Chapter 7: The Role of the Patient in Continuous Quality Improvement Contents Introduction and background Patient involvement in healthcare improvement overview Rationale for Patient Involvement in CQI Methods for Involving Patients in CQI Factors Affecting Patient Involvement The MAPR Model of Patient Involvement Partners to Owners Conclusion Introduction The primary function of health systems is to care for the health and wellbeing of populations in an effective and efficient way. A range of mechanisms exist for measuring the quality of care provided by health systems The role of the patient, family, and caregivers is much less clear History, policy, and causality are conflicted on the role of and outcomes from the patient in CQI Background Most CQI systems value the involvement of the client in systemic change and development Patient safety inquiries show that patients and carers often flagged problems first but were ignored These inquiries were not isolated to one part of the health system – problems are diverse in type and location of occurrence How can CQI help avoid these problems, halt their recurrence and improve systemic approaches? Patient Involvement in Healthcare Improvement Overview Patients are expected to be involved in health care as health systems have developed – CQI is a part of this Social and health sector changes have contributed to the call for patient involvement The dominance of medicine has been questioned by patients, advocates and health practitioners The HIV/AIDS epidemic has been a major force for change in traditional health system approaches Technological shifts have/are having a huge impact e.g. knowledge base, global contacts, volunteers for trials etc. Rationale for Patient Involvement in CQI Greater knowledge of health has increased knowledge of errors in the media and public domains High profile cases continue to get major news coverage e.g. The Shipman Inquiry in the U.K. Health systems have been forced to acknowledge the patient/client/carer perspectives CQI is part of the shift to patient-centered health care e.g. Insurance systems, co-payments etc. also make patients customers Methods for Involving Patients in CQI Three important levels of patient involvement in CQI: Micro-level involvement – active patient involvement as acknowledged in the concept of the self-managing patient; Meso-level involvement – patients involved in health service or even whole system planning, management and evaluation; Macro-level involvement – here patients are involved in national/international safety activities e.g. The WHO London Declaration Factors Affecting Patient Involvement The evidence base for patient involvement is small but growing Patient willingness to participate is affected by several factors e.g. self-efficacy in the role, health literacy, shift/changes required in role Inhibitory factors include e.g. type/severity of condition, SES factors (minority social position), the health setting and ...

1. Chapter 7: The Role of the Patient in Continuous Quality
Improvement
Contents
Introduction and background
Patient involvement in healthcare improvement overview
Rationale for Patient Involvement in CQI
Methods for Involving Patients in CQI
Factors Affecting Patient Involvement
The MAPR Model of Patient Involvement
Partners to Owners
Conclusion
Introduction
The primary function of health systems is to care for the health
and wellbeing of populations in an effective and efficient way.
A range of mechanisms exist for measuring the quality of care
provided by health systems
The role of the patient, family, and caregivers is much less clear
History, policy, and causality are conflicted on the role of and
outcomes from the patient in CQI
Background
Most CQI systems value the involvement of the client in
systemic change and development
Patient safety inquiries show that patients and carers often
flagged problems first but were ignored
These inquiries were not isolated to one part of the health
system – problems are diverse in type and location of

2. occurrence
How can CQI help avoid these problems, halt their recurrence
and improve systemic approaches?
Patient Involvement in Healthcare Improvement Overview
Patients are expected to be involved in health care as health
systems have developed – CQI is a part of this
Social and health sector changes have contributed to the call
for patient involvement
The dominance of medicine has been questioned by patients,
advocates and health practitioners
The HIV/AIDS epidemic has been a major force for change in
traditional health system approaches
Technological shifts have/are having a huge impact e.g.
knowledge base, global contacts, volunteers for trials etc.
Rationale for Patient Involvement in CQI
Greater knowledge of health has increased knowledge of errors
in the media and public domains
High profile cases continue to get major news coverage e.g. The
Shipman Inquiry in the U.K.
Health systems have been forced to acknowledge the
patient/client/carer perspectives
CQI is part of the shift to patient-centered health care e.g.
Insurance systems, co-payments etc. also make patients
customers
Methods for Involving Patients in CQI
Three important levels of patient involvement in CQI:
Micro-level involvement – active patient involvement as
acknowledged in the concept of the self-managing patient;
Meso-level involvement – patients involved in health service or
even whole system planning, management and evaluation;

