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Chapter 7: The Role of the Patient in Continuous Quality Improvement
Contents
Introduction and background
Patient involvement in healthcare improvement overview
Rationale for Patient Involvement in CQI
Methods for Involving Patients in CQI
Factors Affecting Patient Involvement
The MAPR Model of Patient Involvement
Partners to Owners
Conclusion
Introduction
The primary function of health systems is to care for the health and wellbeing of populations in an effective and efficient way.
A range of mechanisms exist for measuring the quality of care provided by health systems
The role of the patient, family, and caregivers is much less clear
History, policy, and causality are conflicted on the role of and outcomes from the patient in CQI
Background
Most CQI systems value the involvement of the client in systemic change and development
Patient safety inquiries show that patients and carers often flagged problems first but were ignored
These inquiries were not isolated to one part of the health system – problems are diverse in type and location of occurrence
How can CQI help avoid these problems, halt their recurrence and improve systemic approaches?
Patient Involvement in Healthcare Improvement Overview
Patients are expected to be involved in health care as health systems have developed – CQI is a part of this
Social and health sector changes have contributed to the call for patient involvement
The dominance of medicine has been questioned by patients, advocates and health practitioners
The HIV/AIDS epidemic has been a major force for change in traditional health system approaches
Technological shifts have/are having a huge impact e.g. knowledge base, global contacts, volunteers for trials etc.
Rationale for Patient Involvement in CQI
Greater knowledge of health has increased knowledge of errors in the media and public domains
High profile cases continue to get major news coverage e.g. The Shipman Inquiry in the U.K.
Health systems have been forced to acknowledge the patient/client/carer perspectives
CQI is part of the shift to patient-centered health care e.g. Insurance systems, co-payments etc. also make patients customers
Methods for Involving Patients in CQI
Three important levels of patient involvement in CQI:
Micro-level involvement – active patient involvement as acknowledged in the concept of the self-managing patient;
Meso-level involvement – patients involved in health service or even whole system planning, management and evaluation;
Macro-level involvement – here patients are involved in national/international safety activities e.g. The WHO London Declaration
Factors Affecting Patient Involvement
The evidence base for patient involvement is small but growing
Patient willingness to participate is affected by several factors e.g. self-efficacy in the role, health literacy, shift/changes required in role
Inhibitory factors include e.g. type/severity of condition, SES factors (minority social position), the health setting and issues around power relations
Clinician attitudes are also a factor including training, personal beliefs and organizational issues such as time
Measuring Patient Involvement in CQI
Patient satisfaction surveys (like customer satisfaction surveys) have become widespread in healthcare
Satisfaction is a problematic measure for a range of reasons e.g. Individual patient/carer reactions to error versus health care provider/system responses
Data collection needs to more closely reflect the kind of knowledge we are trying to produce in patient safety CQI – not just surveys because surveys are the common tool
The MAPR Model of Patient Involvement
The MAPR model aims to canvas all three levels of patient involvement and span most types of health system
Two dimensions of involvement are addressed – (1) active-proactive and (2) passive-reactive
Dimension 1 involves direct patient involvement in identifying, confronting and addressing the sources of error prior to events
Dimension 2 involves responses from patients after error events have occurred e.g. Complaint letters, participation in root cause analysis etc.
The MAPR Model
Dimension of Patient Involvement in Quality Improvement: The M-APR Model
The MAPR Model (continued)
Dimension of Patient Involvement in Quality Improvement: The M-APR Model
Partners in Health: Kaiser Permanente
The program is now more than 10 years old with a focus on chronic disease self-management
Based on the Stanford CDSMP model and research on patient outcomes
The Healthwise Handbook and related resource supports both low and high intensity interventions
Research and RCTs showed a range of positive outcomes for both patients and providers
Kaiser indicated that many of these interventions could be implemented by smaller organizations lacking Kaiser’s resource base
National Patient Safety Goals in the United States
The Joint Commission (TJC) accreditation agency has National Patient Safety Goal 13 to involve patients in their own (safe) care; in 2010 this goal became part of TJC’s standards for accreditation
In 2007 TJC published a Patients as Partners toolkit to support patients and carers in identifying safety issues
TJC has emphasised the role of diversity as a key issue in safety e.g., meeting patient/staff language needs and effective communication more broadly
Patients as Partners Program
Impact British Columbia, an NFP, implemented a patients as partners program based on the BC Health Charter
The focus was chronic disease patients who are English-speaking emphasising diversity effects on health care design and provision
Outreach activities target both health care recipients and health care providers
From Partners to Owners
The SouthCentral Foundation (SCF) in Alaska took on management of all Native health services in its area in 1999
Ownership and control caused a shift in the design and delivery of services
Native people were consulted about their ideas for service delivery and fit
This new model shifted from patient-centered to patient-owned
Conclusion
Patient involvement is now an accepted part of health systems development
In spite of this, error rates have not yet fallen much The key issue is to identify how patient involvement can have a positive impact on this situation
Each system in each country is likely to have a unique response to this problem
The important thing is, whether exclusively unique or similar, that effective responses have a positive impact through CQI
