Can patient centred care plus shared decision making equal lower costs?BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5900 (Published 15 October 2019) Cite this as: BMJ 2019;367:l5900
On a late summer’s day, bees are buzzing near Bernhoven Hospital, attracted by the flowers near the entrance. Bright green bikes are parked next to the revolving door—patients and their friends and families are free to use them to explore Maashorst, the nearby nature reserve. The hospital, situated in the southern part of the Netherlands, is clearly living up to its own slogan: Bernhoven Natural.
The most unique selling point of Bernhoven, however, is not about nature. In fact, it is not even visible from the outside. You see it as you enter the hospital—a poster that says, “Better healthcare starts with a good conversation—in this hospital, we decide together.” This is what makes Bernhoven famous among hospitals around the globe: its hospital-wide, patient centred approach.
Bernhoven is situated near Uden, a town in the province of Noord-Brabant. One of around 85 hospitals in the country, it is medium sized with 380 beds, 18 000 admissions per year, and 2250 employees (including 140 medical specialists).
Like most Dutch hospitals during the past few decades, Bernhoven has struggled with increasing costs. In order to avoid a future scenario in which more efficiency would lead to less time for patients, the hospital decided to cut costs another way. In 2014, Bernhoven began its five year strategy Better care by less care, in which unnecessary consultations, intakes, and operations are avoided as much as possible.
The numbers are good
The first results were promising: overall there was a 17% decline in healthcare costs between 2014 and 2018. The number of patients ending up in expensive hospital beds has decreased by approximately 15%. Two thirds of the patients who come to the emergency department can go home within three hours, and of those admitted to the hospital more than 80% will have a diagnosis and treatment plan within 48 hours.1
“Of course, more and more healthcare institutions are emphasising the importance of patient-doctor interaction,” Wink de Boer, gastroenterologist at Bernhoven, tells The BMJ. “What makes Bernhoven a special case is the hospital-wide approach to implementation.
“The way I see it, many hospitals function as a shopping mall—if you have heart problems, you go to the cardiovascular unit; if you have brain damage you go to neurological intensive care; if you have musculoskeletal problems, you go to the orthopaedic ward,” he says. “But there is too little communication between those units, while there are many patients who suffer from various diseases at the same time, especially with increasing longevity.”
De Boer was medical director of Bernhoven until the summer of 2018, and one of the initiators of the transformation. “It started in 2003, with a merger between two hospitals into Bernhoven. The new building was ready in 2013. It felt like a natural moment to reinvent our purpose—what kind of working environment did we want to create?”
The importance of patient centredness
That it should be patient centred was clear. To reach this goal, De Boer and his colleagues decided to implement more than just new healthcare strategies. “By completely changing the way the hospital was organised, we wanted to create an atmosphere in which a patient centred approach would thrive.” They decided that doctors should participate in the board of directors, in order to enhance understanding and cooperation between management and medical staff; that the hospital should be doctor and patient owned, by means of hospital revenue bonds; and that doctors should be employees with a fixed salary and not “physician entrepreneurs,” as is common in the Netherlands, where payment is based on the number of treatments and operations.
“We didn’t tell the doctors they needed to change to a more patient centred approach,” says De Boer. “We just created the working conditions in which that would be possible. For example, in the emergency department we make sure there are always senior medical specialists available to speed up decision making. That’s quite costly, but patients spend less time in the hospital, so in the end we’re actually saving money.”
Since 2014, the total number of operations has been reduced by 26%, and the nursing time by 28%, Mieke Klerkx-Harkema, programme manager for innovation and strategy, tells The BMJ.
De Boer says, “Going from production oriented care to patient centred care requires a different mindset. You can’t redecorate one of the units in the ‘shopping mall’ and leave the others the same. It is a paradigm shift in which money is no longer an important incentive in decision making.”
In order to come up with new working methods, a weekly focus group was organised in which doctors from Bernhoven could brainstorm together with community GPs and healthcare insurers about new initiatives that could contribute to the patient centred approach. The focus group participants came up with 100 initiatives ranging from an optometry screening centre to having dermatologist consultants in GP surgeries. De Boer says, “At Bernhoven, 70% of patients referred for eye care are seen by an optometrist instead of an ophthalmologist. In that way, a consultation costs €40 (£36; $44) instead of €225, and waiting lists have decreased.”
Letting patients decide
One of the other initiatives is shared decision making (SDM), says Klerkx-Harkema. As programme manager, she is closely involved in implementing this working method in Bernhoven. “SDM is about enhancing awareness of both doctors and patients. We try to stimulate the conversation by encouraging the patient to ask questions like ‘what are my options?’ and ‘what are the possible benefits and risks of those options?’ We also offer decision aids to patients: digital forms that help them decide which option they want to choose, in consultation with their practitioner.”2
In total, more than 25 decision aids are up and running, ranging from topics like gallstone disease to breast cancer and hip arthrosis. “More time for decision making prevents unnecessary surgery and has led to a 13% decline in the rate for gall bladder surgery,”3 says Klerkx-Harkema. “It became apparent that well informed patients often choose quality of life above being operated on at all costs and extending their life span to the maximum.”
Bernhoven is not the only hospital in the Netherlands to implement SDM, but it can be considered a frontrunner because of its hospital-wide approach. “At first, people were a bit sceptical,” says Klerkx-Harkema. “How did we know that people didn’t go to other hospitals instead for their operations, for example. But researchers from Radboud University have studied our working method, and it turns out that there is no such thing as a ‘patient leak’ going on at Bernhoven.”
De Boer nods. “In my opinion, the future of healthcare will also be about cooperation between hospitals. Ideally, there will be more generalist physicians, and less ‘super specialists.’” Specialists may have to travel more between hospitals, and not every hospital will have a brand new computed tomography scanner, he says. “However, this will enhance the communication and cooperation between healthcare institutions.”
He looks at his watch and excuses himself: duty calls. “Time to go to the ward again,” he says, smiling. “I never want to let the patients wait.”
Leon Oosthoek, 58, was diagnosed with rheumatoid arthritis in 2015
Soon after I started therapy, my rheumatologist at Bernhoven introduced me to ReumaNet, an online self management platform used by several hospitals across the country.
Instead of a consultation every three months, I can fill out online questionnaires and check my own results in the graphs. If there’s a weird outlier, I can chat online with the hospital—my rheumatologist and my GP both have access to my results—and if something is wrong, I can make an appointment on the spot.
If everything is fine, I just go to the hospital once a year for check-up. I don’t consider myself a chronic patient at all.
Angelo Schuurmans, 34, was diagnosed with type 1 diabetes in 2000
I was diagnosed in 2000 when I was 15 years old and at that time I stayed in hospital for a month.
Sometimes my life is quite hectic. I work as an actor and I run a foundation that helps refugees integrating in society. In the past, I needed to go to the hospital three or four times a year for a check-up. Nowadays, I can upload data about my health and send it by email.
Thanks to self management, I feel independent. At the same time, they really take personal care of me. They’re my safety net.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare