#MEQAPI – Tweetchat April 5-2018 3:00ET Patient Collaboration in QI

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org

Patient voice is a critical component of quality improvement (QI) and has been a neglected area in healthcare. While clinicians and healthcare workers strive to be patient-centered and to do their best for patients, this does not often manifest in including patients when it comes to planning changes, making decisions, or developing policies. As a result, patients are often a neglected voice in healthcare improvement, even when they are the central goal.

In their British Medical Journal (BMJ) paper titled “What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study“, O’Hara et al discuss a study of patient experience of safety. The study analyzed data from 2,471 patients across 33 wards in three English NHS Trusts, between May 2013 and September 2014.

O’Hara et al found a high rate of patient-reported incidents, but perhaps the most eye-opening finding was that 10% of the patients identified a patient safety issue (boldface added)

Of the 2471 inpatients recruited, 579 provided 1155 patient-reported incident reports. 14 categories were developed for classification of reports, with communication the most frequently occurring (22%), followed by staffing issues (13%) and problems with the care environment (12%). 406 of the total 1155 patient incident reports (35%) were classified by clinicians as a patient safety incident according to the standard definition. 1 in 10 patients (264 patients) identified a patient safety incident, with medication errors the most frequently reported incident.

To put this number into perspective, CDC figures for 2015, show that 83.6% of the U.S. adult population had at least one healthcare encounter in the preceding year, translating into 125.7 million hospital visits, and 990.8 million physician office visits. If 10% of patients discovered and reported a safety issue in that year, millions of additional opportunities for improvement would result.

From a Lean Six Sigma and QI view,  one must take the “workpiece’s” perspective going through the workflow, and the definition of “quality” must derive from the objectives and goals of the “customer”. In healthcare, we typically don’t do this – for workflow we typically look at life through the lens of the physician or capital equipment (that’s why patients sit in waiting rooms queued up waiting on physicians and MRI scanners), and at best, we have somewhat shoddy proxies for whether the patients goals were met.

Likewise, we often nod toward patient goals, but subordinate them to other priorities such as profit, standards of care, purchasing policies, and physician preferences when we think of quality improvement. One egregious example is caesarean section births, which are often used and timed to be convenient to physicians and how the facility operates, rather than what the patient desires or prioritizes. Same often happens with end-of-life care, in which very often the patient’s goals are subordinated to a host of other considerations. Sometimes the lack of patient voice can be as mundane as what medications are prescribed and in what form – again, often the choice has little to do with what the patient wanted most.

So, to be truly patient-centered, healthcare would need to change to prioritize the patients goals, and eliminate waste and waiting as seen from the patient’s eyes – the identification of quality and safety risks, issues, and missed opportunities being one area in which patient-collaboration can help us to make significant improvements.

Some additional sources for this chat:

  1. Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention
  2. How might health services capture patient-reported safety concerns in a hospital setting? An exploratory pilot study of three mechanisms
  3. The patient reporting and action for a safe environment (PRASE) intervention: a feasibility study
  4. Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation
  5. The Patient Feedback Response Framework – Understanding why UK hospital staff find it difficult to make improvements based on patient feedback: A qualitative study


  1. What is your first reaction to the idea of collaborating with patients in healthcare improvement? – What other thoughts occur to you?
  2. What obstacles and opportunities do you see in collaborating with patients for quality & safety improvement
  3. How can we amplify the voices of underrepresented patient subgroups such as women, LGBTQ, and people of color when collaborating with patients for quality & safety improvement?
  4. Who will support and who will oppose collaborating with patients for quality & safety improvement?
  5. What policy, people, materials, measurement, environment, and equipment changes would need to take place to collaborate with patients for quality & safety improvement?



MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Affordability, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.


The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser and board member at the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and blogs regularly for Physician’s Weekly.




Upcoming #MEQAPI Chats

Here is the schedule for forthcoming #MEQAPI chats

  • April 5 Patient Collaboration in QA
    We will chat about including patients in quality improvement – based on BMJ paper by O’Hara et al

Unscheduled but planned:

  • TBI & PTSD
  • Healthcare laws

Note: suggestions welcome! – Please DM @meqapi or use the #MEQAPI hashtag to pass on your ideas/