Involving Patients to Improve Primary Care
Ten years ago, I gave birth in hospital to my first child – a healthy, beautiful baby girl.
I still remember looking into her eyes for the first time and I still remember what it was like to be a patient. I remember wanting to provide feedback to someone about my experiences – both the good (great breastfeeding support) and the bad (being woken before dawn for a blood pressure check). But there was never any opportunity.
As physicians, we are rarely taught to think about the patient’s experience. It was an “a-ha” moment for me when I realized that improving health outcomes is just one arm of the “Triple Aim”. Improving the patient experience is an equally important goal.
Since 2014, our Family Health Team (FHT) has regularly surveyed patients on an annual basis on the month of their birthday to understand and improve their experience of care. At first, we weren’t sure how to do this. We studied the pros and cons of surveying patients via email or in the waiting room and decided on email. Surveying patients via email and reflecting on responses is now part of our routine operations.
When we started, it was something we were asked to do by Health Quality Ontario as part of our Quality Improvement Plan. We didn’t realize at the time how the patient survey would help our organization to embrace quality improvement.
Through these surveys, we learned that patients felt we spent enough time with them and appropriately involved them in decisions about their care. But we also found that some patients reported that it was not easy to get care from us after hours – even though we have offered in-person and telephone-based care on evenings and weekends for years.
Patient feedback has helped us focus our quality improvement efforts. For example, we learned about experience-based co-design and used these techniques to understand patients’ views of our after-hours services and how we advertise them. We implemented their recommendations and perhaps not unsurprisingly, the percentage of patients who reported it was easy getting care from our FHT on the weekend or holidays has increased.
We’ve realized that we are more likely to successfully improve if we listen to patients and involve them in improvement efforts.
Last year, we partnered with Mass LBP to organize a patient engagement day to help plan the development of our Quality Improvement Plan. We emailed 10,000 patients inviting them to spend a Saturday with us to improve a typical medical visit at the Family Health Team. We were amazed when 350 patients volunteered to take part.
Because we wanted the patients attending the day to be representative of our practice we randomly selected 36 to participate based on a few demographic characteristics. We spent half the day educating patients about our FHT and the second half hearing from patients about how we could improve.
Our patients’ recommendations were both thoughtful and practical. For example, they understood by the end of the day that there were many reasons a physician may run late in clinic that were beyond their control. So instead of saying that wait times should be shorter, patients recommended that we simply let them know how many people were ahead of them – and that we measure our waiting times and include it as an improvement goal.
Our patients also made clear that there were lots of things we were doing well. At one point, many of us in the room were moved to tears when a patient described how he volunteered his time as a way to give back because he was so grateful for the compassionate care our team had provided him over the years. Everyone who attended the day was inspired.
We are considering holding another town hall in the future after we tackle the recommendations we heard at the initial meeting. In the meantime, we are still engaging patients in our work. In the fall, we are planning to host a focus group around access to care when sick - an area we have put a lot of energy into but where we haven’t seen much improvement.
Working with patients isn’t always easy. It often means spending staff time or financial resources to properly engage patients and it sometimes means navigating tricky conversations. It’s also a shift in the power dynamic that we’re used to and can feel uncomfortable. It may also mean addressing issues we may otherwise have swept under the rug.
But, ultimately, working with patients to understand and improve their experience of care is critical to building a high quality health care system. And selfishly, it’s in our best interests.
Dr Tara Kiran is Quality Improvement Program Director and Board Chair for the St. Michael’s Hospital Academic Family Health Team.