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Person-centred Care and Patient Experience with Outpatient Cancer Care

Key findings

Measure:  Patient experience with outpatient care

 

Desired Direction:

 

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As of this Report:

 

An image of an arrow pointing straight in a yellow box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is below but approaching target or has notable regional variation.

Cancer patients treated in outpatient settings continue to report a positive experience with most aspects of their care (including respect for patient preferences and physical comfort). Despite this, there remain gaps, regional inconsistencies and opportunities for improvement within certain dimensions of care (such as emotional support and information, communication and education).

Cancer Care Ontario continues to partner with patient and family advisors (PFAs) with diverse experiences in order to ensure a person-centred cancer system. For the first 3 quarters of fiscal year 2017/2018, PFAs reported an overall positive engagement experience with an average score of 88%, which is an increase from 86% from the previous fiscal year. In terms of perceived engagement outcomes, PFAs also reported a positive score of 84%, which is comparable to the previous fiscal year.

What are person-centred care, patient engagement and patient experience?

  • Person-centred care (PCC) is the evolution of patient-centred care. It recognizes that true high-quality care that has a direct impact on the patient experience requires a fundamental shift in our approach to healthcare.
  • PCC is “an approach to the planning, delivery and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare providers, patients and families” [1]. The adoption of a model of PCC requires a different conceptualization of how patients, family members, caregivers and healthcare teams are engaged and work together.
  • PCC drives healthcare services that understand and deliver care that is responsive to the individual goals, needs and preferences of patients. This develops a more person-centred healthcare system where people are supported to successfully manage and make informed decisions about their own health and care. This, in turn, will drive improvements in the overall patient experience.

Measure:  Patient and family advisor engagement experience

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing upwards in a grey box. This indicates that there has been an increase in performance over the previous periods identified and this action does not have identified targets.

  • One approach used to establish a model of PCC is patient and family engagement, which has patients, family members, healthcare providers and professionals working together to plan, deliver and evaluate health services [2].
  • Patient experience has been defined as “the sum of all interactions, shaped by an organization’s culture, which influence patient perceptions and expectations across a continuum of care” [3].
  • In improving PCC, it is important to have insight into the patient’s view of healthcare and their specific wishes, needs and preferences [4]. Increasingly, cancer patients want to play an active role in the care they receive [4].

How are person-centred care, patient engagement and patient experience measured?

  • In Ontario, the Ambulatory Oncology Patient Satisfaction Survey (AOPSS) reports on dimensions of patient experience regarding the care received in outpatient cancer treatment settings (Figure 1). These dimensions are
    • emotional support
    • continuity and coordination of care
    • respect for their preferences
    • physical comfort
    • quality of information, education and communication
    • how well they were able to access their care.

Measure:  Patient and family advisor engagement perceived outcomes

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing straight in a grey box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action does not have identified targets.

  • The AOPSS allows patients who have been currently receiving treatment or those who have received cancer treatment in the last 6 months to provide anonymous, in-depth, open-ended and personalized descriptions of their overall treatment experiences.
  • The Cancer System Quality Index (CSQI) reports on an overall PCC indicator. AOPSS questions were selected to build a PCC composite indicator that is based on 3 dimensions of PCC – communication, self-management and support for shared decision-making (Figure 2) [5].
  • This year’s CSQI also highlights information on patient and family engagement at Cancer Care Ontario with 2 new indicators – engagement experiences and engagement outcomes. Additionally, a regional representation of Cancer Care Ontario’s PFAs is available.

Real-time patient-reported measures

  • Patient-reported Experience Measures (PREMs) capture the patient’s perspective of his or her experience while receiving care [21]. PREMs focus on specific aspects of the care process rather than on an overall evaluation of services.
  • Cancer Care Ontario developed a real-time PREM for adult oncology patients within the treatment phase and with expansion across the care continuum. This systematically captures PREMs and drives quality improvement based on the needs, wants and preferences of patients.
  • Collection of real-time PREMs ensures that local- and system-level planning and quality improvement in the cancer system are rooted in what matters most to patients and their families. Your Voice Matters  empowers and enables patients to share their experience about their most recent visit.
  • Since its deployment in March 2016, Your Voice Matters has been implemented in 14 Regional Cancer Centres (RCCs) in Ontario.
  • Responses from Your Voice Matters are collected in close to real-time on all eligible adult patients in Ontario who are undergoing outpatient cancer treatment. This creates the largest known linkable patient experience dataset in the world.
  • Table 1 indicates the total number of completed Your Voice Matters surveys in 13 RCCs in Ontario from January 2017 to October 2017.