3. Macro-level involvement – here patients are involved in
national/international safety activities e.g. The WHO London
Declaration
Factors Affecting Patient Involvement
The evidence base for patient involvement is small but growing
Patient willingness to participate is affected by several factors
e.g. self-efficacy in the role, health literacy, shift/changes
required in role
Inhibitory factors include e.g. type/severity of condition, SES
factors (minority social position), the health setting and issues
around power relations
Clinician attitudes are also a factor including training, personal
beliefs and organizational issues such as time
Measuring Patient Involvement in CQI
Patient satisfaction surveys (like customer satisfaction surveys)
have become widespread in healthcare
Satisfaction is a problematic measure for a range of reasons e.g.
Individual patient/carer reactions to error versus health care
provider/system responses
Data collection needs to more closely reflect the kind of
knowledge we are trying to produce in patient safety CQI – not
just surveys because surveys are the common tool
The MAPR Model of Patient Involvement
The MAPR model aims to canvas all three levels of patient
involvement and span most types of health system
Two dimensions of involvement are addressed – (1) active-
proactive and (2) passive-reactive
Dimension 1 involves direct patient involvement in identifying,
confronting and addressing the sources of error prior to events

4. Dimension 2 involves responses from patients after error events
have occurred e.g. Complaint letters, participation in root cause
analysis etc.
The MAPR Model
Dimension of Patient Involvement in Quality Improvement: The
M-APR Model
The MAPR Model (continued)
Dimension of Patient Involvement in Quality Improvement: The
M-APR Model
Partners in Health: Kaiser Permanente
The program is now more than 10 years old with a focus on
chronic disease self-management
Based on the Stanford CDSMP model and research on patient
outcomes
The Healthwise Handbook and related resource supports both
low and high intensity interventions
Research and RCTs showed a range of positive outcomes for
both patients and providers
Kaiser indicated that many of these interventions could be
implemented by smaller organizations lacking Kaiser’s resource
base
National Patient Safety Goals in the United States
The Joint Commission (TJC) accreditation agency has National
Patient Safety Goal 13 to involve patients in their own (safe)
care; in 2010 this goal became part of TJC’s standards for

5. accreditation
In 2007 TJC published a Patients as Partners toolkit to support
patients and carers in identifying safety issues
TJC has emphasised the role of diversity as a key issue in safety
e.g., meeting patient/staff language needs and effective
communication more broadly
Patients as Partners Program
Impact British Columbia, an NFP, implemented a patients as
partners program based on the BC Health Charter
The focus was chronic disease patients who are English-
speaking emphasising diversity effects on health care design
and provision
Outreach activities target both health care recipients and health
care providers
From Partners to Owners
The SouthCentral Foundation (SCF) in Alaska took on
management of all Native health services in its area in 1999
Ownership and control caused a shift in the design and deli very
of services
Native people were consulted about their ideas for service
delivery and fit
This new model shifted from patient-centered to patient-owned
Conclusion
Patient involvement is now an accepted part of health systems
development
In spite of this, error rates have not yet fallen much The key
issue is to identify how patient involvement can have a positive
impact on this situation
Each system in each country is likely to have a unique response

6. to this problem
The important thing is, whether exclusively unique or similar,
that effective responses have a positive impact through CQI
HIS-450 Peer Review Worksheet
Writer's Name_____________________________________
Paper Title
_________________________________________________
value
30 Points
30 Points
20 Points
20 Points
Thesis
with generalizations and evidence
Organization
Writing Style
Conventions
(grammar, punctuation)
STRONG
· Thesis: clear, cogent, forceful, interesting
· Generalizations: lucid, clearly stated, precise
· Evidence: precise, accurate details, supports thesis,

7. appropriate amount, linked directly to thesis and
generalizations, interesting, clear
· Organizational statement: clear, logical
· Overall- structure: builds a compelling argument, flows
smoothly, elegant
· Intro with “hook”: creative, interesting, relevant, draws the
reader in
· Paragraphs: flow from generalizations to supporting detail,
foreshadowing/transitions from one paragraph to the next,
variety of length
· Conclusion: relevant to thesis, assesses meaning of argument
presented
· Voice: Active (not passive), confident
· Word Choice: vivid images, strong verbs, precise-not wordy,
avoids needless adjectives
· Sentence Fluency: easy to read, strong cadence flow
· Quotations: pithy, enrich narrative, speak directly to the point.
· Grammar: few or no comma splices, sentence fragments, run-
ons, verb tense disagreements, subject/verb errors
· Punctuation: proper use of periods, commas, semi colon,
colon, apostrophes
· Conventions: proper spelling, capitalization, w ord usage (to or
too, etc.)
· Citations: formatted correctly
· Mechanics: margins, font spacing, indentations, and layout
acceptable and conventional with format
· Overall: Very minor errors, clean copy.
ADEQUATE

