Engaging Patients as Partners in Practice Improvement: A Survey of Community Health Centers

Conceptual Model

As we developed our instrument, we collaborated with clinical leaders and patient advocates within our networks, some of whom were working in clinics on issues of patient engagement, to develop a conceptual model. Through an iterative process, we hypothesized that certain clinic characteristics (eg, size of the practice, PCMH recognition status, having dedicated grant funding to support patient engagement, leadership support for the expansion of patient engagement activities, current engagement level, and having a formal strategy for identifying and engaging patients in an advisory role) would have a direct impact on patient engagement outcomes such as patient influence on clinic-level strategic priorities, policies, and programs (Figure 1). We also hypothesized that the clinic process of setting aside dedicated time for clinic personnel to discuss patient feedback in team meetings would function as a mediator of the outcomes, that is, this clinic process would be the mechanism through which clinic characteristics would be associated with each of these patient engagement outcomes.

Measures

In a review of the literature, we did not find validated instruments for assessing attitudes and beliefs around patient engagement in practice improvement. We convened experts in the field— including staff and clinicians working with patient advisors, patients serving as advisors, and faculty in academia with an interest in patient engagement, including the co-authors—to discuss assessment of patient engagement. Based on their input, we developed 10 items that captured attitudes, beliefs, and practices around patient engagement using a 5-point Likert scale (Figure 2). We pilot tested these questions with 6 primary care practice leaders from the board of WCN and with 3 patient advisory councils in 2 successive waves and modified the questions in response to their feedback.

The primary outcomes of interest were respondents’ perception of patient impact on strategic priorities, policies, and programs. These outcomes were measured by 2 items: “Patient input helps shape strategic goals or priorities” and “Patient feedback has resulted in policy or program changes at our clinic.” Responses were measured on a 5-item Likert scale (1 = Strongly Disagree to 5 = Strongly Agree). Leadership support was measured using a single item that stated, “Our clinic leadership would like to find more ways to involve patients in practice improvement.” Having a formal strategy was measured using a single item that stated, “We have a formal strategy for how we recruit patients to serve in an advisory capacity.” Clinic processes included having dedicated time in meetings to discuss patient input, as measured by the item, “We dedicate time at team meetings to discuss patient feedback and recommendations.”

In addition to the 10 Likert-type items that captured attitudes, beliefs, and practices, we also  asked participants to endorse strategies they used to obtain feedback and suggestions from patients (checklist of options including advisory councils, surveys, suggestion box, etc.). In addition, we assessed practice characteristics such as PCMH recognition status (not applying; in process of applying; received recognition), size of practice (< 5; 5–10; > 10 FTE clinicians), and having dedicated funding such as grant support to pay for patient engagement activities (yes; no).

Data Analysis

Data was analyzed in Stata version 13.0 (College Station, TX). Means and frequencies were used to characterize the sample. Stepwise multivariate modeling was used to identify factors associated with patient engagement outcomes. Organizational characteristics (size of the practice, PCMH recognition status, dedicated funding, leadership support, and having a formal strategy) were included as potential independent variables in Step 1 of the model for each of the 2 hypothesized patient engagement outcomes. Because we theorized that it might be a factor associated with the outcomes that was in turn influenced by clinic characteristics, the process of allocating dedicated time in team meetings to discuss and consider actions to take in response to patient feedback was included as a predictor in Step 2 of each model. Survey items that were not answered were treated as missing data (not imputed). We tested for multiple collinearity using variance influence factors.

Results

Of the 470 CHCs who were invited to participate in the survey, 97 took part, for a response rate of 21%. On individual items the percentage of missing data ranged from 0 to 8%. The majority of respondents (67%; 64/95) reported having 10 or more FTE primary care providers (Table 1). Half of respondents reported that their CHC had received PCMH recognition (52%; 50/97), mostlythrough the NCQA, and one-third reported that they had dedicated funding for patient engagement activities (30%; 28/95). Respondents primarily belonged to clinical (43%) or operational (40%) areas of leadership in their practices.

The most common mechanisms for receiving patient feedback were surveys (94% of respondents; 91/97) and suggestion boxes (57%; 55/97; Table 1). A third of respondents reported soliciting patient feedback on information materials (33%; 32/97), and almost a third involved patients in selecting referral resources (28%; 27/97). As for ongoing participation, 69% (67/97) of respondents reported involving patients on advisory boards or councils, and 36% (35/97) invited patients to take part in quality improvement committees. Other common activities included inviting patients to conferences or workshops (30%; 29/97) and asking patients to lead self-management or support groups (29%; 28/97).

Most respondents (82%; 77/93) agreed or strongly agreed that patient engagement was worth the time it required. About a third (35%; 32/92) reported having a formal strategy for recruiting and engaging patients in an advisory capacity. About half (52%; 49/94) reported setting aside time in team meetings to discuss patient feedback, although fewer (39%; 35/89) reported that their front line staff met regularly with patients to discuss clinic services and programs. Two-thirds of respondents (68%; 64/94) reported that their leadership would like to find more active ways to involve patients in practice improvement. Less than half (44%; 39/89) felt that they were successful at engaging patient advisors who represented the diversity of the population served. When considering downsides of patient engagement, few agreed that revealing the workings of the clinics to patients would expose the clinic to too much risk (8%; 7/89) or that patients would make unrealistic requests if asked their opinions (14%; 12/89).

In Step 1 of the multivariate models, clinic leadership support and having a formal strategy for recruiting and engaging patients was associated with greater patient engagement in shaping strategic goals and priorities (Table 2). For each point increase in these independent variables (on a scale of 1 to 5), respondents reported an increase of 0.31 points and 0.17 points (respectively) in the impact of patient input on strategic goals and priorities. Having a formal strategy also predicted greater impact of patient feedback on policy or programmatic changes (Table 3), with each point increase in having a formal strategy associated with a 0.17-point increase on patient input having resulted in a policy or programmatic change. PCMH recognition, having dedicating funding for patient engagement, and the size of the practice did not predict the outcomes.

When the clinic process of having dedicated time set aside in team meetings to discuss patient input was added to each model in Step 2, it was significantly associated with patient input affecting strategic decisions (Table 2) and patient feedback affecting policy and programs (Table 3), while having a formal strategy was no longer significant in each of these models. Sobel-Goodman mediation tests confirmed a strong relationship between each pair of variables in the model, including a significant relationship between having a formal strategy and setting aside time in team meetings to discuss patient feedback (β = 0.24, P = 0.001). Moreover, the test confirms a mediation effect for the relationship between having a formal strategy and each of these outcomes (Z = 2.57, P < 0.05 for the outcome of patient input in strategic goals and Z = 2.79, P < 0.01 for the outcome of patient influence on policies and programs) [14].