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What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

ABSTRACT: Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT:For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS:Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS:The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS:In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

SUBMITTER: Grob R

PROVIDER: S-EPMC6422610 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

Grob Rachel R Schlesinger Mark M Barre Lacey Rose LR Bardach Naomi N Lagu Tara T Shaller Dale D Parker Andrew M AM Martino Steven C SC Finucane Melissa L ML Cerully Jennifer L JL Palimaru Alina A

The Milbank quarterly 20190301 1

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can lea ...[more]

PMID: 30883954

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Project description:BackgroundCOVID-19 has impacted the context in which healthcare staff and teams operate and this has implications for quality improvement (QI) work. Contrary to the usual ambivalent relationship staff have with QI work, there have been examples of unprecedented staff engagement in implementing rapid changes during the pandemic indicating a change in important underlying factors that impact staff involvement in QI. The purpose of this study is to explore staff perspectives about how experience and skills of QI methods supported them in implementing innovative practices during COVID-19.MethodsThis is a qualitative narrative study based on narrative interviews to collect healthcare staff stories of implementing rapid change. The stories were identified through social media (Twitter) and a national health magazine issued by the Irish health service. Twenty staff members participated in the interviews. Interviews were audio recorded, transcribed, and anonymised. A four-step thematic analysis was conducted.ResultsThe analysis revealed the transformational journey of healthcare staff from the initial shock and anxiety caused by COVID-19 to making sense of the situation, implementing rapid changes, and acknowledging COVID as a learning experience. Six themes were evident from the analysis: COVID anxiety and fear, emotional supports and coping mechanisms, person-centric changes, COVID as a 'forcing function' for change, a collective way of working and looking back and thinking ahead.ConclusionsWhile most rapid changes during COVID-19 did not represent a systematic and explicit QI application, QI principles were evident throughout the stories and actions taken, including making small changes, testing changes, learning, reflecting as a team, and improving. Many staff members were able to retrospectively identify the relevance of QI principles. COVID-19 eliminated some traditional barriers to change leading to efficient solutions, thus highlighting a need to sustain these positive changes into routine practice to develop an adaptive healthcare system receptive to QI.

Project description:Engaging health care staff in new quality improvement programs is challenging.We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program.Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation).A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%).Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.

Project description:IntroductionResidents are on the front lines of medical care in academic institutions. Their daily interactions are crucial to the quality of care received by patients in these settings, and thus, knowledge of patient safety and quality improvement is essential. The Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs as part of their residency training. To meet this need, we developed a curriculum in patient safety and quality improvement for pediatric residents.MethodsThis curriculum describes four short modules focused on quality improvement, patient safety, evidence-based practice, and other quality improvement-related topics. These modules can be given during one rotation, throughout residency, or partnered with a practical application, such as a project. A 17-question quality improvement and patient safety knowledge test was developed after an extensive literature review to reflect module goals and objectives. A validated, 12-question attitudes survey was administered before and after the modules.ResultsOf the 57 eligible residents, 42 completed the knowledge pretest, and 20 completed the posttest. Mean posttest results (M = 91.00 [± 9.12]) were considerably higher than mean pretest scores (M = 75.24 [± 11.74]) when utilizing the independent t test (p < .001). Of the 57 eligible residents, 11 completed the attitude presurvey, and 13 completed the attitude postsurvey. Median responses from the survey mostly fell within the 2-3 range of slightly to moderately comfortable. Significant differences showing improvement between presurvey and postsurvey time frames were found in identifying and comparing best practices (p = .02), using the PDSA model (p = .002), and identifying how data are linked (p = .001).DiscussionKnowledge and perception surveys suggest that resident knowledge and attitudes statistically improved, and faculty and residents participated in even more quality improvement initiatives after completing the curriculum.

Project description:ObjectiveDespite having a detailed MRI-safety questionnaire check at the point of referral, we have encountered a significant number of near-misses with patients being identified with MRI-Unsafe devices at the time of appointments, making this an important safety hazard.Methods and materialsA two-part survey was performed to assess referrer compliance of asking MRI-questionnaires. 120 outpatients across 3 MRI sites were interviewed at the time of appointment to confirm whether their referrers completed the MRI questionnaires with them at the time of referral.Location:Department of Radiology, Ninewells Hospital, Perth Royal Infirmary and Stracathro Hospital in Scotland.ResultsOnly 50-55 % of patients confirmed that they were asked about presence of a pacemaker at the point of referral. Less than 50 % of patients reported being asked about other potential hazards.Suggested strategies for change: (1) Risk Alert-Sent to all MRI referrers in the organization. ( 2) Changes to MRI Safety Questionnaire. (3) Feedback mechanism to referrers-NHS trust website publications on number of recorded near-misses and wasted appointments due to MRI-safety issues. (4) Compulsory education/training of future referrers (junior doctors/allied health professionals). (5) Education of patients/public on MRI safety-Displaying patient information leaflets/posters in waiting areas of the hospital.Key measures for improvement: (1) Reduction in number of recorded near-misses. (2) System improvements, referrer and patient education, reduction of wasted MRI appointments and improvement of waiting-times for MRI appointments Effects of survey and conclusions: The survey highlights the possibility of inadequate referrer attention, and poor patient communication about MRI safety questionnaire with regards to potential hazards of MRI examination in presence of undeclared implants. It initiated several interventions resulting in improved patient safety, with no events in next 12 months, whilst promoting public and referrer's understanding of potential MRI safety issues. Such actions are recommended for all NHS centres across UK since there are significant similarities in functioning across UK.

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What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

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What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

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