120

THE WE-CARE ROADMAP: A FRAMEWORK FOR

IMPLEMENTATION OF PERSON-CENTRED CARE

AND HEALTH PROMOTION IN MEDICAL ORGANIZATIONS

Roman Lewandowski, PhD

University of Social Sciences, Lodz, Poland

Voivodeship Rehabilitation Hospital for Children in Ameryka, Poland

Abstract

As a result of a multinational and multi-industrial scientific project, a framework

supporting implementation of Person-Centred Care (PCC) and Health Promotions

(HP) has been developed. The framework has been called “WE-CARE Roadmap” and

consists from five enablers: technology, quality measures, infrastructure, incentive

systems and contracting strategies. (PCC) and (HP) are promising approaches to

contain costs of healthcare while maintaining and even improving the quality of

medical services. However, the implementation of PCC and HP in many organisations

was unsustainable. They were implemented as projects or interventions but after the

cause of implementation despaired (e.g. the research program was finished) the care

slipped back into ‘usual care’. The WE-CARE Roadmap appears to have a great

potential to become an important implementation tool ensuring PCC and/or HP

sustainable functioning in medical organisations. Initial research has shown the WE-

CARE Roadmap potential. However, the framework is not widely recognised and

needs revision and explanation. The main barrier to more extensive usage of the

framework may be the lack of comprehensive definitions and descriptions of the five

enablers. What each enabler stands for, what it embraces, and what are the

mechanisms through which the five enablers support the implementation of PCC

and/or HP. Thus, the study revises and defines the enablers, as well as deepens the

understanding, how each enabler separately and all of them together, as a system of

enablers, facilitate the implementation of PCC and/or HP. The comprehensive

definition of enablers and analysis of their functioning may help researchers to further

investigate the promising framework and managers use it as a tool for PCC and/or HP

implementation in their organisations.

Keywords: healthcare management, person-centred care, health promotions,

implementation sciences, healthcare quality, cost containment

JEL Codes: M12, D22, I18

Received: August 17, 2020

Revised: September 15, 2020

Accepted: September 19, 2020

Lewandowski, R. (2020), “The WE-CARE Roadmap: A

Framework for Implementation of Person-Centred Care and

Health Promotion in Medical Organizations”, Journal of

Applied Management and Investments, Vol. 9 No. 3, pp.

120-132.

Introduction

From decades developed countries have been suffering from the continuous

growth of healthcare expenditure which has been faster than the GDP growth, what in

the future may jeopardize the ability to provide high-quality healthcare to all citizens.

This problem enforced representatives from 28 European countries of key players from

the pharmaceutical industry, technology sector, academic researchers, and health

professionals, together with patient representatives and politicians to establish the WE-

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CARE project (Grant Agreement 602131) funded by the EU’s Seventh Framework

Programme for Research (FP7). During five workshops in 2014 and a conference in

April 2015, a framework called the WE-CARE Roadmap has been developed (Ekman

et al., 2016). The framework identifies the principal areas where interventions and

policies are required to address the major challenges for healthcare systems. The WE-

CARE Roadmap proposed two major themes Person-Centred Care (PCC) and Health

Promotion (HP) capable of increasing quality and contains costs in healthcare as well

as five critical enablers supporting the implementation of PCC and HP. These enablers

are: technology, quality measures, infrastructure, incentive systems and contracting

strategies (Ekman et al., 2016).

Person-Centred Care (PCC) and Health Promotions (HP) are promising

approaches to contain costs of healthcare while maintaining and even improving the

quality of medical services (Ekman et al., 2012; Fossey et al., 2006; Fors et al., 2016;

Fors et al., 2017). However, the implementation of PCC and HP in many organizations

was not sustainable. They were implemented as projects or interventions but after the

cause of implementation despaired (e.g. the research program was finished) the care

slipped back into ‘usual care’ (Alharbi et al., 2014; Moore et al., 2017). The WE-

CARE Roadmap appears to have a great potential to become an important

implementation tool ensuring PCC and/or HP sustainable functioning in medical

organizations. Some first research has shown the WE-CARE Roadmap potential

(Lloyd et al., 2020), however, the framework is not widely recognized and needs

revision and explanation. The main barrier to more extensive usage of the framework

may be the lack of comprehensive definitions and descriptions of the five enablers.