Table 1. Total number of completed Your Voice Matters surveys by Ontario Regional Cancer Centre (RCC), 2017

Regional Cancer Centre (RCC)

Number of completed Your Voice Matters surveys

All reporting RCCs

16,103

Windsor RCC

688

London RCP

2,704

Grand River RCC (Kitchener)

617

Juravinski (Hamilton)

1,025

Carlo Fidani (Peel)

1,459

Odette (Toronto Sunnybrook)

2,451

Stronach RCC (Newmarket)

1,100

MDRCC (Oshawa)

1,621

Southeastern RCC (Kingston)

412

Ottawa RCC

1,175

Simcoe-Muskoka RCC

1,715

North East (Sudbury)

540

Northwestern (Thunder Bay)

596


Note: Results from UHN/PMH Regional Cancer were not available at this time

Person-centred care is a partnership. We also have to understand the nurses and the doctors on the other side. They have to understand what it’s like from our side. Then we work together in a partnership.

Joanne M., Patient/Family Advisor

Figure 1. Percentage of positive responses for 6 dimensions of outpatient care, fiscal year 2014/2015 to fiscal year 2016/2017

More information regarding the methodology is available.

Report date: January 2018

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 2. Percentage of positive responses to selected questions based on 3 dimensions of care (communication, self-management and support for shared decision-making), by Regional Cancer Centre (RCC) and select partner sites, fiscal year 2014/2015 to fiscal year 2016/2017

More information regarding the methodology is available.

Report date: January 2018

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 3. Number of Cancer Care Ontario patient and family advisors, by Regional Cancer Program

 

Figure 4. Average score for ongoing engagement experience and perceived outcomes of Cancer Care Ontario patient and family advisors, fiscal year 2016/2017 and fiscal year 2017/2018

More information regarding the methodology is available.

Report date: January 2018

Data source: CCO Advisor Experience Survey for On-going Engagement

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions
  2. Please note fiscal year 2017/2018 only includes data from quarter 1 to quarter 3.

 

Data Table 1. Percentage of positive responses for 6 dimensions of outpatient care, fiscal year 2014/2015 to fiscal year 2016/2017

Domain of care Percentage of positive responses in fiscal year 2014/2015 Number of positive responses in fiscal year 2014/2015 Total number of responses in fiscal year 2014/2015 Lower confidence interval in fiscal year 2014/2015 Upper confidence interval in fiscal year 2014/2015 Percentage of positive responses in fiscal year 2015/2016 Number of positive responses in fiscal year 2015/2016 Total number of responses in fiscal year 2015/2016 Lower confidence interval in fiscal year 2015/2016 Upper confidence interval in fiscal year 2015/2016 Percentage of positive responses in fiscal year 2016/2017 Number of positive responses in fiscal year 2016/2017 Total number of responses in fiscal year 2016/2017 Lower confidence interval in fiscal year 2016/2017 Upper confidence interval in fiscal year 2016/2017
Emotional support 54.3 18,583 34,197 53.8 54.9 54.3 18,382 33,855 53.8 54.8 54.0 15,154 28,058 53.4 54.6
Coordination and continuity of care 70.5 33,929 48,118 70.1 70.9 70.9 33,631 47,411 70.5 71.3 71.5 28,629 40,031 71.0 72.0
Respect for patient preferences 81.9 27,340 33,391 81.5 82.3 81.5 26,920 33,049 81.0 81.9 80.8 22,555 27,916 80.3 81.3
Physical comfort 80.7 12,321 15,261 80.1 81.4 79.0 11,779 14,916 78.3 79.6 78.3 9,062 11,572 77.5 79.2
Information, communication and education 68.0 35,206 51,805 67.6 68.4 66.5 34,237 51,447 66.1 67.0 65.4 28,058 42,889 64.9 66.0
Access to care 71.4 18,995 26,608 70.8 71.9 71.5 18,665 26,101 71.0 72.1 72.1 15,445 21,430 71.4 72.8

