Environmental Scan Report
Patient and family engagement (PFE) is an evolving concept in health care transformation in the United States and worldwide. A growing body of evidence suggests that PFE can improve the safety and quality of care delivery.1–5 The Agency for Healthcare Research and Quality (AHRQ) contracted with MedStar Health Research Institute to develop the Guide to Improving Safety in Primary Care Settings by Engaging Patients and Families (the Guide). The Guide is being developed to provide primary care practices with interventions they can use to engage patients and families in ways that lead to improved patient safety.
The comprehensive Guide will include explicit instructions to help primary care practices, providers, and patients and families adopt new behaviors to increase patient and family engagement to improve patient safety. The first step in developing the Guide was to perform an environmental scan of the peer-reviewed and grey literature to understand the state of the field.
The purpose of the environmental scan was to identify:
- Descriptive, qualitative, and quantitative studies on methods to engage patients and families in their care in primary care settings and the impact of these methods on patient safety.
- Existing interventions and associated tools and materials for engaging patients and families in the primary care setting to improve safety.
- Gaps between existing tools and materials and those that need to be developed to ensure that the Guide is comprehensive in addressing PFE in primary care.
The project team used the York framework6 for conducting scoping reviews to direct the environmental scan.7–10 The primary research question the scan addressed was: "What are effective and potentially generalizable approaches for engaging patients and families to improve patient safety in primary care settings?" Informal interviews and surveys of subject matter experts helped to inform electronic database searches and targeted searches of Web sites for interventions to improve patient safety by engaging patients and families.
We limited all literature database searches to English language articles and articles with English abstracts. We reviewed articles published between 2011 and November 2015. Two independent team members conducted data abstraction. They then identified articles for inclusion in the Guide based on established inclusion and exclusion criteria.
Stakeholder consultation was ongoing throughout the environmental scan.6 Common themes emerging from the environmental scan were validated by subject matter experts and by members of the project’s Technical Expert Panel.
Results and Discussion of Findings
Patient safety in primary care is influenced by patient-related factors, provider-related factors, and health system or practice-related factors. Although the team identified policy-related factors, they are beyond the scope of this project.
Factors influencing patient safety within primary care seldom occur in isolation but are part of a complex matrix within the health care environment.11 Four key threats to patient safety in primary care emerged:
- Communication breakdowns among patient, provider, and practice staff
- Medication management issues, including reconciliation, prescribing, adherence, and overuse
- Diagnosis and treatment issues, such as decisionmaking, information transfer, missed diagnosis, and delayed diagnosis
- Fragmentation and environment of care issues, including identification issues, transfers, and care coordination, as well as safety culture, reporting, and error management
The environmental scan revealed that while the field of patient safety in primary care is new, there have been several important innovations.12–17 Interventions exist that focus on providers, patients, and practices as the target audience, including:
- Shared decisionmaking tools.
- Patient and family advisory councils or committees.
- Team-based care, including the patient as a member of the primary care team.
- Medication management, including medication lists and medication reconciliation.
- Family engagement in care.
- Structured communication tools, such as checklists, tools for being prepared to be a patient, and tools for asking questions.
Several gaps in the evidence emerged from the environmental scan:
- There are few well-evaluated studies in patient engagement to improve patient safety in primary care.
- There is limited evidence of infrastructure to support safety in primary care.
- There are limited measures to assess patient safety in primary care.
- There are limited measures to assess the impact of engagement on patient safety.
- There is limited evidence of patient involvement in intervention development.
- There is a lack of culturally sensitive and culturally appropriate tools.
Limitations of the Environmental Scan
The strength of evidence supporting patient safety improvement through intervention varies. Our approach sought to triangulate evidence, wherever possible, from the peer-reviewed literature, domain experts (patients, providers, practice staff/leaders, policy and research experts), and a robust grey literature search. Much of the work identified draws on expert panel recommendations, reports, and well-described case studies of interventions. Large-scale demonstration projects in the field have not yet emerged for many of the recommended practices.
Implications for the Guide
The environmental scan resulted in several implications to be considered in Guide development:
- Patient safety in primary care continues to evolve.
- Currently, engagement interventions focus on the patient as the agent of change.
- Education alone is unsustainable.
- Most of the materials identified were complex or had poor usability.
- Many of the materials identified were at a literacy level or health literacy level that could limit adoption for many of AHRQ’s priority populations (e.g., racial and ethnic minorities for whom English is a second language).
