Impact, obstacles and boundaries of patient partnership: A qualitative interventional study in Lebanon.

The patient as partner approach is a modern ‎model of patient engagement that integrates the patients' knowledge and skills into managing their own health. This study aims to evaluate the benefits and barriers of patient partnership in a healthcare setting. It is a qualitative and interventional study that implemented a patient and family partnership committee (PFPC) at a Lebanese hospital during the COVID-19 pandemic. A purposeful guided approach was used for sampling, and data was collected by structured questionnaire ‎interviews. Seven PFPC team dynamics building blocks were generated: transparency, support, motivation, comfortable communication, mutual understanding, equity in positions and empowerment to participate. Both the patient partners (94%) and healthcare professionals (90%) were satisfied with the PFPC experience. The majority of the healthcare professionals (HP) reported a noticeable change in the quality improvement process (QIP) (89%) and approved to standardize the PFPC (93%). The patient partnership benefits were clear, and the PFPC was perceived positively by both patient partners (PP) and HP. PP experienced distress relief (37%), gained ideas (41%) and felt that their opinion was heard (27%) after PFPC participation. PP reported benefits to hospitalized patients, including respect and care (63%) and patient satisfaction (20%). The main challenges for PFPC implementation were time availability and conflicts. Lessons from patient partnership can be utilized to improve the patient care policies in the Lebanese healthcare system. Moreover, developing countries can benefit from the patient partnership approach in their healthcare settings.

Introduction

Quality is defined as the patient’s overall judgment on the excellence of healthcare services [1]. Although the quality of care is linked directly to patients, they are excluded during the quality improvement process (QIP). In this paternalistic model of care, patients are not involved in important QIP such as areas for improvement analysis and decision-making. The World Alliance for Patient Safety urges health care organizations to direct their healthcare improvement efforts into patient and family participation [2]. The patient as partner concept integrates the involvement, participation, engagement and empowerment terms. These terms are differentiated by the extent of the patient intervention. The highest rank of the patient and caregiver relationship ladder is patient partnership. The intermediate one is patient participation, in which the healthcare staff assesses a patient’s knowledge and provides education accordingly. The lowest rank is the patient involvement in concerns such as the timing of visits and daily living recommendations [3]. Patient partnership represents the optimal mean of patient participation in healthcare quality improvement. Several studies have proposed different definitions for patient partnership, which are summarized in Table 1.

Table 1

The different patient partnership definitions from literature.

Source	Patient partnership definition
Fumagalli Health Policy [4]	The concept of patient engagement integrates the patient’s knowledge, skills, individual ability and willingness to actively participate in managing his own health with the interventions provided by the healthcare practitioners, designed to increase activation and promote positive patient behavior.
Vahdat Iranian Red Crescent Medical Journal [5]	The engagement of the patient in decision making by expressing opinions and thoughts about different treatment choices, which includes a coordinated sharing of information and feelings between the patient and the healthcare professionals while accepting health team instructions.
The African Partnerships for patient safety (APPS) [6]	A collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical.
The Centers for Medicare and Medicaid Services (CMS) [7]	The patients and families are partners and are crucial in defining, designing, participating in and assessing the care processes and systems that deliver care to them in a respectful manner and based upon patient preferences, needs, and values.

The first patient partnership office was established in Canada by a chronically ill patient who believed in the experiential knowledge acquired during a long illness [8]. A study in Montreal revealed that trained patients who participated in quality improvement committees suggested solutions that were more simple to implement than those proposed by professionals [9]. Another study exploring patient partnership in Florida focused on the shared decision-making between patients, their families and the diagnostic team. It revealed the importance of information disseminated by patients in improving the clinical care delivered by practitioners [10]. Patient partnership also supports professional development by valuing the voice of the frontline workers, fostering a trust culture and providing problem-solving authority to employees [11]. Empowerment of staff in decision-making results in sustainable improvements of the healthcare system.

Patient partners and healthcare providers identified many barriers to patient partnership. The most challenging one was accepting the new healthcare giver-role of patients [12]. Additional barriers were the lack of health literacy [12], demographic variables, disease severity [12], lack of computer and internet access [13], time availability and mental health [14]. Moreover, healthcare providers tend to question the knowledge of individuals without medical training or academic degrees [15].

Patient partnership initiatives are centralized in developed countries, especially in Canada’s center of excellence on partnership with patients and the public (CEPPP) [8,9]. Still, the boundaries of patient partnership have not been assessed yet. There’s little to no evidence of research on partnership in developing countries. The Lebanese accreditation system allocated a whole chapter for the patient and family rights as a base for engagement [16], but failed to mention patient partnership. This study aims to explore the benefits and barriers of implementing a patient and family partnership committee (PFPC) in an under-resourced and low-income country. Moreover, it aims to determine the perception of participants on the extent of patient contribution to the QIP through the PFPC. This study also aims to assess the decision-making boundaries of the patient partners in PFPC. Our results will create knowledge and tools to initiate, implement and evaluate patient partnership in healthcare settings in Lebanon.

