The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital
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 rearticulated 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.
© 2017 Society of Hospital Medicine
Application of the SDM 3 Circle Model
Although the SDM process is similar across clinical settings, its operationalization varies in important ways for hospital decision-making. In some situations, patients may defer all decisions to their providers or decisions may be considered with multiple providers concurrently. In the hospital, SDM may not be possible, such as in emergency surgery for an obtunded patient or when the patient and surrogate are not available or able to participate in the decision. Therefore, providers may bypass the steps of information sharing and discussion of the decision (big arrow in the Figure and supplemental
DISCUSSION
The SDM 3 Circle Model provides a concise, ecologically valid, contextually sensitive representation of SDM that synthesizes and extends beyond recent SDM models.3,7,40 Each circle represents the forces that influence SDM across settings. Although the multistep SDM pathway occurs similarly in outpatient and inpatient settings, how each step is operationalized and how each “circle” exerts its influence may differ and warrants further consideration throughout the SDM process. For example, hospitalized patients may have greater stress and anxiety, have more family involvement, be more motivated to adhere to treatment, and may be under greater financial and social pressures. Unlike outpatient primary care, patients are less likely to have an existing relationship with their inpatient providers, potentially compromising patient confidence in the provider, and necessitating expeditious trust building.
The SDM 3 Circle Model captures “setting” in both the broader environmental frame and within the provider/team category of variables. The frame also captures health system and broader community variables that may influence the practicality of some medical decisions. Within this essential frame, all 3 categories of patient, provider, and medical context are included as part of the SDM process. A better understanding of their interplay may be of great value for clinicians, researchers, administrators, and policy makers who wish to further study and promote SDM. Both the SDM 3 Circle Model and its accompanying pathway (Figures 1 and 2) highlight opportunities for intervention and research, and may drive quality improvement initiatives to improve clinical outcomes.
Limitations
We did not perform a new systematic review, potentially omitting lesser-known publications. We mitigated this risk by using recent systematic reviews, searching multiple databases, hand searching citation lists, and making inquiries to SDM experts. Our selection of models used as a foundation for the synthesized model was based on consensus, which included an element of subjective, clinical judgment. Our SDM expert sample was small and limited to authors of the papers we reviewed, potentially restricting the range of viewpoints received. Lastly, the SDM 3 Circle Model highlights key concept areas rather than all possible factors that influence SDM.
CONCLUSIONS
We present a peer-reviewed, literature-based SDM model capable of accounting for the unique circumstances and challenges of SDM in the hospital. The SDM 3 Circle Model identifies the primary categories of variables thought to influence SDM, places them in a shared environmental frame, and visually represents their interactive nature. A multistep representation of the SDM process further illustrates how the unique features and challenges of hospitalization might exert influence at various points as patients and providers reach a shared decision. As the interrelationships of patient and provider/team, medical context, and the environmental frame in which they occur are better understood, more effective and targeted interventions to promote SDM can be developed and evaluated.
Acknowledgments
The authors would like to thank Evans Whitaker for his assistance with the literature review and the Patient Engagement Project volunteers for their support and assistance with data collection.
Disclosure
Financial support for this study was provided entirely by a grant from NIH/NCCIH (grant #R25 AT006573, awarded to Dr. Jason Satterfield). The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Stephanie Rennke, MD, Patrick Yuan, BA, Brad Monash, MD, Rebecca Blankenburg, MD, MPH, Ian Chua, MD, Stephanie Harman, MD, Debbie S. Sakai, MD, Joan F. Hilton, DSc, MPH., and Jason Satterfield, PhD.