What each enabler stands for, what it embraces, and what are the mechanisms through

which the five enablers support the implementation of PCC and/or HP.

Thus the paper aims to revise and define the enablers, as well as deepens the

understanding, how each enabler separately and all of them together, as a system of

enablers, facilitate the implementation of PCC and/or HP. The comprehensive

definition of enablers and analysis of their functioning may help researchers to further

investigate the promising framework and managers use it as a tool for PCC and/or HP

implementation in their organizations.

Person-Centred Care and Health Promotion

Person-Centred Care (in Great Britain this concept is usually called Person-

Centred Coordinated Care (P3C)) is an approach getting its popularity in an increasing

number of countries. PCC usually entails three pillars (Britten et al., 2017, p. 408). The

first pillar consists of initiating a partnership by eliciting the patient narrative. The

narrative refers to the sick person’s description of their illness, symptoms and impact

the illness has on their lives. It embraces the person’s functioning in everyday life,

what capabilities they have, including patient’s social network, which could facilitate

treatment and everyday life. The ill person personal account about living with the

illness is in contrast to medical narratives that reflect the biomedical markers and

evidenced-based guidelines for treating the disease. The second pillar covers the

process of shared decision-making concerning treatment plan, based on sick person

capabilities, goals and weaknesses derived from patient narrative and medical

knowledge of the professional. The aim is to work together as a team. Patient, very

often their relatives and professionals, on equal terms – to achieve mutually agreed

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treatment goals. The third pillar encompasses the process of permanent safeguarding

the partnership by documenting the sick person’s narrative and recommendations of a

professional as a jointly agreed treatment plan (Ekman et al., 2011; Lewandowski et

al., 2020).

Health Promotion (HP) is an approach in many cases working in synchronicity

with PCC and is understood here as a vehicle for supporting people to increase control

over their health by influencing individuals and communities mostly through

information while taking into consideration their life context and socioeconomic

conditions (Lloyd et al., 2020).

WE-CARE Roadmap and the Five Enables

The WE-CARE Roadmap was developed to support the implementation of PCC

and/or HP and make it a sustainable solution. However, so far there is very little

research about the framework. Especially there is a lack of comprehensive definitions

of the enablers.

Figure 1. Dimensions and critical enablers of the revised WE-CARE Roadmap

framework

Information system (quality measures)

In the first version of the framework used a narrow definition of the information

system, referring only to the quality measures. This appears an important omission. If

the framework is expected to contain costs it cannot avoid measuring them. Measuring

only quality may lead to increase in costs instead of their containment. The

measurement system should also be an important tool for monitoring the depth to

which the PCC and/or HP was implemented in a medical organization. Because

otherwise, the organization is unable to assess to what extent it works in concordance

with the PCC and/or HP approach. The information system has to measure for

example, how many patients are embraced with PCC and/or HP practices? For how

many patients professionals document patient's narrative? How accurately and how

deeply professionals follow the principles of the PCC approach? Thus, in the revised

framework the enabler ‘quality measures’ is exchanged by a more broad and relevant

category, an ‘information system’.

Accurate measurement of quality of care and costs in a proper span of care and

scope of time is one of the most important condition to achieve improvement in health

care (Porter, 2010). However, proper measurement is extremely difficult since many

patients suffer from multiple medical conditions and are treated by many providers at

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the same time. Quality in healthcare could be measured in three fundamental areas:

structure, processes and outcomes (Donabedian, 1966; Lewandowski and Kowalski,

2008).

Structure embraces all of the factors that create the context in which care is

delivered. This comprises the physical facility such as buildings, IT, medical

equipment; human resources (levels of professional and social skills). The structure is

often the simplest area of quality to observe and measure and it may be the primary

cause of problems identified in processes (Donabedian, 2003).

Processes could be classified as technical procedures including diagnosis and

treatment, but also preventive care, patient education and interpersonal processes

regarding how care is delivered and involvement of patients’ families and members of

their social networks. According to Donabedian (2003), the measurement of processes

is almost equivalent to the measurement of quality of care since processes encompass

all aspects of healthcare delivery. Thus processes are core components which should be

adjusted for sustainable implementation of PCC and/or HP.

