Citizen Engagement in Primary Care

THE INNOVATION

Engaging patients is essential to advancing quality improvement in primary care, but there are many barriers to effective engagement including time, money, and the representativeness of patient advisors. We describe using methods of citizen engagement to gather recommendations from a representative group of patient advisors to prioritize areas for improvement in a primary care practice.

WHO AND WHERE

We are a large, academic, interprofessional primary care organization with 6 clinics serving approximately 40,000 patients in the urban core of Toronto, Canada. We partnered with MASS LBP, a company that has pioneered the use of civic lotteries and reference panels to engage citizens in tackling tough policy choices.

HOW

We sent an email invitation to 10,000 patients inviting them to volunteer to spend a Saturday with us to improve the typical medical visit. Respondents indicated their availability via an online survey where they were prompted to answer a few demographic questions. Three hundred fifty people volunteered for the engagement event. From these volunteers, we randomly selected 36 patients to attend the engagement day, stratifying our selection by self-identified sex, housing, age-group, and self-reported health status to match our practice demographics.

The first 2 hours of the engagement day were spent orienting patients to the primary care organization’s services offered, patients served, and the health care context within which the team operates. Volunteers had the opportunity to ask questions from a panel of health care providers who worked in the organization about a typical work day. Volunteers were then divided into 6 groups, with each group tasked to identify friction points for a different element of a typical visit, from booking an appointment to following-up on test results. Following lunch, volunteers chose to join a small group to make recommendations related to these improvement opportunities.

Post-event evaluations revealed that all volunteers’ expectations were met and that all enjoyed the experience. Recommendations were shared with organizational leadership and within a month of the event, we communicated to our volunteers which of the recommendations we could advance in the short-term (Supplemental Figure 1, http://www.annfammed.org/content/16/2/175/suppl/DC1). Approximately 18 months following the event, we have made progress on about one-half of the recommendations (Supplemental Table 1, http://www.annfammed.org/content/16/2/175/suppl/DC1). We have tried to involve patient volunteers who were not selected for the engagement day in other practice improvement opportunities.

LEARNING

First, random selection of patient volunteers based on self-reported demographic data helped us engage a diverse and representative group of patients. A post-session survey confirmed that final participants were diverse not just in terms of the self-reported demographics used for random selection, but also in terms of ethnicity and immigration history. Most participants, however, were well educated with at least a college or university degree. The diversity was educational for some of our volunteers who had previously assumed most patients had similar abilities and backgrounds to themselves. Second, educating patients about our operations was critical to ensuring that patient recommendations were practical. For example, patients articulated the importance of being seen promptly when they arrived for a scheduled appointment but during the panel, they heard why sometimes it may be hard for a physician to stay on time during a clinic. Patients understood these potential circumstances and recommended not that wait times be reduced but rather that patients be informed at check-in about the number of patients ahead of them in the queue. Third, in-person engagement revealed improvement opportunities for us that had not been elicited through our practice patient experience surveys, such as removing a plexiglass barrier from the check-in area. Finally, although patients made many constructive suggestions for improvement, they also conveyed how deeply they valued the care we provided them. Patients were motivated to volunteer as a way of giving back to the clinic and their community. The event was inspiring and energizing for all who attended as well as for staff who interacted with patient volunteers after the event.