Listening to people

Welcoming input from others to share a decision opens a door of creativity which an individual will rarely come up with on their own. It can easily become a Pandoras Box though if disagreement is not anticipated and addressed early.

Listening to people sits well with my divergent decision making [1]. Bringing people to the table to share issues, ideas and strategies is a great way to see the world through other people eyes. Throughout my career I have applied this to deliver better clinical services, design health promotion projects and even discover the meaning of life [2]. I have refined a process for how to approach shared decision making which can be applied to a decision of any size.

A typical listening or “engagement” process collects ideas and prioritises them to assist with make a better decision. The more that other people will be affected by a decision, the more they should be involved in as many steps of this process as possible.

Following the steps below will give the decision maker confidence around what the issue and expected outcome is, and how to effectively let other people take part. It is based on the democratic process so should be something people living in the West are used to seeing in action.

Individual negotiation often goes along a similar pathway, for example on pizza and video night I usually narrow down the genre with my significant other to pick which movie we expect to enjoy. Kevin McCloud does a great job teasing out the intricacies of identifying negotiable elements between stakeholders when building a house, and the way personalities affect the ability to share decisions.

A prime opportunity to implement this is with the recently announced review of the Personally Controlled Electronic Health Record (PCEHR) [6]. This outline includes how I would implement the framework to ensure the public receive the most valuable service for any given investment:

Steps for sharing a decision

(and how they could be applied to the PCEHR review)

1. Identify why a shared decision will be valuable

Clearly define the problem as you see it, what resources are available and what changes are needed to address it. Outline the initial expected outcomes from having others participate in the decision making process eg more ownership of the final outcome.

The current problem is that most health resources are consumed by people managing a chronic illness. This means most people accessing services require improved health literacy and access to information to look after themself within a supportive multidisciplinary team. Involving people in offering ideas for the PCEHR will increase the chance of delivering a product which meets their highlighted needs. Also involving consumers will enhance marketing strategies and ultimately uptake through direct endorsement of the resulting changes made.

2. Outline what is negotiable and to what degree

This is a good step to reflect on just how much you value the involvement of others. If there is nothing that can be changed by involving others, or you aren’t willing to loosen up and let others have a say, then maybe a shared decision is not the way to go. If it strongly affects others you might just have to push ego to the side and put trust into the crowd sourcing process [3], or do some more reading on the importance of democracy [4].

For big decisions the International Association of Public Participation (IAP2) spectrum of public participation [4] can be a good reference tool.

Part of the PCEHR review process should involve deconstructing which elements of the current service are:

a)     Non negotiable (for legal or privacy reasons)

b)     Moderately negotiable (such as what personal information is captured and sharable)

c)     Highly negotiable (such as the user interface and marketing)

Given the size of this project each level of negotiation would likely need its own plan. Taking the initial plan to health consumers and their representative groups would be highly valuable at this stage. It always amazes me how things which are considered set in stone can be altered if it is identified as a real hassle for end users. Also this would set the tone that the government wants to listen to peoples concerns, and quickly identify any problems in the strategy.

3. Identify stakeholders

List all people who will be affected by the decision being made. Where possible identify groups in the local community who include or could represent the target demographic.

A mapping exercise will be needed here alongside data to see who has the most potential to use and benefit from the project based on: where they live, what condition they are managing, how old they are, their level of literacy, when they need access, and what the expected outcomes are for each of these groups.

4. Ask stakeholders how they want to be asked

The community may have concerns regarding confidentiality, timing, location, literacy and interpersonal communication when being consulted. Ask the target community what methods they prefer, and put forward the pros and cons of some more innovative options such as World Café, or even speed dating! This is a great way to achieve a sense of ownership before a formal listening process starts.

Asking the target audience what the best ways are to get their input will guide where to direct resources for listening activities. My initial thoughts are that older adults and younger families would be the highest users of consolidated personal health information. Liaising through governing bodies or non-profit groups would be an efficient way to gain feedback on how to best gain a good image of what their needs are.

This may result in a multipronged approach to gaining feedback, such as online surveys for young families, and more face to face opportunities for older adults. Linking in to existing events or surveys might be a way to improve access to the different target demographics.

5. Get support and plan ahead (recruit an expert and scribe)

Once a method has been identified plan ahead to ensure it is done effectively. Use the background information above to develop a clear set of questions to be asked.

Early focus groups will be needed at this stage to refine what questions to ask, and their order of importance. This should include experts in the areas of service delivery, information collection and  consumers. I try to narrow it down to about half a dozen questions to capture the main elements of feedback. This helps the project team to prioritise what decisions are open for influence by the public, and also prevents the public from being overwhelmed by questions.