Outcome covers all the effects of healthcare on patients or populations, including

improvements of different aspects of patients’ health, experience and especially health-

related quality of life. Outcomes could be seen as the most important indicators of

quality since neither good healthcare structure nor the best processes guarantee an

improvement in patients quality of life. Porter claims that ‘Measuring, reporting, and

comparing outcomes is perhaps the most important step toward unlocking rapid

outcome improvement and making good choices about reducing costs. Outcomes are

the true measures of quality in health care.’ (2010b, p. 1). However, measurement of

outcomes of healthcare intervention is very difficult since identifying relations between

structure, processes and outcomes require large research sample, considering many

personal and socio-environmental factors, and long-term follow-ups - as outcomes may

take considerable time to become observable (Donabedian, 2003; Kowalski et al.,

2015). In order the quality and costs could be used for comparison and learning, they

should be measured for each condition, with the presence of the other conditions used

for risk adjustment (Porter, 2010).

The measurement of the two other areas (structure and processes) without

measuring outcomes tends to distort efforts taken by the professionals and providers.

Measurement of structure could lead to excessive staffing and investment spending.

Measurement of processes may be equal to control of people behaviour that may lead

to micro-management and incremental improvements limiting ground-breaking

innovations. Since innovations cannot be achieved while following rigid behaviour

rules. Only measuring all of these three areas with a substantial focus on measuring

actual outcomes, may allow comparison between today’s care and innovative care.

Improvement in healthcare quality without slowing down the cost increase is

unsustainable. Although management accounting is well developed on a providers’

level there is still a lack of systems capable to track costs of patients’ treatment during

the whole cycle of care including other providers. This means that current cost

measurement is fragmented, reflecting patients’ costs in a particular medical setting, do

not allow to monitor costs of the individual patient through the entire chain of

providers patients are going through and for all their medical conditions

(Lewandowski, 2014). This fragmentation excludes the possibility of comparing costs

against outcomes and thus evaluate what value healthcare is delivering. The only

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comparison of outcomes with costs gives the opportunity to contain spending by

reallocation of patients to more efficient types of services, eradicate of non-value-

adding procedures and better utilize resources (Porter and Teisberg, 2006). Well

established measurement and sophisticated analysis (e.g.: Kriksciuniene et al., 2019a;

Kriksciuniene et al., 2019b) allow learning and improvement of healthcare by the

delivery of adequate information and knowledge to decision makers.

Technology

One of the most important themes of the technology area is an information

technology (IT), which has been the driver for many latest innovations in most

industries. IT does not only allow the information flow regarding Electronic Health

Record (EHR) but also supports the collection of information, application of incentive

systems and contracting strategies.

IT enables the building of information systems containing time series of different

quality measures including periodically repeated Patient Reported Measures (PRMs)

which could be analysed for assessment factors influencing the process behaviour

(Kriksciuniene et al., 2019b) and the cause-effect relationship as well as strengthen the

interdependences among measures (Kriksciuniene et al., 2019a). Wearable electronic

devices could deliver health and activity-related data which together with artificial

intelligence and machine learning could serve in the implementation of PCC and HP

(Giżewski et al., 2008; Ognjanović et al., 2020; Mountford et al., 2016). All these may

lead to innovative ways of increasing quality and containing costs. IT role is to cope

with the communication gap, ensure interactive data flow, which can build new

knowledge and wisdom. Consequently, communication processes become more

efficient in terms of cost reduction and better quality.

Contracting Strategies

Contracting strategies (CS) are methods of financing of medical services at the

macro and meso levels. CS are usually sets of conditions related to structural,

processual and outcome quality measures and other factors (e.g. patient-related risk

factors) constructed by payers to influence the behaviour of healthcare providers

towards groups of patients by the flow of financial resources. In Europe there are

various types of contracts, among others: capitation, case-mix, fee for service, pay-for-

performance, fixed budget, and each of them stimulates different behaviour of

providers. For example, fee for service incentivizes to a greater number of services

(some unnecessary), but capitation and a fixed budget to the opposite direction (under

treatment) (Getzen, 1997).

To counteract these adverse phenomena more complex case-mix systems were

introduced which makes the amount of the payment dependent on patients’ condition

or diagnosis, demographics, such as gender or age, delivered treatment, and length of

hospitalization. However, some providers used case-mix conditions to screen patients

and apply pressure on doctors to admit only the profitable ones (Covaleski et al., 1993;

Lewandowski, 2014). Hence, contracting strategies should reward providers activities

related to PCC and/or HP such as listening to patients’ narrative and identification of

patients personal goals, co-creation of treatment and care plans, improvement in patient

self-efficacy and HP behaviours. All these activities are performed on the interpersonal

level between patients including their social networks and professionals. Thus,

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professionals’ motivation to follow PCC and/or HP approach is a paramount issue.

Thinking about the construction for an environment facilitating PCC and/or HP

implementation on a large scale, such as national or European scale, it has to be

remembered that contracting strategies could significantly affect how managers of

medical providers shape organizational infrastructure, measurement and incentive

systems as well as employed technologies. Although professionals would advocate

PCC and/or HP approach, managers cannot support them against incentives enforced

by contracting strategies implemented by the payers and even cannot buffer

professionals from the incentives produced by contracting strategies since

professionals are the core operational staff delivering medical services and producing

organizational results (Lewandowski, 2013; Lewandowski and Sułkowski, 2018).

Incentive Systems

Incentive system should create motivation for both professionals and patients to

work according to PCC and/or HP principles. Motivation is a fundamental component

of any human activity and as such is a central constituent of medical services delivery

(Goncharuk, 2018; Goncharuk et al., 2020; Franco et al., 2002), personal health and

well-being (Fisher et al., 2003). The problem of incentive systems and motivation

relates to healthcare employees and patients to greater extend that in ‘usual care’, since

PCC and HP by definition require more intense personal involvement in the

relationship during treatment process by both parties.

Although motivation is a complex issue (Ryan and Deci, 2000) it could be

condensate to two main forces: extrinsic or intrinsic (Cerasoli et al., 2014; Flamholtz,

1996). When people behave in a certain way because they are interested in something,

and the behaviour arises from within the individual because an activity itself is

satisfying, in other words, the behaviour is driven by internal rewards - incentives are

intrinsic. When people follow a particular behaviour due to the rewards they expect to

receive from others (praise, pay) - incentives are extrinsic.

Extrinsic rewards require an assessment tool which could compere actual

behaviour with the standard, and reword the behaviour which follows the standard.

Assessment processes could be either subjective, based on supervisor ratings or

objective build on quantitative measures of performance. Objective assessment calls

for accurate and verifiable measures viable to reflect real performance in pivotal areas.

If measures do not meet these requirements might be manipulated, or people could in

good faith achieve good levels of measures but cause the harm to the expected

performance (cf. Malina and Selto, 2001). In the treatment processes employing PCC

and/or HP, these measures have to clearly address PCC and/or HP fundamentals, such

as elicitation of the patient narrative and the depth/strength of the partnership. These

features are very complex to assess using quantitative measures. However even if

quantitative measures would be designed, studies suggest that extrinsic motivators,

especially financial one are positively related to the number of tasks completed but not

with their quality (Ferreira and Otley, 2009). This suggests that incentive systems

should be built on qualitative assessment rather than on a quantitative one. But the

proper qualitative evaluation by superior of employee performance regarding

elicitation of the patient narrative and the depth/strength of the partnership is also not

straight forward.

Taking into account the complexity of the incentive systems based on extrinsic

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motivators in PCC and HP approach and potential risk of their failure the intrinsic

motivation would be the preferable solution. But intrinsic motivation is hardly

dependent on external activity undertaken by organizational managers. The problem

with external incentives is extremely significant since no matter whether the extrinsic

rewards are objective (e.g. based on quantitative measures) or subjective (based on

supervisor assessment) tend to undermine intrinsic motivation for rewarded behaviour

(Deci et al., 1999; Levy et al., 2017). This could be one of the reasons, why sustainable

implementation of PCC and/or HP are not frequent (Alharbi et al., 2014; Moore et al.,

2017)

In this disadvantageous situation, some hope could be given by a human-

focused-design (Sanchez-Gordón et al., 2016). Human-focused-design defines people

intrinsic motivators and gives tools that allow effectively refer to these motivators to

increase professionals’ and patients’ positive experience with performed work, which

may increase their involvement in the treatment process (level of engagement in the

narrative, partnership and documentation). Designing patients and professionals

experience in the context of identifying and referring to their intrinsic motivators could

significantly increase the quality of care without increasing costs (Sanchez-Gordón et

al., 2016). It has been proven that human-focused-design solutions improve the degree

of compliance with medical recommendations and healthy living principles by patients

(Guthrie et al., 2015).

Infrastructure

Infrastructure could be understood very broadly as all physical and nonphysical

environments within which health services are delivered. However, in WE-CARE

Roadmap some important areas are distinguished separately, such as IT, information

systems (quality measures – in the previous version of the Roadmap), incentives and

contracting strategies. Thus, here infrastructure is defined as the all other aspects of the

physical and nonphysical environment such as buildings and medical equipment, a

different type of organizations (e.g.: hospitals, outpatient clinics, charities), internal

structure of these organizations (Lewandowski, 2010) quality and management systems

(Lewandowski, 2009) and relationships between these organizations, professions and

professional associations, medical guidelines and protocols, education and training

infrastructure, policy regulators, accreditation institutions (Kautsch and Lewandowski,

2009), just to mention a few. But the main challenge is how to transform sufficient part

of this infrastructure in such a way that it supports the implementation and sustainable

development of PCC and/or HP.

How the Enables of the WE-CARE Roadmap Works

The five enablers build into the WE-CARE Roadmap are strongly interwoven.

Any changes in one enabler must be synchronized with the others, so as not to cause

conflicting behaviours. Albeit enablers perform different functions in the process of

supporting the implementation and functioning of PCC and/or HP, to some extent they

overlap each other. Figure 2 shows the mutual relations between enablers. The PCC

and/or HP implementation process should start from adapting the general PCC and/or

HP principles to the local conditions of a given organization (box 1). The result of this

adaptation should be policies, instructions, procedures and guidance of behaviour

tailored to individual providers, the scope of treated medical conditions and the forms

127

of provided care.

Processes:

- Delivery of care

- Development of sup orting PCC and HP

- Implementation o

according to PCC and HP standards and procedures

sup orting PCC and HP

/or

p /or

/orf

p

Infrastructure

Technology

Design of:- -

Contracting strategiesIncentives

PCC and HP

standardsand procedures

/or

Information about /orPCC and HPstandards and procedures

Information system:

o measuresQuality (costs) measuresHealth utcomes

- -

Results:High qualityLow ostc

Financial and non-financial rewards , when providers follow PCC and/or HP requirements

Adjustment of /or

principles tothe specific organisation

PCC and HP

Evaluative feedback

Corrective feedback

1

2

3

5

Figure 2. Interrelationships between enablers in the WE-CARE Roadmap

framework

These policies, instructions, procedures, and guidelines should incorporate into

the processes of care and treatment, including creating the appropriate infrastructure

and implementing supporting technologies (box 2). The specification and adaptation of

PCC and/or HP to a specific organization also allows the design of adequate

‘contracting strategies’ and ‘incentive systems’ at various levels of the organizational

structure (box 3). Incentives have to create guidelines in such a way that, every

employee must know exactly what to do to support the PCC and/or HP in their

organization.

Technology fulfils many functions in PCC and/or HP. In addition to purely

medical functions related to MHR, the support of the treatment and diagnosis process

itself, technology is an important element backing the implementation, functioning,

and improvement of PCC and/or HP. The critical function of technology (IT) is to

collect data on the quality and costs of treatment, on the activities performed by

professionals and on patients' condition and experience. IT systems must not only

support, but taking into account the level of information of the contemporary medical

organizations, IT must be the main vehicle of the information system. The information

system has to embrace all structures capable of collecting, processing, storing and

analysing data on the functioning of PCC and/or HP (also those collected manually).

