BackgroundHealthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs.MethodsWe conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains.ResultsSites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges.ConclusionsTransforming healthcare systems to focus on patient-centered care and better serve the “whole” patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

BackgroundPatient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing.ObjectiveTo examine how hospital employees conceptualize patient‐centred care.Research DesignWe conducted qualitative interviews about patient‐centred care during site four visits, from January to April 2013.SubjectsWe interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient‐centred care transformation.MeasuresData were analysed using grounded thematic analysis. Findings were then mapped to established patient‐centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient‐as‐person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor‐as‐person.ResultsWe identified three distinct conceptualizations: (i) those that were well aligned with established patient‐centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient‐centred care into the organizational culture, encompassing the entire patient‐experience; and (iii) still others that were poorly aligned with patient‐centred care constructs, reflecting more traditional patient care practices.ConclusionsPatient‐centred care ideals have permeated into healthcare systems. Additionally, patient‐centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient‐centred care so broadly, it encompasses on‐going hospital initiatives, while others consider patient‐centred care as inherent to specific positions. These latter conceptualizations risk undermining patient‐centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

Designing interventions to improve patients' hypertension self-management requires consideration of patients' explanatory models and their daily-lived experience. We propose a new conceptual model - the dynamic model of hypertension self-management behavior - which incorporates these key elements of patients' experiences.

Participants did not experience hypertension as a discreet clinical condition; rather, they self-managed hypertension concurrently with other conditions, leading to a breakdown in hypertension self-management. We provide strategies to address each of the four barriers to better equip providers in addressing their clinically salient concerns.