6. Make people feel welcome

When going live to start listening, setting agreed values will support people to feel at ease about sharing ideas. The goal is to develop a long list of creative suggestions at this stage. This is my favourite step as there is an opportunity to apply the art of listening here to strike a fine balance between staying neutral but making it fun and respecting others concerns, all the while keeping within the initial scope of how much people can influence the final decision.

The style of listening to people can make a big different to both the quality but more importantly the quantity of information gathered. Research shows that when people feel relaxed and are having fun they are more likely to put forward creative solutions to a problem [7].

Humorous anecdotes or light jokes can help to limber people up before undertaking an engagement process. It is often valuable to clearly outline the values held by the project, and how they are being put into practice eg respect by not talking over each other. It may need to be made clear that the process is not to address specific issues but to reflect on how they could be improved by a better functioning PCEHR.

Given the current heat in the issue surrounding a poor return in investment for the PCEHR to date this may need to be addressed prior to then undertaking feedback on how it can be improved.

7. Record all suggestions raised and prioritise where possible

Widening the net to capture the maximum number of ideas for a solution to a problem is the preferred method for most “engagement” processes. This will assist to broaden the understanding of the impact of the final decision, identify other resources to assist in making change, and build a clearer shared vision of what outcome is expected. No judgement is applied to initial suggestions, time is allowed for all participants to air their thoughts and if any ideas are ambiguous ask for clarification.

Early planning to scope exactly what issues are being addressed, which elements are negotiable and having solid data on which to make estimates becomes crucial at this step. Health projects often encompass issues across much of the rest of society which can make analysis and evaluation difficult. The process of prioritising may take several stages depending on the breadth of input being sought.

8. Include ideas raised in the decision making process

Collate all feedback that was received and review to determine if enough information is now available to make a well informed decision. Conduct follow up listening events if needed before having enough information to make the best decision.

The outcome of a successful listening process will be a document which clearly outlines what the requirements are of the end users, and the degree to which the different options meet those needs. This step will test the resolve of government to unsettle existing health related databases, interfaces and branding to deliver what the public want from a revised PCEHR.

9. Thank and let others know how their input was used

A simple note of thanks will set the tone that community input was appreciated and respected. Outlining specifically how their ideas were used in the final decision can build trust in the process and relationships formed.

Keeping track of what suggestions were put forward by different groups will make this step easier. There will likely be several key themes which arise from the listening process. Correlating the feedback and how it was incorporated to changes made will increase the sense of ownership by the community for the final product.

10. Ask how to do better next time

Reflecting on the shared decision making process can provide insight into how to do a better job next time. This is an important way to improve local decision making in the organisation.

Health services are in a constant change process. Gaining feedback on what worked and what didn’t will serve to increase the knowledge base for how to refine and possibly streamline the process for sharing decisions with health consumers.

Summary

Getting into the finer details of how to share a decision shows just how important it is to plan ahead. It also highlights how often people are regularly applying negotiation to share the myriad of decisions we make which influence others.

I have already jumped the gun and gone straight to designing a new data set and interface for the Australian PCEHR [7]. Going through the motions above would be particularly useful for a specific condition which has a high prevalence and potential for improved health outcomes through better information sharing and teamwork. Heart failure or chronic obstructive lung disease are initial suggestions which could serve as a testing ground for exactly how the PCEHR should work for consumers.

Getting some early testimonials would also be a great marketing strategy which in many cases can lead to growing a critical mass of support for any new initiative.

Are you looking forward to the outcomes of the PCEHR review? Do you have any ideas or feedback on how this should be undertaken to create a more patient based service? Please let me know in the comments below.

[1] Penson, Joel (April 2013). How I Make Decisions. Better Decisions Blog.

http://betterdecisionsblog.blogspot.com.au/2013/04/how-i-make-decisions.html

[2] Penson, Joel (July 2013). Finding the meaning of life. Better Decisions Blog.

http://betterdecisionsblog.blogspot.com.au/2013/07/finding-meaning-of-life.html

[3] Albert, Dori (May 2013). Crowd Sourcing Drives Brand Value by World Leaders. Lionsbridge Blog.

http://blog.lionbridge.com/enterprise-crowdsourcing/2013/05/28/crowdsourcing-drives-brand-value-for-world-leaders/

[4] USAID (October 2013). Position Statement on Importance of Democratic Governance.

http://www.usaid.gov/what-we-do/democracy-human-rights-and-governance

[5] International Association of Public Participation (2013). Spectrum of Public Participation.

http://www.iap2.org.au/resources/iap2s-public-participation-spectrum

[6]  Kate McDonald (13 November 2013). Barriers to PCEHR uptake in the real world, IT + Pulse.

http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1660:barriers-to-pcehr-uptake-in-the-real-world&catid=16:australian-ehealth&Itemid=327

[7] Lorraine Twohill (April 2012). The Curious Case of Creativity, Google Think Insights.

http://www.google.com/think/articles/the-curious-case-of-creativity.html