Report date: January 2018

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 2. Percentage of positive responses to selected questions based on 3 dimensions of care (communication, self-management and support for shared decision-making), by Regional Cancer Centre (RCC) and select partner sites, fiscal year 2014/2015 to fiscal year 2016/2017

RCC Percentage of positive responses in fiscal year 2014/2015 Number of positive responses in fiscal year 2014/2015 Total number of responses in fiscal year 2014/2015 Lower confidence interval in fiscal year 2014/2015 Upper confidence interval in fiscal year 2014/2015 Percentage of positive responses in fiscal year 2015/2016 Number of positive responses in fiscal year 2015/2016 Total number of responses in fiscal year 2015/2016 Lower confidence interval in fiscal year 2015/2016 Upper confidence interval in fiscal year 2015/2016 Percentage of positive responses in fiscal year 2016/2017 Number of positive responses in fiscal year 2016/2017 Total number of responses in fiscal year 2016/2017 Lower confidence interval in fiscal year 2016/2017 Upper confidence interval in fiscal year 2016/2017
All reporting RCCs 70.7 41,257 58,366 70.3 71.1 70.1 40,395 57,623 69.7 70.5 69.6 33,691 48,375 69.2 70.1
Windsor RCC 67.3 2,353 3,494 65.8 68.9 65.1 2,153 3,308 63.5 66.7 68.8 2,201 3,200 67.2 70.4
London RCP 71.3 3,296 4,625 70.0 72.6 70.7 3,213 4,547 69.3 72.0 69.2 1,833 2,650 67.4 70.9
Grand River RCC (Kitchener) 76.7 2,617 3,412 75.3 78.1 72.3 2,396 3,314 70.8 73.8 66.9 1,106 1,652 64.7 69.2
Juravinski (Hamilton) 69.7 2,871 4,119 68.3 71.1 69.4 2,970 4,281 68.0 70.8 68.4 2,333 3,412 66.8 69.9
Niagara Health System 67.9 1,967 2,899 66.2 69.6 71.7 2,166 3,021 70.1 73.3 68.5 1,902 2,778 66.7 70.2
Carlo Fidani (Peel) 70.0 2,613 3,735 68.5 71.4 67.5 2,851 4,223 66.1 68.9 69.3 2,388 3,444 67.8 70.9
UHN/PMH (Toronto) 66.3 2,659 4,008 64.9 67.8 66.2 2,732 4,130 64.7 67.6 63.7 1,698 2,665 61.9 65.5
Odette (Toronto Sunnybrook) 65.1 1,983 3,046 63.4 66.8 68.3 1,949 2,853 66.6 70.0 67.8 1,624 2,396 65.9 69.7
Stronach RCC (Newmarket) 73.8 2,619 3,548 72.4 75.3 71.7 2,346 3,272 70.2 73.2 72.0 2,212 3,074 70.4 73.5
MDRCC (Oshawa) 72.7 3,031 4,171 71.3 74.0 70.0 2,948 4,214 68.6 71.3 70.8 2,669 3,770 69.3 72.2
Southeastern RCC (Kingston) 75.5 3,565 4,722 74.3 76.7 73.7 3,229 4,382 72.4 75.0 75.5 3,429 4,540 74.3 76.8
Ottawa RCC 71.9 3,436 4,776 70.7 73.2 72.4 2,939 4,059 71.0 73.8 67.8 2,587 3,814 66.3 69.3
Simcoe-Muskoka RCC 73.0 2,759 3,781 71.6 74.4 74.5 2,653 3,561 73.1 75.9 73.0 2,391 3,274 71.5 74.6
North East (Sudbury) 67.6 2,967 4,389 66.2 69.0 67.7 3,086 4,560 66.3 69.0 70.3 2,825 4,016 68.9 71.8
Sault Area Hospital 72.9 846 1,160 70.4 75.5 76.9 898 1,167 74.5 79.4 69.4 671 967 66.5 72.3
Northwestern (Thunder Bay) 67.5 1,675 2,481 65.7 69.4 68.3 1,866 2,731 66.6 70.1 66.9 1,822 2,723 65.1 68.7

Report date: January 2018

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 3. Number of Cancer Care Ontario patient and family advisors, by Regional Cancer Program

Map Specifications 2016/2017 2015/2016 2014/2015
Emotional support 54.01 54.3 54.34
Coordination & continuity of care 71.52 70.94 70.51
Respect for patient preferences 80.8 81.45 81.88
Physical comfort 78.31 78.97 80.74
Information, communication & education 65.42 66.55 67.96
Access to care 72.07 71.51 71.39

 

Data Table 4. Average score for ongoing engagement experience and perceived outcomes of Cancer Care Ontario patient and family advisors, fiscal year 2016/2017 and fiscal year 2017/2018

PFA engagement area Average score (%) in fiscal year 2016/2017, Q1 to Q4 Standard deviation in fiscal year 2016/2017, Q1 to Q4 Total number of surveys in fiscal year 2016/2017, Q1 to Q4 Average score (%) in fiscal year 2017/2018, Q1 to Q3 Standard deviation in fiscal year 2017/2018, Q1 to Q3 Total number of surveys in fiscal year 2017/2018, Q1 to Q3
Engagement experience 86.2 15.2 144 88.2 15.7 71
Engagement outcomes 83.7 15.5 144 84.4 15.2 71

Report date: January 2018

Data source: CCO Advisor Experience Survey for On-going Engagement

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions
  2. Please note fiscal year 2017/2018 only includes data from quarter 1 to quarter 3.

What do the results show?

Most patients are satisfied with their experience but gaps remain (Figure 1).

  • In fiscal year 2016/2017, 6,296 individuals responded to the AOPSS survey, an overall response rate of 47% (data not shown).
  • Figure 1 shows results for patients responding positively to the statements. For all 6 dimensions of care, more than half of all responses were positive.
  • “Respect for patient preferences” (81%) and “Physical comfort” (78%) were the highest scoring dimensions in fiscal year 2016/2017.
  • Similar to previous years, “Emotional support” continues to score the lowest (54%), followed by “Information, communication and education” (65%). The “Information, communication and education” dimension has been steadily decreasing since fiscal year 2014/2015.
  • Specific “Emotional support” questions related to possible changes in sexual activity are reported in the Access to Psychosocial Oncology Services section of the CSQI.
  • Specific “Coordination and continuity of care” questions are reported in the Survivorship Care section of the CSQI.
  • Ontario’s Regional Cancer Programs (RCPs) continue to implement quality improvement plans to focus specifically on these dimensions of care.

There is regional variation for the PCC composite measure (Figure 2).

  • There is little change for the PCC composite measure overall in the province (70%) compared to the previous 2 years.
  • Patients from the Southeastern RCC (Kingston) were the most satisfied (76%) with the 3 components of care – communication, self-management and support for shared decision-making.
  • The Windsor RCC experienced the largest percentage increase for this composite measure, up from 65% in fiscal year 2015/2016 to 69% in fiscal year 2016/2017.
  • Patients from the UHN/PMH (Toronto) were the least satisfied (64%) with the 3 components of care.
  • The Sault Area Hospital experienced the largest decrease for this composite measure, from 77% in fiscal year 2015/2016 to 69% in fiscal year 2016/2017.

Cancer Care Ontario patient and family engagement has diverse regional representation, and advisors have positive engagement experiences (Figures 3 and 4).

  • PFAs are individuals from across the province who have a range of experience with Ontario’s cancer system as patients, family members and caregivers.
  • PFAs partner with Cancer Care Ontario to provide direct input into policies, programs and practices that affect patient care and services.
  • Cancer Care Ontario has approximately 100 active PFAs across all 14 regions in Ontario (Figure 3).
  • When asked about their engagement experience with Cancer Care Ontario, PFAs reported an overall positive experience in fiscal year 2017/2018, with an average score of 88%. This is a slight increase from 86% from the previous year.
  • A positive engagement experience consists of (a) ensuring clear agenda and meeting topics to which PFAs can contribute, (b) encouraging PFAs to express their views freely and (c) giving PFAs the opportunity to actively participate in engagement opportunities.
  • Cancer Care Ontario’s PFAs reported an overall positive engagement outcome during fiscal year 2017/2018, with an overage score of 84%. This is consistent with the previous year.
  • Positive engagement outcomes include (a) Cancer Care Ontario staff sharing the progress of the work with PFAs, (b) Cancer Care Ontario ensuring that a person-centred perspective is considered in decision-making and (c) PFAs feeling as though their contributions to the group will result in improvements to the person-centred experience in the health system. 

Why is this important to Ontarians?

Person-centred care leads to better care, outcomes and quality of life.

  • The provision of whole person care as reflected in the Cancer Care Ontario Person-centred Care Guideline is essential. Whole person care includes not only cancer treatment and physical care, but also identifying the individual’s psychosocial health needs and providing the resources to support individuals in managing the emotional, practical, social and spiritual elements of their experience.
  • Effective communication has been shown to improve psychological adjustment, adherence to treatment plans and satisfaction with care [6–8]. It includes active listening, expressions of empathy and sensitivity to the experience of the person affected by cancer.
  • The patient experience has been associated with a variety of outcomes, including patient quality of life [9–11], survival [12, 13], clinical effectiveness and safety [14], and specific outcomes (e.g., appointment adherence, improvements in screening and a decrease in anxiety and depression) [11, 15, 16].
  • Improved patient experience also has been linked to lower healthcare-related costs [17–19].

Understanding patient needs and their experiences with care helps providers and staff respond to gaps.

  • Looking at experience across several dimensions and types of cancer helps providers and cancer centres better direct their efforts and address gaps in patient need [20].

Next steps

Expanding the implementation of Your Voice Matters

  • Cancer Care Ontario is in the process of completing an evaluation of the implementation of Your Voice Matters.
  • Cancer Care Ontario will continue to work on increasing the uptake of Your Voice Matters among patients and families in Ontario. This will ensure that the voices of all Ontarians are considered and improvements across the cancer continuum are based on the wants, needs, and preferences of patients and families.

Introducing a new disease-specific patient-reported experience measure

  • Generic patient experience surveys often are not able to identify patient experience issues that are specific to a particular disease. As a result, these surveys may lack the responsiveness needed to institute quality improvement projects specific to certain populations. Disease-specific surveys can be developed to address the specific aspects of the patient experience that are important for a particular patient population.
  • In partnership with PFAS, Cancer Care Ontario has developed a disease-specific patient experience survey for patients diagnosed with acute leukemia or for those who undergo a stem cell transplant. Called Your Voice Matters – Acute Leukemia and Stem Cell Transplant, the survey will be deployed in Ontario later in 2018.

Enhancing person-centred care through person-centred communication

  • Developed in partnership with the Program in Evidence-Based Care (PEBC), the Person-centred Care: A Year in Review  is the first of its kind in Canada. It outlines a level of service that every person accessing adult oncology services in Ontario should expect to receive.
  • A key area of the guideline is “enabling patients to actively participate in their care.” Patients are enabled to be active participants in their own healthcare through their involvement in the creation and management of their health strategy and the use of services. A crucial prerequisite for self-management and self-care is effective patient–provider communication.
  • In January 2018, Cancer Care Ontario hosted a communication skills training workshop for a sample of cancer care providers from across the province. The purpose of this workshop was to build capacity within the RCCs to deliver care during the clinical encounter using a person-centred communication style. Cancer Care Ontario will be evaluating outcomes associated with the communication skills training workshop, including clinician burnout, clinician empathy and patient experience.
  • For more information on oncology patient experience surveys, please see the Your Symptoms Matter – General Symptoms