Only such a comprehensive information system may allow an adequate assessment of

PCC and/or HP functioning in a given organization and consequently improve

outcomes of treatment and care processes (box 4). It is worthy to mention, that

information system in the shape described above is similar to many concept

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functioning in organizational studies, such as Management Information Systems,

Performance Measurement and Management Systems, including Balanced Scorecard

(Lewandowski, 2008).

The information systems produce numbers which can serve to monitor the extent

to which PCC and/or HP goals and standards have been achieved. This means that they

can be used in two different modes: diagnostic and interactive (Lewandowski et al.,

2018, pp. 144–150; Simons, 1994). In diagnostic mode to assess whether the

modification of other enablers brings expected outcomes. And also to measure the

performance of care teams, individual providers and chains of providers as well as the

entire organization in order to take ‘corrective actions’. The corrective actions are

based on the ‘corrective feedback’ (box 5) which is the results of the comparison

between established targets and their achievement.

In diagnostic mode measures (corrective feedback) allow the providers of care

(box 2) take the self-corrective actions within their processes of care when measures

are not achieving earlier planned levels. Similarly, organizational leaders responsible

for the implementation of PCC and/or HP may undertake corrective actions when the

functioning of PCC and/or HP is not on the track. In other words, when the quality and

costs of medical services deviate in the wrong direction. Organizational leaders may

‘keep the implementation of PCC and/or HP on track’ by many actions, for example,

they can adjust ‘contracting strategies’, ‘incentive system’ and ‘infrastructure’ or

technological support.

Through the measurement process per se, information system draw the attention

to subjects (areas) of measurement. This tends to influence the behaviour of the staff

and even patients when quantitative goals are set in the treatment plan. It is long

recognized that the measurement process itself invokes self-correction actions

(Flamholtz, 1996) and thus the measurement become themselves an incentive.

In the interactive mode, the information system facilitates the process of learning

how the whole idea of PCC and/or HP and five enablers functioning in a particular

setting. Here measures are used to ask questions, explore problems and challenge

assumptions. Whether the actions undertook to design each of the five enablers were

appropriate in a given environment? Maybe different measures should be used? Maybe

the strategy of PCC and/or HP implementation should be changed? By using the

‘information system’ interactively the PCC and/or HP actual general assumptions

could be confronted and modified.

Conclusions

The aim of the research was the clarification of definitions of the enablers the

theoretical analysis of mechanisms through which the WE-CARE Roadmap facilitate

the implementation of PCC and/or HP in medical organizations. This research was

important since some studies take for granted the effectiveness of the WE-CARE

Roadmap as an implementation tool (Lloyd et al., 2020). While there is neither

empirical nor theoretical research proving the effectiveness of the framework. The

important conclusion of the study is the necessity to more broadly define the

measurement. Not only restrain it to medical quality, but also include other areas such

as costs, and the functioning of the PCC and HP processes itself.

The study showed that enablers influence implementation of PCC and/or HP by

many mechanisms. Firstly the WE-CARE Roadmap indicates areas on which

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organizational leaders should concentrate to eradicate or at least diminish barriers and

strengthen facilitators to create a friendly environment for the implementation.

Secondly, the five enablers working together may amplify its facilitating force. For

example, ‘technology’ and ‘information systems’ working together might create a

much stronger impact than each of them separately. Additionally, ‘technology’ and

‘information systems’ significantly enhanced the impact of ‘incentive systems’ through

the measurement process and the possibility to generate accurate reports and share

them among professionals and patients.

Hence from the analysis appears that WE-CARE Roadmap may be a valuable

tool supporting the implementation of PCC and/or HP in medical organizations and

consequently improve quality and contain costs of healthcare systems. It has to be

noticed, however, that this theoretical analysis can only be treated as an encouragement

for further research based on empirical studies of implementations of PCC and/or HP

in medical organizations where WE-CARE Roadmap was used as an implementation

tool.

Acknowledgements

This research was partly funded by COST Action CA15222 “European network

for cost containment and improved quality of care” (costcares.eu), 2016-2020 and the

National Science Centre, Poland (Grant Number: 2015/17/B/HS4/02747).

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