Materials and methods

Research design

This qualitative study included 68 participants from Saint George’s hospital (SGH) between July 1st, 2020 and September 15th, 2020. We conducted descriptive analysis on data collected from 27 healthcare professionals (HP) and 41 patient partners (PP).

Ethical consideration

The Saint George’s Hospital ethical committee approved this study. Written consents were obtained from the PFPC members who attended the direct meetings. Those who attended online provided verbal ‎consents. Data was kept confidential and used for research purposes only. ‎

Recruitment and selection

A total of 68 participants were included in this study. Before selection, an online video on the value of partnership was disseminated. It was intended to increase awareness and encourage participation among patients, family members and healthcare workers. The sampling strategy was based on a purposeful theory-guided sampling approach [17], which assumes that certain participants with specific characteristics are good candidates to reach the study’s objectives. An eligibility screening questionnaire—defined by the inclusion criteria—was implemented in the selection and recruitment of patient partners. It was available in a google survey form and disseminated by the social media platforms of SGH. Since it came back without responses, we directly contacted random potential patients and family members who were staying at the hospital during the recruitment phase. Out of 1997 hospitalized patients, we contacted 70 candidates. Only 41 patients and family members were eligible and willing to participate as a PP. Out of 389 healthcare employees, 121 were multidisciplinary healthcare workers with a minimum experience of two years and previous quality improvement expertise. However, only 27 HP were willing to participate, considered eligible and included.

The inclusion criteria for the PP were as follows: having—personally or through a family member—a wealth of information regarding hospitalization from a chronic illness experience (i), being in a period of stable health to allow safe participation during meetings (ii), having a constructive critical attitude and an ability to identify areas for improvement (iii), possessing good personal communication skills (iv), driven by the will to help others beyond personal experience enhancement (v), being available and willing to allocate time and effort (vi) and being treated at SGH or other healthcare facilities (vii).

Regarding the HP’s inclusion criteria, the study enrolled: multidisciplinary healthcare workers with a minimum of two years of experience to facilitate the evaluation of healthcare services (i); hospital leaders, since they are the primary policymakers (ii); physicians with different specialties (iii); healthcare workers with previous quality improvement expertise and training (iv); healthcare workers working in SGH or other healthcare facilities to enrich the quality improvement discussion (v). These assumptions used for successful implementation were carefully studied and compared to similar methodologies from literature [3,8,9].

Participants were excluded if they were less than 18 years old (i), unwilling to participate in the PFPC meetings (ii) or not motivated to enhance the healthcare experience (iii). PP were excluded if they didn’t have a chronic illness experience. Finally, HP with less than two years of professional experience were excluded.

Methodology

The partnership coordinator provided individualized 15-minutes training to each participant before the PFPC meetings. Training topics included the patient partnership concept, QIP and medical and quality terminology. The PFPC was implemented in focus groups consisting of at least 2 PP and 2 HP. Its time length ranged between 60 and 90 minutes. The participants selected a QIP topic to discuss in the PFPC among three options: conversation time with patients (i), workplace violence (ii) and hand hygiene compliance (iii). Participants who attended direct meetings were provided with a free meal and parking space. The process for PFPC implementation is summarized in Fig 1.

Fig 1

Flowchart of the patient and family partnership committee process.

(1) PFPC is initiated by posting a video online to increase the awareness of patients on patient partnership. The opportunity for participation in the PFPC is announced for HP at the healthcare setting. (2) After recruiting eligible participants, patient partners are trained individually by the PFPC coordinator. Healthcare professionals are also trained prior to the meetings. (3) The PFPC meetings are conducted directly or online, and (4) participants are evaluated by individualized interviews. (5) After data collection, the quality improvement process can be initiated. (6) Moreover, the suggested opportunities for improvement can be addressed. (7) Participants are followed-up post-PFPC.

Data collection

We collected data using direct or online individualized interviews. We utilized two different structured qualitative questionnaires for PP and HP. Patients, healthcare providers and research experts checked the questionnaires for their content validity, length appropriateness and questioning flow. The language in both questionnaires was clear and comprehendible. To explore the theoretical framework, many data points should be generated in qualitative research. The questions in both interview guides were open leading to the emergence of specific themes. Interviews were conducted between August 2nd, 2020 and September 5th, 2020. They ranged in length between 10 and 30 minutes. Theoretical saturation was attained following the completion of 15 out of 25 PFPC and 50 out of 68 interviews. Thus, the data collected had identified and filled the properties of the theoretical category [17]. The remaining PFPC and interviews did not produce new ideas, but rather confirmed and stabilized the previous theoretical leads.

