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 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.

Figure 1. SDM 3-Circle Conceptual Model and Multistep Shared Decision-Making (SDM) Pathway

¹Patient/Family: A patient’s ability to engage in SDM reflects one’s health (e.g., functional and cognitive status) and life circumstances (e.g., socio-economic status; presence of a family member to serve as a surrogate). ²Provider/Team: SDM engagement is influenced by characteristics of an inpatient team (e.g., attending physician, trainees, nurse, social workers, case managers, dietitians, therapists) and characteristics of the healthcare providers it comprises (e.g., fatigued vs. well-rested; variable familiarity with SDM guidelines). ³Medical Context: Some decisions require a patient to provide informed consent (e.g., invasive hospital tests and procedures; blood product transfusions); others require a patient to play a fundamental role (e.g., adhere to prescription or course of rehabilitation). ⁴Environment: A clinical service (e.g., medicine or pediatrics, emergency department, hospital floor or intensive care unit) operates within a hospital (e.g., university-based/community-based) located in a community (e.g., transportation options) and health system (with varying incentives and priorities). Features of each level can influence the SDM encounter through their bearing on the three domains. * Certain situations may warrant bypassing or limiting the steps of information sharing and decision discussion such as time-sensitive emergencies (e.g. emergency surgery) or if the patient and/or surrogate are uninterested or unable to participate in SDM