

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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 educa- tion on the delivery of patient-cen- tered care. A qualitative meta-syn- thesis of four studies found evidence of sustained high commitment nec- essary to the development of person- centered cultures in clinical settings (McCormack, Karlsson, Dewing, & Lerdal, 2010). However, other cultur- al 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 expecta- tions, 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 expecta- tions cannot be met because they are

not identified. McCormack and co- authors (2008) suggested a direct relationship between patients’ expe- riences of daily care and their percep- tions of service effectiveness.

To close this gap and understand patient preferences, nursing adminis- trators need to promote an interac- tive feedback loop that provides health care providers with a mecha- nism to view care through the eyes of patients and families as well as to link the patients and nursing staff togeth- er (DiGioia et al., 2010). A collabora- tive relationship between health care providers and patients can assist in shaping realistic patient expectations

FIGURE 1. The Four-Gap Model of Patient-Centered Care Quality in Nursing Practice

Quality of

Patient-Centered Care in Nursing

Practice

Patient perceived service

Patient expectation

Delivery of patient-centered

standards

Nurse and nursing

administrator perception of patient

expectation

Nurse and nursing administrator transla-

tion of perceptions into patient-centered care

standards

Gap B: Nurse and nursing

administrator perceptions vs. patient-centered care

standards gap

Gap D: Patient expectation of health care service vs. patient

perception of actual health care service received gap

Gap A: Patient expectation

vs. nurse perception gap

Gap C: Patient-centered care

standards vs. delivery of patient- centered care gap

 

 

November-December 2013 • Vol. 22/No. 6 363

related to patients’ individual health care needs, and minimize false per- ceptions due to lack of understand- ing. 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 qual- ity (see Figure 1) to examine their practice. This approach will provide opportunity to identify gaps as well as develop nursing practice interven- tions to close the gaps indicated in this new model. For example, nurse executives and managers may devel- op appropriate outcome measures to monitor the closeness of each corre- sponding gap (e.g., patient satisfac- tion measures; patient-centered out- comes such as survival, function, symptoms, and health-related quali- ty 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-cen-

tered 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 emo- tional needs that otherwise may be missed or overlooked. Future research that captures the degrees of similarity or difference between patient per- spectives 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 serv-

ice 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 bet- ter 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, poli- cies relevant to the characteristics of the clinical settings can be estab- lished to promote patient-centered care. McClelland (2010) claimed understanding the patient perspec- tive of health care services is piv- otal to the development of patient- centered, quality services. The shift of health care from a clinician-cen- tric 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 inter- actions with patients (Epstein et al., 2010).

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(2009). National healthcare quality report. Retrieved from http://ahrq.gov/ qual/qrdr09.htm

Andrews, S.M. (2009). Patient family-centered care in ambulatory surgery setting. Journal of PeriAnesthesia Nursing, 24(4), 244-246. doi:10.1016/j.jopan. 2009.05.100

Berwick, D. (2009). What ‘patient-centered’ should mean: Confessions of an extrem- ist. Health Affairs, 28(4), w555-w565.

Charmel, P.A., & Frampton, S.B. (2008). Building the business case for patient- centered care. Healthcare Financial Management, 62(3), 80-85.

DiGioia, A., III, Lorenz, H., Greenhouse, P.K., Bertoty, D.A., & Rocks, S.D. (2010). A patient-centered model to improve met- rics without cost increase: Viewing all care through the eyes of patients and families. Journal of Nursing Admini – stration, 40(12), 540-546.

Epstein, R.M., & Street, R.L. (2011). The val- ues and value of patient-centered care. Annals of Family Medicine, 9(2), 100- 103.

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), 1489-1495.

Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T.L. (1993). Introduction:

Service Quality and Patient-Centered Care

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 con-

tact 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 www.amsn.org/library

2. Evaluations must be completed online by December 31, 2015. Upon comple- tion 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 interest- ed in service quality and patient-centered care. After studying the information pre- sented 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 clar- ify 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 5387. 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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Groene, O. (2011). Patient centeredness and quality improvement efforts in hospitals: Rationale, measurement, implementa- tion. International Journal for Quality in Health Care, 23(5), 531-537.

Hobbs, J.L. (2009). A dimensional analysis of patient-centered care. Nursing Re – search, 58(1), 52-62.

Hunt, M.R. (2009). Patient-centered care and cultural practices: Process and criteria for evaluating adaptations of norms and standards in health care institutions. HEC Forum, 21(4), 327-339.

Institute of Medicine (IOM). (2001a). Six aims for improvement. In Crossing the quality chasm (pp. 41-61). Washington, DC: National Academy Press.

Institute of Medicine (IOM). (2001b). Executive summary. In M.P. Hurtado, E.K. Swift, & J.M. Corrigan (Eds.), Envisioning the national healthcare qual- ity report (pp. 1-18). Washington, DC: National Academy Press. Retrieved from http://books.nap.edu/catalog.php? record_id=10073

Johnson, B., Abraham, M., Conway, J., Simmons, L., Edgman-Levitan, S., Sodomka, P., … Ford, D. (2008). Partnering with patients and families to design a patient and family centered healthcare system. Bethesda, MD: Institute of Family Centered Care.

Levinson, W., Lesser, C.S., & Epstein, R.M. (2010). Developing physician communi- cation skills for patient-centered care. Health Affairs, 29(7), 1310-1318.

Luxford, K., Safran, D.G., & Delbanco, T. (2011). Promoting patient-centered care: A qualitative study of facilitators and bar- riers in healthcare organizations with a reputation for improving the patient expe- rience. International Journal for Quality in Health Care, 23(5), 510-515.

McClelland, H. (2010). Service improvement and patient experience. International Emergency Nursing, 18(4), 175-176.

McCormack, B., Karlsson, B., Dewing, J., & Lerdal, A. (2010). Exploring person-cen- teredness: A qualitative meta-synthesis of four studies. Scandinavian Journal of Caring Sciences, 24(3), 620-634.

McCormack, B., Manley, K., & Walsh, L. (2008). Person-centered systems and processes. In K. Manley, B. McCormack, & V. Wilson V (Eds), International prac- tice development in nursing and health- care (pp. 17-41). Oxford, England: Blackwell Publishing.

Montgomery, K., & Little, M. (2011). Enriching patient-centered care in serious illness: A focus on patients’ experiences of agency. The Milbank Quarterly, 89(3), 381-398.

Morgan, S.S., & Yoder, L. (2011). A concept analysis of person-centered care. Jour – nal of Holistic Nursing. doi:10.1177/ 0898010111412189

Parasuraman, A., Zeithaml, V., & Leonard, B. (1985). A conceptual model of service quality and its implications for further research. Journal of Marketing, 49(4), 41-50.

Patient-Centered Outcomes Research. (2013). Patient-centered outcomes re – search. Retrieved from http://www.pcori. org/research-we-support/pcor/

Scott, A. (2010). Quality lessons. Patient- centered care vital to outcomes, cost. Modern Healthcare, 40(46), 22.

The Joint Commission. (2010). Advancing effective communication, cultural compe- tence, and patient- and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: Author.

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