Person-centred care and measurement: The more one sees, the better one knows where to look.

Abstract

Determining the quality of a health system is a complex and challenging endeavour. The variety of perspectives needed to determine quality means that increasingly complex measurement frameworks are often employed. Providing the best possible health care has always been a priority for health system leaders, individual professions and individual professionals. But the importance and significance of measuring quality has increased since the evolution of quality-improvement methodologies for health-care quality standardisation in the 1990s. Audit and feedback systems evolved into quality-control methods with the increased industrialisation of health systems. As the patient voice became increasingly important, with the rise in advocacy groups and patient-representative organisations, the focus on controlling the quality of services through a managerialist ideology was challenged. Broader, more inclusive, approaches to quality were embraced. Quality-improvement methodologies aim to adopt an inclusive approach to ongoing quality enhancement, ensuring that services are continuously developed and improved. This evolutionary context is important when considering the measurement methods that dominate health systems. To some extent, it could be argued that while health care cultures have shifted their focus from one of control to improvement, approaches to measurement continue to privilege standardised, quantifiable data and information that can be used for quality standardisation. Despite more than 30 years of developments in patient-centred and then person-centred care, the focus on quantitative measurement has continued to dominate, even though it does little to inform stakeholders about the person-centredness of a health system. The person-centred care movement is not new in health care and there are some who would argue that other approaches, such as relationship-centred care, have superseded person-centredness. The lack of concept clarification and theory-driven methodologies by researchers in the field has done little to help this situation. This failure has also been reflected in approaches to measurement and evaluation. The paper by Cribb in this issue of the Journal of Health Services Research & Policy highlights this problem precisely, that is, the interchangeable use of patientand person-centred care and a lack of definition of either! In 2017, Dewing and McCormack highlighted the problem of researchers evaluating person-centredness without defining what they mean. After more than 20 years of research in this field, including the publication of concepts, models, theories and frameworks, it is unacceptable not to present a clear definition as a basis of an evaluation methodology. This lack of precision carries on through the focus on person-centred care as an isolated activity associated with providing care to patients – as if somehow person-centred care practices can be isolated from the context in which they exist. Previously, Laird et al. argued that the majority of patients experience ‘person-centred moments’ only and few experience ‘person-centred care’. Their research highlighted the inconsistencies that exist in and between different practitioners/staff in providing care, influenced by a variety of cultural and contextual factors in different care settings. Key issues highlighted include how work is organised, what practice is prioritised and privileged, leadership practices and multi-disciplinary decision-making. Evaluating person-centred care as a specific intervention or group of interventions, without understanding the impact of these cultural and contextual factors, does little to inform the quality of a service. Indeed, measuring person-centred care ignores a central tenet of this approach, that is, the provision of person-centred care is predicated on the existence of a person-centred culture – a culture that is developed and sustained by person-centred staff and supported by person-centred organisational values and systems. Person-centred care can only happen if there are cultures in place in care settings that enable staff to experience person-centredness and work in a person-centred way. With a focus on culture, Dewing et al. adopted the following definition of person-centredness: