Essay: Grant Making With An Impact: The Picker/Commonwealth Patient-Centered Care Program
1998; Project HOPE; Volume: 17; Issue: 1 Linguagem: Inglês
10.1377/hlthaff.17.1.236
ISSN2694-233X
AutoresDennis F. Beatrice, Cindy Parks Thomas, Brian Biles,
Tópico(s)Healthcare Systems and Technology
ResumoGrantWatch Health AffairsVol. 17, No. 1 Essay: Grant Making With An Impact: The Picker/Commonwealth Patient-Centered Care ProgramDennis F. Beatrice, Cindy Parks Thomas, and Brian Biles AffiliationsDennis Beatrice is management professor and director of policy at the Institute for Health Policy, Heller School, Brandeis University, in Waltham, Massachusetts. Cindy Thomas is a research associate and doctoral candidate at the Heller School. Brian Biles, a physician, is senior vice-president of the Commonwealth Fund.PUBLISHED:January/February 1998Free Accesshttps://doi.org/10.1377/hlthaff.17.1.236AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPatient-centered careCommunicationsGrantsHealth care providersGrant makingPatient testingMediaSystems of careManaged careHospital careHealth philanthropy faces the basic challenge of how best to use limited resources to have a positive effect on policy, practice, or institutions in a trillion-dollar health care system. Insightful, well-crafted grants, coupled with effective communication of results, are the best way for a foundation to increase its impact. Evaluation also is essential to guide ongoing and future work. The Picker-Commonwealth Patient-Centered Care Program was an important initiative of the Commonwealth Fund that produced groundbreaking research in its area and serves as an illustration of how a foundation can move a new field forward.The Patient-Centered Care Program was a set of eleven interrelated projects that were intended to enhance communication between patients and their health care providers for the purpose of improving health care. The Commonwealth Fund granted hospitals, health care organizations, and physician groups funds with which to develop and implement surveys of patients to elicit their perceptions of the quality of care they received. The program sought to explore how patients experience care in hospitals and other sites; what constraints and opportunities providers face in practicing patient-centered care; what practices work best in given institutional settings; and how providers and organizations can implement changes to enhance patient-centered care.The Commonwealth Fund made grants totaling $9.7 million under the program between 1987 and 1995. Of this amount, $5.8 million supported the eleven projects, and $3.9 million was for program administration, the initial survey of patient-centered care, and communicating the results of the program through conferences, books, and videos.This essay uses the Patient-Centered Care Program as a case study to derive lessons and suggest ways to sharpen foundation programs. We identify lessons in four areas that are important to successful grant making: choosing a program area; designing and implementing the program; measuring accomplishments; and communicating results. To accomplish this, we reviewed program materials and conducted seventeen interviews with Commonwealth Fund staff, project directors, and informed observers of the program.BackgroundIn July 1986 the James Picker Foundation transferred its assets to the Commonwealth Fund to make support available to institutions to pursue the Picker Foundation's interest in furthering humane medical care. Harvey Picker, the Picker Foundation's donor, believed strongly in increasing the health care system's capacity to respond to patients as persons, not as "imbeciles or inventory." He wanted to change the fabric of care instead of tinkering at the margins, and he wanted to do it as a friend of the court, not by attacking the health professions. In response, the Commonwealth Fund chose to use the Picker Foundation's assets to increase patients' participation in their medical care. Margaret Mahoney—then president of the Commonwealth Fund—was instrumental in bringing the Picker Foundation's resources into the fund, making possible the Picker/Commonwealth Patient-Centered Care Program. Through a grant to Beth Israel Hospital in Boston, the program initiated a framework for inquiring about patients' perceptions of their care. A patient survey was developed, pilot tested, and fielded in conjunction with Louis Harris and Associates. 1 Problem areas identified as a result of the survey included a lack of a relationship of trust with any hospital staff member other than the treating physician; inadequate communication between patient and staff, leading to specific problems such as less-than-optimal pain management; and patients' not being adequately informed regarding the details of their care. In addition to fielding the survey, the project team conducted site visits at a number of hospitals that were identified through literature review or the survey as having highly effective programs, to document specific practices that lead to patient-centered care. The results of the program were reported in Health Affairs , a national conference was held to report results to the industry, and articles highlighting the program appeared in professional and trade publications. 