The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families is emerging at a time of tremendous transformation within the health care system as organizations across the country take up the banner of population health.18–20 At no other time in history has primary care been so central to the long-term sustainability of our population’s health.
Our model will aid in translating our thinking of patient safety in primary care and will guide our efforts to ensure that each intervention selected addresses the needs of the patient and family, primary care providers, and practice staff. Our team will remain vigilant in our efforts to be informed of changes in policy and practice in the primary care domain to promote interventions that are feasible, achievable, and sustainable.
- Herrin J, Harris KG, Kenward K, et al. Patient and family engagement: a survey of U.S. hospital practices. BMJ Qual Saf 2016 Mar;25(3):182-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4789699/. Accessed December 8, 2016.
- Smith KM, Hatlie MJ, Mayer DB, et al. A 10-year journey engaging patients in patient safety education, research and improvement [abstract]. In: International Society for Communication Science and Medicine; 2015 Jun 15; Montecatini Terme, Italy; SP57, p. 36. https://static1.squarespace.com/static/561c0d01e4b0b5ad2e65cc48/t/561d44dfe4b089431662d174/1444758751213/LibrettoProgramma.pdf. Accessed December 8, 2016..
- Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research & Quality; June 2013. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html. Accessed December 8, 2016.
- Scholle S, Torda P, Peikes D, et al. Engaging patients and families in the medical home. Rockville, MD: Agency for Healthcare Research and Quality; June 2010. AHRQ Publication No. 10-0083-EF. http://pcmh.ahrq.gov/sites/default/files/attachments/Engaging Patients and Families in the Medical Home.pdf. Accessed December 8, 2016.
- Lewis BM. PFACs: where’s the money? The financial impact on hospitals. Southlake, TX: The Beryl Institute; 2014.
- Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19-32.
- Brien SE, Lorenzetti DL, Lewis S, et al. Overview of a formal scoping review on health system report cards. Implement Sci 2010;5(1):2. doi:10.1186/1748-5908-5-2.
- Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci 2010;5:69. doi:10.1186/1748-5908-5-69.
- Daudt HML, van Mossel C, Scott SJ. Enhancing the scoping study methodology: a large, inter-professional team's experience with Arksey and O'Malley's framework. BMC Med Res Methodol 2013;13:48. doi:10.1186/1471-2288-13-48.
- McDonald J, McKinlay E, Keeling S, et al. How family carers engage with technical health procedures in the home: a grounded theory study. BMJ Open 2015;5(7):e007761. doi:10.1136/bmjopen-2015-007761.
- Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ 2001;323(7313):625-8. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1121189&tool=pmcentrez&rendertype=abstract. Accessed December 8, 2016.
- Longtin Y, Sax H, Leape LL, et al. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc 2010;85(1):53-62. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800278/. Accessed December 9, 2016.
- Bell BG, Spencer R, Avery AJ, et al. Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method. BMC Fam Pract 2014;15:110. doi:10.1186/1471-2296-15-110.
- Hernan AL, Giles SJ, Fuller J, et al. Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study. BMJ Qual Saf 2015;24:583-93. http://qualitysafety.bmj.com/content/24/9/583.abstract. Accessed December 9, 2016.
- Daker-White G, Hays R, McSharry J, et al. Blame the patient, blame the doctor or blame the system? A meta-synthesis of qualitative studies of patient safety in primary care. PLoS One 2015;10(8):e0128329. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128329. Accessed December 9, 2016.
- Baker R, Willars J, McNicol S, et al. Primary care quality and safety systems in the English National Health Service: a case study of a new type of primary care provider. J Health Serv Res Policy 2013;19(1):34-41. DOI:10.1177/1355819613500664.
- McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf 2013;22(Suppl 2):ii33-9. doi:10.1136/bmjqs-2012-001623.
- Martin D. Triple aiming higher: dreaming big in pursuit of healthcare transformation. Healthc Pap 2013;13(3):58-63; discussion 85-9. http://www.ncbi.nlm.nih.gov/pubmed/24524573. Accessed December 9, 2016.
- 2015 annual progress report to Congress: national strategy for quality improvement in health care. Rockville, MD: U.S. Department of Health and Human Services; 2015. http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2015annlrpt.htm. Accessed December 12, 2016.
- Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18(6):424-8. doi:10.1136/qshc.2009.036954.