Improving equity in patient and family engagement and strengthening engagement efforts

  • Cancer Care Ontario recently launched a CCO Advisor Socio-Demographic Survey to our PFA community. The survey enabled the assessment of Cancer Care Ontario’s patient engagement capacity in terms of its ability to account for the diverse perspectives that reflect the unique characteristics of each patient, family member or caregiver.
  • As a result of this survey, Cancer Care Ontario developed a framework to understand the potential impact of forming partnerships with community organizations and non-health based organizations. The framework uses real-world examples from under- and never-engaged patient populations to identify appropriate policies and procedures that will support equitable engagement in future work.

Notes

  1. What is patient- and family-centred care? [Internet]. Institute for Patient- and Family-Centred Care; 2014 [updated 2018 Mar 21; cited 2016 Mar 14]. Available from: here.
  2. Cancer Care Ontario. Improving Ontario’s health system through patient and family engagement. Toronto: Cancer Care Ontario; 2014.
  3. Foot C, Fitzsimons B. The policy and practice of measuring patient experience. Nurs Manage. 2011;18(3):18–19.
  4. Defining Patient Experience [Internet]. Bedford (TX): The Beryl Institute; 2014 [cited 2016 Mar 14]. Available from: here.
  5. Ahmad N, Ellins J, Krelle H, Lawrie M. Person-centred care: from ideas to action [Internet]. London (UK): The Health Foundation; 2014 [cited 2016 Mar 14]. Available from: here.
  6. Adler NE, Page EK, editors. Cancer care for the whole patient: meeting psychosocial health needs. Washington (D.C.): The National Academies Press; 2008.
  7. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. NIH Publication No. 07-6225. Bethesda (MD): National Cancer Institute; 2007.
  8. Hack TF, Degner LF, Parker PA. The communication goals and needs of cancer patients: a review. Psycho-Oncology. 2005;14:831–845.
  9. Wong WS, Fielding R. The association between patient satisfaction and quality of life in Chinese lung and liver cancer patients. Med Care. 2008;46:293–302.
  10. Kim S, Bae JM, Kim YW, Ryu KW, Lee JH, Noh JH, et al. Self-reported experience and outcomes of care among stomach cancer patients at a median follow-up time of 27 months from diagnosis. Support Care Cancer. 2008;16:831–9.
  11. Frojd C, Lampic C, Larsson G, von Essen L. Is satisfaction with doctors’ care related to health-related quality of life, anxiety and depression among patients with carcinoid tumours? A longitudinal report. Scand J Caring Sci. 2009;23:107–16.
  12. Gupta D, Rodeghier M, Lis CG. Patient satisfaction with service quality as a predictor of survival outcomes in breast cancer. Support Care Cancer. 2014;22:129–34.
  13. Gupta D, Lis CG, Rodeghier M. Can patient experience with service quality predict survival in colorectal cancer? J Healthc Qual. 2013;35(6):37–43.
  14. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.
  15. Arbuthnott A, Sharpe D. The effect of physician–patient collaboration on patient adherence in non-psychiatric medicine. Patient Educ Couns. 2009;77:60–7.
  16. Sequist TD, Schneider EC, Anastario M, Odigie EG, Marshall R, Rogers WH, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008;23(11):1784–90.
  17. Stewart M, Ryan BL, Bodea C. Is patient-centred care associated with lower diagnostic costs? Healthc Policy. 2011;6:27–31.
  18. Coulter A, Collins A. Making shared decision making a reality: no decision about me, without me. London (UK): King’s Fund; 2011.
  19. Mulley A, Trimble C, Elwyn G. Patients’ preferences matter: stop the silent misdiagnosis. London (UK): The King’s Fund; 2012.
  20. Cancer Quality Council of Ontario. Environmental scan: patient and family experience? [Internet]. Toronto: Cancer Care Ontario; 2013 June [cited 2014 Mar 18]. Available from: here.
  21. Patient Experience [Internet]. Ottawa: Canadian Institute for Health Information; c1996–2018 [cited 2016 Mar 15]. Available from: here.