Environmental Scan Report
Implication 1: Patient Safety in Primary Care Continues To Evolve
The fields of patient safety and patient and family engagement in primary care settings are evolving at a tremendous rate. Our initial environmental scan focused on literature, reports, and resources published between 2012 and November 2015. Since that time, our team has received almost daily notifications of emerging tools, technologies, interventions, toolkits, and consensus reports that continue to frame the state of the evidence within the field. Where possible, we have included these resources and integrated them into the narrative.
It is anticipated that the fields of patient safety and patient engagement in primary care will continue to outpace our ability to identify, review, and synthesize the evidence during our work and that our interventions themselves will emerge at a time of increased readiness for change in the health care landscape. In addition, multiple initiatives are competing for provider and practice attention for implementing change at the practice level. Coupled, these forces may affect Guide development and dissemination, as well as practice recruitment efforts for field testing the Guide.
Strategies to mitigate the impact of competing priorities and environmental pressures include maintaining awareness of competing initiatives and looking for areas of synergy where appropriate. Our project team members are actively engaged in other projects within the fields of patient safety and patient and family engagement, including the Centers for Medicare and Medicaid Innovations Transforming Clinical Practice Initiative and the Centers for Medicare & Medicaid Services next iteration of Partnership for Patients.
These initiatives focus on improving patient outcomes with clinical transformation in the practice environment through engagement of patients and families. Dissemination of the Guide case studies, interventions, and implementation strategies within the full Guide are happening early in the development of these initiatives. This approach presents significant opportunities to have our work incorporated into these large-scale demonstration and implementation projects.
Implication 2: Engagement Interventions Need To Focus on the Patient as Change Agent
Our environmental scan found a significant body of work on approaches to engage patients and families in their care. Those interventions that also aimed to improve patient safety were targeted toward changing the patient's individual behaviors. These include interventions to encourage patients to speak up, ask questions, maintain and carry comprehensive medication lists, and act as a champion for safety and quality in their own care. Challenges in patient adoption of these interventions stem from vulnerability of the patient, illness, literacy and health literacy, activation, empowerment, and confidence to speak up.
For Guide development, we will need to ensure that we provide guidelines and implementation strategies for each stakeholder in the model of safety to support adoption. Patient-focused materials will also need recommendations and guidelines for providers and practice staff in how to support patients in adopting these tools and interventions as part of complex behavior change activities. This approach will require additional development to complement existing materials revealed during the scan.
Implication 3: Education Alone Is Unsustainable
The preponderance of evidence revealed during our environmental scan included "education"” as a key driver in behavior change to improve patient safety by engaging patients and families. Evidence and experience in patient safety, however, demonstrate the limitations of education to support widespread adoption of health behaviors or to integrate sustainable programs, processes, and practices into daily workflow.276
Implications for the Guide development process include bringing our human factors and safety specialists, health behavior change experts, and adult learning specialists together with our patients and primary care providers and practice staff to build robust processes to support adoption in practice. Feasibility of implementation will be guided by practice stakeholders and experts in establishing patient-centered medical homes.
Our Technical Expert Panel will also engage in development efforts, lending their experience and expertise to the work. This innovative and comprehensive approach to intervention and Guide development should yield sustainable processes and practices for patients, family members, providers, and practices to adopt to improve patient safety.
Implication 4: Evidence Is Limited on Usability of Identified Resources
While the environmental scan identified more than 300 tools, toolkits, interventions, and resources to support improvement of patient and family engagement and patient safety in primary care, usability of these approaches varied quite a bit. We found the strongest evidence of usability in tools and toolkits that were multifocal and provided several methods and mediums from which providers, practice staff, and patients could learn how to use and adopt the tools in practices.
To overcome issues with end-user adoption of the interventions developed as part of the Guide, our Guide development team will use a multimodal strategy for reviewing the interventions with all three stakeholder groups (patients, providers, and practice staff). We will identify barriers and facilitators of adoption in practice and will validate our assumptions with these stakeholders in a process of participatory action.277,278 Our team's experiences with these approaches, coupled with the opportunity to engage experts in health care complexity, influence, simulation, behavior change, human factors, and usability, should yield sustainable and usable interventions.
Implication 5: Health Equity and Literacy Need To Be Addressed
Health literacy is a major concern affecting usability of the tools, techniques, and resources identified, but few of the materials we reviewed for this scan were at a literacy level or health literacy level that would influence adoption for many of AHRQ's priority populations. An additional consideration for our Guide is that one size does not and will not fit all, especially when we consider the diversity of the patients and families who will use it.
To overcome this potential gap, special consideration from a health equity perspective will be given. The goal will be to understand the end users (race/ethnicity, age, gender, sexual orientation, social status, place of residence, educational attainment, etc.) and their unique needs in terms of how the Guide would realistically serve them.
The Guide (and interventions) will need to be adapted to address specific population groups' needs and circumstances in order for the Guide to have its intended and optimal impact, fairly and equally for all users. Our team of subject matter experts includes expertise in health equity, literacy, and community action at the patient level and the scientific perspective. Efforts to develop culturally sensitive and appropriate approaches to reaching patients at all literacy levels will be considered.