2A series of grants were made to extend the program to the practices of nurses in hospitals, physicians in office practice, and directors of teaching and public hospitals. In each case, the grantee organization worked with Commonwealth staff as well as a program office at Beth Israel Hospital to adapt, test, and field the survey instrument. Projects funded in the following years included retooling the instrument for use in managed care settings, group practices, community/migrant health centers, and New York City public hospitals. Grantees included the Rush-Presbyterian-St. Luke's Medical Center, the American College of Physicians, and the National Association of Community Health Centers.The Commonwealth Fund also decided to help establish a freestanding organization designed to institutionalize the principles of patient-centered care. During the final years of the program, and following a market study of the concept, a business plan was developed for the creation of the not-for-profit Picker Institute, dedicated to furthering patient-centered care. The Picker Institute establishes relationships with hospitals and other health care providers, surveys patients, assists providers in using the information to become more responsive to patients, and conducts research in the field.Choosing A Program Area■ TIMELINESSThe Patient-Centered Care Program was well timed to address changes in the health care environment. Historically, patients' concerns and reactions had not been a major focus of health care administrators. But as the program was gearing up, important changes were under way in health care. The growth of managed care and aggressive efforts by purchasers to get volume discounts squeezed hospitals financially, making competition for patients more intense. In this environment, patients and purchasers became more interested in looking at the value of services, not just price comparisons. The Patient-Centered Care Program "caught a wave"—the growth of competition among health care organizations and systems and the need for areas of comparative advantage that would help providers to attract patients.Although there was an element of serendipity in these developments, luck is the residue of skill. An important part of the art of grant making is being ahead of the curve in identifying trends. Effective grant making requires a compelling initial insight (such as the fact that patients lacked sufficient input on their care, and that this lack of input would become even more important in an increasingly competitive health care environment). Successful grant making also must be well executed and focused on a timely, relevant topic.Great timing need not be an accident. Instead, foundation staff must function as "spotter pilots," seeing what is ahead and planning for it. Put another way, foundations should pick program areas that address new or growing problems in the health care system. A powerful strategy is to provide a technique (such as patient-centered care) to those who must respond to problems generated by change (here, increased competition and growth of managed care). This connection of program idea to environment is critical; the alternative is well-intentioned foundation programs that lack an audience and that are un likely to have an impact on policy or practice."Foundations may find that moving from a general blueprint to a functioning foundation program can be difficult."■ FROM ARTICULATION TO IMPLEMENTATIONThe program illustrates the importance of an initial program insight, followed by solid program development work to flesh out the concept and strong leadership to implement the effort. The program benefited from the fact that Commonwealth Fund staff, leading thinkers in the field (who became grantees and managers of the initiative), and Harvey Picker all shared perspectives and worked together to move from articulating a vision to building and implementing a program. Thomas Moloney, at the Commonwealth Fund, collaborated with Harvey Picker and Thomas Delbanco, at Beth Israel Hospital, to frame the effort. Delbanco provided medical input and helped to move the program from concept to reality, working with Paul Cleary of Harvard Medical School and Susan Edgman-Levitan, the project director through the grant phase and now president of the Picker Institute.This collaboration illustrates a tenet of the best foundation work: Values and vision must come first and then be carefully thought through and implemented. This combination is important. A series of individual grants that have a clearly defined overarching goal is the strongest basis for a program initiative.■ TENSION AMONG GOALSIn the Patient-Centered Care Program, a largely unstated truce existed among several goals: (1) to pursue a research agenda by stating hypotheses related to patient-centered care and then testing them; (2) to develop a product to measure patients' responses to their care; and (3) to fuel a patient-centered care movement by seeding the idea broadly and making it a part of the regular dialogue on quality in health care. Several grantees believed that the program was ambiguous about which of these goals was paramount. The program tended to encourage behavior that was more patient-friendly and to develop and disseminate tools to measure patients' responses.It is not a question of pursuing the "right" goal; various goals could be valid and would have supporters. The need is to articulate a choice of goals up front. In this way, foundation staff can shape individual grants to advance the goals and set out program markers to gauge accomplishments. Criteria for the choice of goals will of course depend on the purposes of the particular initiative.A clear and early statement of goals also ensures a good match as the foundation chooses people to run the program and its individual projects. Early choices of grantees and key program managers may determine the shape and course of the program, so it is important that foundation staff make these decisions with a clear sense of where they want the program to go. In his summary remarks from the July 1995 Commonwealth Fund trustees' meeting, John Evans captured the front-end challenge that foundations often face as they begin new programs: One of the most labor-intensive and difficult issues is getting the question right as the basis for a program of support. The process is staff-intensive and requires real intellectual leadership within the foundation and in collaboration with the best possible brains outside. Unless one gets the question right, it is usually difficult to stick with the problem over an extended period and to avoid disruption of grantees due to changing messages.The timing of an initiative, linking broad vision with a plan to implement the program, and resolving (or at least clarifying) tensions among goals are all elements of "getting the question right." Many subsequent features of the program and its ultimate success hinge in large part on making these strategic decisions up front.Design And Implementation Richard Nathan has said that implementation is the short suit of American politics and that we have the nasty habit of promising the moon but planning as if we were installing a light bulb. 3 Foundations also may find that moving from a general blueprint to a functioning foundation program can be the most difficult aspect of philanthropy. The Patient-Centered Care Program suggests several lessons about the design and implementation process. ■ SUFFICIENT RESOURCESThe Commonwealth Fund committed sufficient resources and maintained the effort long enough to give patient-centered care a fair test. The initiative and its projects spanned nine years and represented an investment of nearly $10 million. This critical mass of investment, coupled with support for the Picker Institute, provided ample opportunity to institutionalize the work of the program. Each project was funded for a number of years, which allowed each grantee involved to adequately consider the role of patient-centered care in the grantee's setting; take ownership of it; and develop, test, and field the instrument to measure patients' responses to their care. The sustained commitment and enthusiasm of the program administration group and foundation staff provided a sense of continuity and credibility. Investing enough in a target area is necessary; programs an inch deep and a mile wide will not have the desired impact. Foundations may find it difficult to maintain this focus and may need to fight donor fatigue in order to provide the continuity needed for a major initiative, especially one like the Patient-Centered Care Program, which had the difficult goal of moving a new field forward rather than the more straightforward purpose of testing a model in a single location or supporting a research project.■ BROAD INSTITUTIONAL INVOLVEMENTThe Commonwealth Fund saw the advantage of broad institutional and professional involvement in the Patient-Centered Care Program. By involving hospitals, physicians, nurses, health maintenance organizations (HMOs), and community health centers in the effort, the program gave a range of groups the opportunity to struggle with the concept, take ownership, and act as ambassadors for the idea with their own colleagues and associations. It is sound foundation practice to extend major initiatives to a number of possible professional and institutional audiences. Grafting an idea more broadly increases the chance of its taking hold and growing in a particular environment. Moreover, just as foundations themselves should not be isolated in their efforts, their programs also should not be isolated in a narrow slice of the health care system. Such a limitation makes it harder to explore various settings with a program to see where it works best and to branch out and survive after the foundation's funding stops.■ MANAGEMENT ISSUESThe Patient-Centered Care Program struggled with a range of management issues common to all substantial foundation efforts. The program's handling of these issues illustrated the advantages and disadvantages of different management decisions. Here are some examples.Leadership. The program exhibited a tension sometimes seen in foundation work between choosing established leaders to serve as grant-ees and seeking new talent. With limited exceptions (for example, the HMO providers), the program chose to support persons and organizations well known to the Commonwealth Fund. This has the obvious advantage of minimizing surprises. But it may make sense in a multimillion-dollar, multiyear effort to use a request for proposals (RFP) for at least a portion of the work. In this way, a foundation can combine the advantages of dealing with persons who have a proven track record, identifying and developing new talent, and building a cadre of interested persons. Follow-up efforts. As the Patient-Centered Care Program matured, more provider groups and institutions (and countries) were targeted, and a second survey was commissioned. This growth and development is a healthy feature of a foundation program. Encouraging growth by building in checkpoints to examine emerging opportunities and the latitude for foundation, program, and grantee staff to propose enhancements and corrections are worthwhile design features. Much foundation activity is directed at developing the next generation of initiatives rather than strengthening and extending existing ones. The "tyranny of the board book"—the need to be creative three or four times a year when new proposals are brought to a foundation's board of trustees for consideration—should not be allowed to distract staff from developing logical next steps in existing programs. Yearly funding cycle. Administrative support for the program was provided as a series of one-year grants. Although this created work and some anxiety about continued funding for the Beth Israel Hospital professionals who staffed the program office, it also kept the program flexible and allowed it to make mid-course corrections. Yearly work plans from the project office at Beth Israel proved to be a useful discipline and provided a vehicle for Commonwealth Fund staff to stay apprised of program developments and to intervene as they saw fit. The work plans also provided grantees with the opportunity to reflect on progress and accomplishments and to propose ways to build on the work already done. Dedicated staff. Susan Edgman-Levitan provided excellent leadership for the Patient-Centered Care Program. We believe that it is critical to the success of a foundation program to designate a person who focuses on the program consistently and who has its well-being at the top of his or her agenda. Using a set of persons who give a foundation program only part of their time and attention is a recipe for implementation failure. Measuring Accomplishments "Success" and "accomplishments" are relative terms. Therefore, the first job in assessing the Patient-Centered Care Program, or any foundation initiative, is to define success . The next, closely linked step is to determine how to measure what the foundation has done. There is no shortage of factors to consider. A foundation can evaluate progress by examining a defined aspect of a program (how many persons were served, was policy changed in response to a foundation-sponsored analysis or program); by considering whether institutions changed their behavior as a result of the initiative; by determining how many policy or institutional insiders know about the effort; by counting press clippings; by adding up funds invested by other foundations in the program or in related programs in the same area; by assessing whether public programs incorporated the foundation's idea; or by making a judgment about whether the program shifted the debate on the issue being addressed. After deciding what constitutes success and how to measure it, a foundation must determine if the accomplishments were sufficient to justify the funds invested. In this regard, one can place the burden on program developers and managers to show visible, tangible changes in policies, practice, institutions, or professions. If that is determined to be an unrealistic standard, evaluators can look for more qualitative evidence that the idea has been diffused and the field in which the program operated has moved forward. The Patient-Centered Care Program had limited success in meeting the standard based on having grantees show specific, quantifiable evidence of impact. Nevertheless, the program has much to recommend it and much to suggest about foundation efforts elsewhere.■ THE CONCEPT OF PATIENT-CENTERED CAREOne observer noted that the program was an early step in the evolution of patient-centered care, the "Model T stage of a new discipline." In this view, the program increased the credibility of patient-generated data as a measure of quality and developed and tested mechanisms to survey patients and feed the results back to providers. Although not a strict research project, this initiative did move the state of the art forward, notably in the areas of measuring patient satisfaction and providing a practical tool for industry use.It need not be a shortcoming that the program did not serve as a definitive lab test to prove the value of patient-centered care; rather, the program represented an early point on the continuum along which new ideas grow and move into the mainstream. Foundations sometimes become involved in an area only after an idea or approach is proved, or at least widely accepted. They then add value by extending the idea to other organizations or further developing one aspect of the intervention. In contrast, thework of the Patient- Centered Care Program was more developmental, approximating a research and development effort. This illustrates an advantage enjoyed by foundations: They can pursue higher-risk, higher-payoff efforts that government and the private sector oftenwill not undertake.■ ADVANCING VALUE PURCHASINGThe program had other effects as well. It provided a boost to the "value purchasing" movement, in which buyers of health care look at both cost and value. Since plans may not be able to differentiate themselves on the basis of price alone, patient-centered information provides a tool for providers seeking to present other advantages to purchasers. While skeptics might say that the value of patient-centered care to hospitals is in marketing to purchasers, it also would be fair to note that anything that helps purchasers to make prudent decisions is worthwhile.■ FACILITATING CHANGEThe real impediment to institutional change may not be lack of knowledge; lack of courage, commitment, and vision may be the true limiting factors. The commitment and enthusiasm of foundation and program staff may be as effective as an elegant research design and findings in breaking through these barriers. A foundation program can be a catalyst for institutions to act, as well as a source of information to guide the action.■ SHAPING SUCCESSOR PROGRAMSMoreover, an important contribution of a foundation effort can be to shape its successor programs. The Patient-Centered Care Program engendered a new set of projects at the Commonwealth Fund to protect quality of care in the face of health system changes. It is an important indicator of success if a program is recognized as the leading edge of continued foundation involvement in an area.The Patient-Centered Care Program illustrates that accomplishments come in many forms, and that the standards to be applied and ways of measuring progress should be specified early, so a program does not need to retrospectively search for anecdotal evidence to justify itself. Contributions discovered later should be pleasant surprises, not serve as the basis of assessment.■ AN EXIT STRATEGYOne major accomplishment of the Patient-Centered Care Program was not in the field of patient-centered care but in grant making, since the Picker Institute exemplifies an innovative exit strategy for foundations. The problem of how to end a long-term grant commitment always plagues foundations. It is troubling to see a longstanding initiative just stop, but there must be limits to the scope and duration of foundation support. The Picker Institute is an example of a way out of this dilemma. Begun in 1994 and seeded with the last administrative grant and an interest-free loan from the Commonwealth Fund as well as a grant and loan from Beth Israel Hospital, the institute has taken the program's techniques and, through a freestanding nonprofit organization, brought them to interested hospitals. The Picker Institute now employs more than thirty persons, has $4 million in annual revenue, and is an important player in the quality-of-care movement.Here is how this strategy can work. During the grant period, a program idea and applicable tools and methodologies are developed. An institute, set up with transitional foundation funding, submits the effort to a market test and creates its own dissemination network. If providers find the product useful and express that feeling by purchasing the product, this institute will succeed, and another funding source can replace foundation support. As an exit strategy, setting up an institute is a way for a foundation to leverage its own investment and to continue to meet needs in the field after its direct involvement ends. As such, an institute represents a special attempt to seek to institutionalize foundation programs.Setting up a freestanding institute may be most relevant for large foundation efforts that seek to develop and diffuse a new model or for demonstration programs that could be replicated. For this segment of a foundation's portfolio, the institute approach described here may be an example of how to wind down a foundation commitment while keeping alive the idea that initially galvanized the foundation to act. In general it is likely that program staff would welcome such an opportunity, and they would provide a willing core of institute entrepreneurs. Patient-Centered Care Program staff saw the potential of the Picker Institute, and the Commonwealth Fund and Beth Israel invested in that idea. If more foundations adopt this as an exit strategy from long and expensive grant programs, the Picker Institute could be the program's most enduring legacy.Communicating ResultsThe goal of foundation communications— and of foundation programs—is to move ideas in American life. A communication plan should do this by reaching the right audience with the right message, using the best available communication vehicle. Effective communication amplifies a foundation's voice; foundation studies, demonstration results, and survey results reported in the media reach policymakers with greater force than a project report they receive in the mail. Creative use of the media to point out important facts and trends and to educate the public can get grantees' products off the shelves and into the hands of decisionmakers.There are many different and valid ways of communicating results, but several basic choices must be made before a communication plan can be implemented. First, the audience must be chosen: Is the target audience professionals who work in the program area (generally public- or private-sector decision-makers) or the public, which might change its behavior or exert pressure on the system if it were informed of the foundation's work? These options are not mutually exclusive, but most communication plans emphasize one or the other. Early on, the Patient-Centered Care Program decided to focus on professional audiences. This was largely because of the newness of the experiment measuring patients' experiences with their hospital care and the providers' fears that results could be misunderstood or misinterpreted by the public at large. The target professional audience was reached through a book ( Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care ), a video, articles, a newsletter, and frequent speeches at professional meetings by program staff. This program shows the possible tension between a broader public-or media-oriented communication strategy and one that targets professional audiences. The need for timely and quick release of information to educate the public or inform policy-makers might conflict with the need to have final results for a peer-reviewed journal. These tensions need to be addressed early in the process so that the various communications strategies will fit together. Publications do not equal impact, but they can be an important ingredient in a strategy. Second, responsibility for communication and dissemination must be clearly lodged with either program office staff, grantees, or foundation officers. The job can be shared, but the roles must be clear. A complex program has many possible story lines that must be woven together to produce the strongest statement of the program's purposes and results. This difficult and time-consuming process requires careful orchestration. A good communication plan represents more than a set of unrelated communication activities.Third, communication plans must be built into the fabric of a program, from the beginning of program planning. Effective communication cannot be an afterthought. It requires framing of program questions properly, making a series of design and implementation decisions with communication in mind, and monitoring accomplishments so that the program will have something to say. In communication the pieces of a foundation program—generating the idea, designing and implementing the program, and measuring results—come together.Fourth, a foundation must decide on the appropriate allocation of resources between conducting a program and communicating about it. Obviously, communication cannot displace getting the work done, but it is important to provide adequate support for communication efforts from the beginning.Finally, a foundation must link its grant making to issues that matter to policymakers rather than carving out a niche where important work may be accomplished, but in which public and private decisionmakers have little interest. This is why a communication strategy must reach all the way back to the choice of a topic; communication is made difficult by the failure to choose a program area that connects to real concerns. Foundations also can highlight issues before they become crises that demand policymakers' attention. This early-warning role is significant and forms another possible the
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