Engaging Patients as Partners in Practice Improvement: A Survey of Community Health Centers
Discussion
Among the CHCs surveyed, we found that having a formal strategy for recruiting and engaging patients in practice improvement efforts was associated with patient input shaping strategic goals, programs, and policies. Devoting time in staff team meetings to discuss feedback from patients, such as that received through advisory councils or patient surveys, appeared to be the mechanism by which having a formal strategy for engaging patients influenced the outcomes. Leadership support for patient engagement was also associated with patient input in strategic goals. In contrast, anticipated predictors such as PCMH recognition status, the size of a practice, and having dedicated funding for patient engagement were not associated with these outcomes.
This is the first study known to the authors that examines factors associated with patient engagement outcomes such as patient involvement in clinic-level strategies, policies, and programs. The finding that having a formal process for recruiting and engaging patients and devoting time in team meetings to discuss patient input are significantly associated with patient engagement outcomes is encouraging, because it suggests relatively practical and straightforward actions for primary care leaders interested in engaging patients productively in practice improvement.
The level of patient engagement reported by these respondents is higher than that reported by some other studies. For example, 65% of respondents in this study reported conducting patient surveys and involving patients in ongoing roles as patient advisors, compared to 29% in a 2013 study by Han and colleagues for 112 practices that had received PCMH recognition [6]. This could be partially explained by the fact that many CHCs are federally qualified health centers, which are mandated to have consumer members on their board of directors, and in many cases patient board members may be invited to participate actively in practice improvement. In this study, it is also interesting to note that more than 80% of respondents agreed with the statement that “engaging patients in practice improvement is worth the time and effort it takes,” suggesting that this is a group that valued and prioritized patient engagement.
A lack of time or resources to support patient engagement has been reported as a barrier to effective engagement [15], so it was surprising that having dedicated funding to support patient engagement was not associated with the study outcomes. Only 30% of CHC leaders reported having dedicated funding for patient engagement, while over 80% reported soliciting patient input through longitudinal, bidirectional activities such as committees or advisory councils. While financial support for this vital work is likely important to catalyze and sustain patient engagement at the practice level, it would appear many of the practices surveyed in this study are engaging their patients as partners in practice transformation despite a lack of dedicated resources.
The lack of association that we found between PCMH recognition status and patient influence on strategies, programs, and policies is corroborated by work by Han and colleagues [6], in which they found that the level of PCMH status was not associated with the degree of patient engagement in practice improvement and that only 32% of practices were engaging patients in ongoing roles as advisors.
Devoting time in team meetings to discussing patient feedback seemed to be the mechanism through with having a formal strategy for patient engagement predicted outcomes. Although it may seem self-evident that taking time to discuss patient input could make it more likely to affect clinic practices, we have observed through regular interaction with dozens of health centers that many have comment boxes set up but have no mechanism for systematically reviewing that feedback and considering it as a team. This is also borne out by our survey finding that fewer than 60% of sites that report conducting surveys or having suggestion boxes agree that they set aside time in team meetings to discuss the feedback gleaned from these sources. Thus, the results of this survey suggest that there are simple decisions and structures that may help to turn input from patients into clinic actions.
This study has several limitations. Causation cannot be inferred from this cross-sectional study; additional research is required to understand if helping clinics develop formal strategies for patient recruitment or set aside time in meetings to discuss patient feedback would lead to greater influence of patients on strategic goals, policies, and programs. Data were self-reported by a single person from each CHC, and although members of WCN typically represent clinic leaders who are actively engaged in PCMH-related activities, it is not clear if respondents were aware of the full range of patient engagement strategies used at their clinical site. Front-line clinicians and staff could provide a different perspective on patient engagement. There was no external validation of survey instrument statements regarding the impact of patient input on strategic goals, policies, or programs. The number of respondents (n = 97) is limited, but it is comparable to that in other existing studies [6]. The response rate for this survey was 21%, and respondents may have differed from non-respondents in important ways. When respondents of this study are compared to national samples reporting to the Uniform Data System, the proportion of CHCs with PCMH recognition is lower in our sample (52% versus 65%) [16]. The high level of patient engagement reported by CHC leaders in this study compared to other studies suggests that highly engaged practices may have been more likely to respond than those with lower levels of engagement with their patients. There may have been differences in how patient engagement and advisory roles were interpreted by respondents.
Conclusion
CHC leaders who reported a formal strategy for engaging patients in practice improvement and dedicated time to discuss patient input during team meetings were more likely to report patient input on policies, programs, and strategic goals. Developing a formal strategy to engage patients and establishing protected time on team agendas to discuss patient feedback may be practical ways to promote greater patient engagement in primary care transformation.
Acknowledgements: The authors wish to thank the leadership of Western Clinicians Network. A special thanks to Dr. Carl Heard, Dr. Mike Witte, Dr. Eric Henley, Dr. Kevin Grumbach, Dr. David Thom, Dr. Quynh Bui, Lucia Angel, and Dr. Thomas Bodenheimer for their feedback on survey and manuscript development. Valuable input on the survey questions were also received from the UCSF Lakeshore Family Medicine Center Patient Advisory Council, the San Francisco General Hospital Patient Advisory Council, and the Malden Family Health Center Patient Advisory Council. Finally, thanks to the community health centers who shared their time and experiences through our survey.
Corresponding author: Rachel Willard-Grace, MPH, Department of Family & Community Medicine, UCSF, 1001 Potrero Hill, Ward 83, Building 80, 3rd Fl, San Francisco, CA 94110, rachel.willard@ucsf.edu.
Funding/support: Internal departmental funding covered the direct costs of conducting this research. This project was also supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number UL1 TR000004 which supported Dr. Potter’s time. Dr. Sharma received support from the UCSF primary care research fellowship funded by NRSA grant T32 HP19025. Contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
