The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital

Abstract

Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an “environmental frame.” The resulting Venn diagram includes overlapping circles for 1)patient/family, 2)provider/team, and 3)medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then re-articulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each “circle” and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.

Key components of shared decision making models: a systematic review

“…All authors referred to the broader SDM literature including SDM-models, although existing SDM-models may not have explicitly formed the origin of their own model. Twenty-one SDM-models were explicitly based on one or more of the SDM-models included in this review 5 15 17 18 20 22 23 25–29 31 32 38 39 43 45–47 51Online supplementy appendix B shows that especially the models of Charles,17 49 Towle,16 Elwyn,14 29 and Makoul5 informed other SDM-models.…”

“…Twelve SDM-models were generic (ie, specified as such or no healthcare setting specified) 5 13–23. The other 28 SDM-models had been developed for a particular healthcare setting or patient group, namely primary care,24–29 screening,30 31 the inpatient setting,32 paediatrics,33–35 mental healthcare,36–38 emergency care,39 40 oncology care,41 42 chronic care,43 44 nursing care,45 physical therapy,46 older patients,47 48 serious illness,49 50 or diabetes 51…”

“…Thirteen models were focused more or less explicitly on treatment decision making,14 17 28 34 36 38 41–43 46 48 49 51 two on screening,30 31 one on test and treatment decision making,50 one on disease prioritisation and treatment,44 one on goals and actions,27 and one on decisions regarding diagnostic testing, treatment, or follow-up 19. For the other 21 models, the authors did not explicitly state the type of decision 5 13 15 16 18 20–26 29 32 33 35 37 39 40 45 47…”

“…Online supplementy appendix B shows that especially the models of Charles,17 49 Towle,16 Elwyn,14 29 and Makoul5 informed other SDM-models. Two-thirds of the models (26/40) were further or solely based on analytical thinking of the authors (ie, no data were collected in patients and/or healthcare professionals with the purpose to inform the model); of note, empirical data collected for other purposes may have informed these models 5 14 15 17 19 21 22 24 28 30–35 38–41 43–46 48–50. The development of the other models (14/40) was informed by empirical data gathered with the purpose to inform the model 13 16 18 20 23 25–27 29 36 37 42 47 51.…”

“…Three models identified the patient and several healthcare professionals as actors,25 26 30 three models identified the underaged patient, the parent, and the healthcare professional as actors 33 35 38. Ten models identified solely the healthcare professional as actor 14 21 23 24 29 32 37 39–41…”