Patient Engagement—Is Fair Process Needed?

“Nothing about me, without me.”  Perhaps not exactly presented as promoted by Dr. Donald Berwick, previously at CMS (sadly not true for the future, but that’s another story). It was a mantra used by him in his ongoing crusade to advance the patient-centered concept into our health care system.   His energy in promoting the needed transformation from the provider-centered world we presently inhabit to one focused on the patient has been unabated.

I’ve recently written a short piece for The Minnesota Physician, addressing the need to continue our efforts in furthering patient engagement.  (http://bit.ly/teOcxo )  I drew on the work of Jessie Gruman from the Center for Advancing Health, and others who have been strong advocates in this area.  Her story, both as a patient with multiple serious cancer episodes, and as a “scientist” in the area, have given me much to think about.  Adding in my appreciation for the work of Judy Hibbard and the Patient Activation Measure, Bev Johnson and the wonderful work of the Institute for Patient and Family Centered Care, and having engaged in lively discussions with Jennifer Sweeney from the National Partnerships for Women and Families, has stretched and stressed my physician-trained brain in a good way, or so I’d like to believe.

It is critical we continue to move toward a model which engages our patients, families and communities as active and equal partners in addressing the crisis which is confronting us in our present disjointed, disconnected and fragmented health care system.

So, as is my wont, let’s add another perspective that has struck me as potentially useful in helping us understand how and why this engagement is critical.  And it comes to me from my work in culture change and leadership in which I gained an understanding of the importance of “fair process” in working within our health care system in changing our culture to one focused on patient-centered care.

Fair process is a term derived from a Harvard Business Review article written by Kim and Associates, initially published in 1998, and republished in 2003.  It addresses the need to manage differently in the evolving knowledge economy in which we live.  It has become an intrinsic part of our collaborative work at ICSI, and has been of great value in our efforts to bring together multiple stakeholders to work on complex topics.

It addresses the need humans have to be involved and feel part of the change that is swirling around us.  Basically, it concludes that as a leader/manager, there is a greater likelihood your staff will go along with a new process  if they felt they were part of the effort, even if they don’t agree with the outcome than if a smaller group of well intentioned, dedicated colleagues come up with a change suggestion they agree with, but weren’t involved in the development of that process.  Consider the impact of that for a minute—it’s the need to be involved and feel part of the process that in many cases has more importance than the actual outcome.

In their article, Kim and Associates address that there are three elements critical in fair process:  Engagement, Explanation, and Expectation Clarity.  First, engagement is exactly what I’ve mentioned—including and involving those affected in the decision making, allowing opportunity to voice opposition, raise questions, contribute to the discussion.  Second, explanation—ensuring that the rationale and reason for the decision is clear and understandable.  That includes a discussion of the various perspectives and opinions that were considered and a clearly communicated message as to why the decision was made.  And last, but certainly not least, there is a need for expectation clarity—a clear statement of what the new “rules of the game” are, what the behavior expectations will be, what the penalties for failure to become accountable to this new change are.  This creates a clarity that allows the employee to focus on the task immediately at hand after this decision has been reached—using fair process.

It strikes me that this same type of “fair process” should and must be a part of any effort to engage patients and their families as active partners in their health care efforts.  Consider the idea of engagement as described by Kim—doesn’t this totally crosswalk with the need for shared decision making, consideration of values, provision of choices, and consideration of the patient’s perspective?  Explanation is critical, but needs to be more than the provision of printed patient education materials, a paternalistic set of “physician orders” or directives to “change what you’re doing if you want to improve.”  It’s a very different type of explanation than the often times confusing terminology used by many in the medical profession to communicate their recommendations, equating silence on the part of the patient as acceptance rather than what it truly might represent—disbelief and confusion.

Lastly, as Jessie Gruman and others in their work on patient engagement articulate, we need to create an expectation clarity—or terms of engagement as it’s often called.  Patients need to clearly hear and understand what is needed of them, no, in fact is expected of them, if we’re to work as a team.

There are other complicating factors, and perhaps this is just another way of saying the same thing, an unnecessary redundancy, but I find it another useful contextual framework on which to build our efforts in this critical area.  As we move forward in “co-creating” our health care system, it reinforces the importance of our efforts, but through a different terminology.  That’s only “fair” don’t you think?  Would your patients feel they’re experiencing the fair process which seems a critical part of any type of change effort in which we ask them to engage as a part of their “partnership” in maintaining and improving their health?

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