8. · Thesis: general, predictable
· Generalizations: wordy, not precise or clear
· Evidence: connection to thesis and generalizations not clear,
not precise, skimpy support
· Organizational statement: unclear, inconsistent with paper
· Overall- structure: average, reader must work to follow the
flow, larger argument obscure
· Intro with “hook”, bland
· Paragraphs: connection between generalization and details not
clear
· Conclusion: little connection to thesis, little assessment of
meaning
· Voice: some passive, safe
· Word Choice: general, too broad, bland, wordy
· Sentence Fluency: minimal variation, predictable
· Quotations: few or too many, not relevant
· Grammar:
· Punctuation
· Conventions:
· Citations:
· Mechanics:
The above categories’ errors do not obscure meaning or flow of
paper, basic things done well, evidence of editing and proof
reading.
WEAK
· Thesis: fuzzy, non-existent

9. · Generalizations: fuzzy, non-existent, inaccurate
· Evidence: little or none, no real connection to thesis
· Organizational statement: missing, muddled
· Overall- structure: muddled, scattered, incoherent to the larger
paper
· Intro with “hook”: none
· Paragraphs: little or no relation between generalization and
details
· Conclusion: none, or ending is abrupt, unfinished
· Voice: dull, passive
· Word Choice: wordy, words used incorrectly, repeated words
· Sentence Fluency: hard to read out loud, choppy/awkward,
incomplete
· Quotations: few or none, no relevance, dull
· Grammar:
· Punctuation
· Conventions:
· Citations:
· Mechanics:
The above categories’ mistakes impair flow and clarity of
paper, sketchy or little editing, basic things done poorly.
SCORE
_______ /30

10. _______ /30
_______ /20
_______ /20
COMMENTS: Write a three to five sentence response for each
of the following prompts listed below. Provide substantive
feedback challenging/questioning the argument or evidence,
suggesting possible improvements to the clarity or flow of the
argument, or asking for further clarification of the evidence
presented. Explain your rationale for your critique. Include at
least three positive aspects of the research paper and at least
three areas for improvements with suggestions for making
improvements.
1. Does the author present a clear and well-delineated thesis in
their research paper? What makes it a strong thesis statement or
why do you think it could be stronger?
The title of the paper does a better job presenting the thesis of
the paper than the paper itself does. I read the paper without
looking at the title and missed the thesis until I got to the
conclusion. The topic is an interesting one, however without the
title I would have missed the thesis and the topic of the paper.
1. Does the narrative of the research paper support the thesis
statement with strong arguments? How does it or how does it
not support the thesis statement? Is the narrative well
organized?

11. The paper is organized well and provides clear arguments for
the thesis by discussing the goals of the Civil Rights Movement
and how successful those goals were. The background on Jim
Crow America was solid and helps explain why the Civil Rights
Movement was needed.
1. Are the sources properly categorized as either primary or
secondary sources?
There are plenty of great sources for this paper. The paper uses
the references well, however they are not sorted between
primary and secondary. They are however organized
appropriately for APA format.
1. Does the content of the research paper reflect the use of
multiple avenues of approach in finding sources?
The paper makes use of the different approaches towards
finding sources. The bulk of the paper uses plenty of sources
and quotes breaking up monotony and same sounding passages.
All in all it is well pieced together.
1. Are there errors of grammar, spelling, and other punctuation
issues? Identify any errors in the mechanics of writing and offer
corrections.
Most of the grammar in paper is fine. There are some spots
where a space wasn’t placed between the words and maybe a
few places where commas could be added, and civil i n Civil
Rights was not capitalized in a few spots but beyond that not
much needed grammatically.
1. What value does this presentation have to the study of the
United States during the Civil War era?
I believe the Civil War portion belongs to a different class . In

12. all seriousness, the study of the effects the Civil Rights
Movement had on the lives of African Americans is a fantastic
topic. By looking back to what led the US to the point of the
Civil Rights Movement helps show how important the
movement was to the lives of disenfranchised people.
© 2021. Grand Canyon University. All Rights Reserved.
HIS-450 Reflection of Peer Review and Instructor Comments
REQUIREMENTS:

13. POSSIBLE
ACTUAL
Peer Review:
The student wrote a three-to-five-sentence reflection on what
changes they would make to improve their paper.
5
The student wrote a three-to-five-sentence reflection about how
the instructor and peer reviewer’s comments helped them to see
where they could improve their research paper.
5
The student wrote a three-to-five sentences on how reviewing
another students paper has helped them improve their personal
writing.
10
Total
20
Instructor comments:

14. © 2020. Grand Canyon University. All Rights Reserved.