On June 2, 2007, Laura Lorenz presented a slide series on the role of fair process and the importance of the patient perspective in the rehabilitation of traumatic brain injury survivors at the annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the PowerPoint® File (670 KB).
Laura S. Lorenz, M.A., M.Ed., Ph.D. Candidate
Schneider Institutes for Health Policy
The Heller School for Social Policy and Management,
Brandeis University
This organizational behavior model, adapted from March & Simon's 1958 text, Organizations, involves taking a complex model of reality and simplifying it in order to apply problem-solving processes. The model predicts that division of labor causes organizational subunits to consider only some of the information that could be important in helping them reach goals.
Narrowing the focus of information leads to a differentiation, or splintering of subgoals. Together time pressure and these splintered subgoals cause organizations to narrow their focus of attention.
This model is a good snapshot of what happens in the rehabilitation organization.
March & Simon 1958
This graphic serves to illustrate the splintering of subunits in the rehabilitation organization, where different therapies often occupy separate units.
Each therapy has distinct subgoals, which become their focus of attention. Time and subgoal pressures mean that the provider may limit discussions of possible treatment approaches with the TBI patient—thus creating limits on the rehabilitation focus of attention.
The March & Simon model encompasses rehabilitation as it occurs inside the organization. Yet TBI survivors spend only a small amount of time in rehabilitation services. For the most part, they are in their communities and homes.
This model does not include the environment, where patients must take action to heal. It does not include the patient's perspective on quality of care and the healing process. Where is the patient? Where are the patient's goals? This model is not patient-centered care.
March & Simon 1958
From a patient perspective, quality is not a simple concept but is best understood in terms of five dimensions, as described in this graphic by Chilingerian. These dimensions are:
Failure to include these aspects of quality from a patient's perspective can be considered a justice issue (van den Bos, et al, 1998).
Chilingerian 2004
Kim and Mauborgne, in their seminal 1997 article, argue that justice is a performance issue. Their research with 19 companies found a direct link between organizational processes, attitudes, behavior, and performance. They argue that procedural justice in the form of fair process leads to trust and commitment, voluntary cooperation, and exceeded expectations.
Kim & Mauborgne 1997
In the rehabilitation organization, fair process occurs during the patient-provider interaction. Fair process at this level is interactional and informational justice.
Conceptually, fair process opens the door to bringing the patient's expertise into the work of developing rehabilitation goals and strategies. With TBI, there are no cookie cutter solutions. Each patient's injury and healing are different, and quality means tailoring rehabilitation plans to the individual. With fair process, there is give and take as providers explore diagnostic issues and treatments with patients, explain the rationale for decisions, and set expectations about roles and responsibilities. With fair process, evaluation and learning are mutual.
Kim & Mauborgne 1997; Van der Heyden, et al 2005; Chilingerian 2006
In this image, a wire is sticking out of the wall, not connected to anything. For this respondent, the image communicates how her brain felt when she was newly injured and for the first two or three years after. She felt that there were gaps in her brain, and her thoughts would bump up against these gaps and prevent her from connecting with other people and her environment.
This analysis of her interview text structures her discourse into its idea units. I then grouped these units into 10 four-line stanzas and three 2-line codas. The stanzas address her perceptions of her brain injury; the codas reveal her perceptions about communicating using a photograph. I created a title for each stanza and coda, using key phrases by the respondent. And finally, I grouped the stanzas and codas into 4 parts, again creating titles using the respondent's own words.
Part 1: Why I took this picture
Stanza 1: That's how I felt.
Stanza 2: I thought that kind of depicted it.
Coda: A lot of unsaid things there.
Part 2: Everything was new
Stanza 3: It was like living in the middle of nowhere.
Stanza 4: It was as though you were just born anew.
Coda: Hard to explain.
Stanza 5: I basically laughed through every day.
Part 3: How I see it now in hindsight
Stanza 6: It all had to like be reestablished.
Stanza 7: I had so many gaps in my brain.
Stanza 8: My reaction was this laughter.
Coda: A perfect way to sum it all up.
Part 4: I couldn't feel really connected, in lots of ways
Stanza 9: Are you really, truly connecting?
Stanza 10: That's what I meant.
This summary of the titles for the stanzas, codas, and parts is a type of executive summary, or abstract, if you will, of what this respondent said about this picture. The narrative shows coherence. In part 1, she introduces the picture and why she took it. Part 2 explains how she felt when she was first injured. In part 3, she distances herself from that time and looks at it from her current perspective. Part 4 sums up her narrative and what she meant.
Becker 1986, Gee 1991, Reissman 1993, Rose 2007
The photograph becomes the focus of the interaction and engages the professional as well as the patient in exploring experience and building relationships. For this study, the camera becomes an instrument of justice.
Using an organizational lens helps to illuminate gaps in our knowledge and new avenues of research. Potentially an organizational lens will help us to identify ways to translate these research findings to quality improvement interventions in future.
Current as of September 2007
Internet Citation:
Using Fair Process to Cross the Quality and Healthcare Chasm: Eliciting the Perspective of Traumatic Brain Injury Survivors. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/lorenztxt.htm