Data analysis

We used the grounded theory approach for data analysis [17]. We analyzed qualitative data from the inductive inquiries in parallel with data collection. We initiated analysis by an open coding phase following the first 10 interviews. Phase one consisted of reviewing the ‎interview transcripts, identifying repeating themes, defining excerpts, and tagging them into an initial coding system. The second phase of analysis was the selective coding, where we organized the primary codes developed and grouped them into categories. A thematic coding structure was hence created by linking, comparing and discussing data. We had utilized the paper coding technique to conduct the different stages of coding strategies. The approved coding categories were then applied to all interview transcripts to ensure grounding of the data. This established a conceptual outline of the participants’ perception of the patient partnership approach. The research team constantly interpreted possible relations and compared emergent themes until attaining theoretical saturation. ‎The coded data was entered and analyzed using the IBM SPSS statistics software (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Descriptive analysis was performed on data collected from interviews ‎with patients and HP. The research team focused on identifying and minimizing potential sources of bias. The sampling method may constitute a potential source of bias by only recruiting patients who were more capable or willing to participate. Another concern was that some participants may have answered the interview questions in a manner which they perceived as socially acceptable. To mitigate this bias, we conducted individualized interviews, provided definitions of concepts with examples as needed and related concepts to scenarios. The subjective nature of qualitative studies complicates a researcher’s attempt to completely detach from the data. To minimize bias during data interpretation, we recorded summaries of interviews and conducted regular research meetings. Moreover, two researchers independently analyzed the data and then compared their results jointly.

Results

Sample characteristics

Of 68 eligible and included participants, 27 (40%) were HP and 41 (60%) were PP. Half of the PP were represented by family members (51%). The majority of PP occupied jobs that were not related to the healthcare industry (76%). Cancer (66%) was the most common chronic illness among PP. Only 37% of PP had at least 10 years of experience with healthcare services. Nurses took the lead among HP who participated in the PFPC (41%) followed by leaders with managerial titles (33%), quality and safety specialists (22%) and physicians (4%).

Females constituted the majority of PP (61%) and HP (70%) participants (Table 2). The median age of PP and HP was 43 and 28 years respectively. Most PP (71%) and HP (59%) participated directly in the PFPC meetings. All participants chose the QIP topic pertaining to the conversation time with patients.

Table 2

Sample characteristics of the healthcare professionals and the patient partners.

Sample Characteristics	Healthcare professionals (n = 27)	Patient Partners (n = 41)
Gender, n (%)
Male	8 (30%)	16 (39%)
Female	19 (70%)	25 (61%)
Age, n (%)
Less than 40 Years	24 (89%)	18 (44%)
More than 40 Years	3 (11%)	23 (56%)
Age, median (SD)	28 (6.79)	43 (13.57)
Selected QIP topic1, n (%)
Conversation Time With Patients	27 (100%)	41 (100%)
Meeting type, n (%)
Direct Meeting	16 (59%)	29 (71%)
Online Meeting	11 (41%)	12 (29%)

1 Selected from three suggested topics: Conversation time with patients (i), workplace violence (ii), and hand hygiene compliance (iii).

Abbreviations: QIP, Quality Improvement Process; SD, Standard deviation.

The team collaborative process and dynamics

All PP agreed that the PFPC was easy to join online or through direct meetings. PP were active members and felt comfortable communicating their ideas. The majority of HP had an excellent impression of the PP solutions (78%). HP agreed that PP were active members (89%) who were comfortable in communicating ideas (93%). HP had to change some quality terminology used in the PFPC meetings.

PP considered having a motivation to participate (44%), ideas (32%) and personal experience (24%) as supporting elements for the PFPC. Moreover, HP expressed the need to have an appropriate PFPC time and place (26%), empowered patients (59%) and transparency (15%).

The PFPC advantages

Both HP and PP learned from the patient partnership experience and acquired communication and listening skills. Moreover, HP reported gaining brainstorming (11%) and interview skills (19%) and PP reported respect (5%) and analytical skills (12%).

Both PP and HP expressed benefits to hospitalized patients including respect and care, patient satisfaction and enhanced ‎patient ‎experience. Only PP reported the shared decision-making benefit (10%).

Regarding the benefits ‎gained by participants, ‎‎ PP experienced distress relief (37%), felt their opinion was heard (27%), were satisfied by the new ‎experience (12%) and gained ideas (41%). HP reported benefits of mutual understanding (48%), gaining new experience (37%), shared decision making (22%) and work enhancement (4%).

Concerning the PFPC implementation advantages, both PP and HP reported patient loyalty preservation (i), achieving patient satisfaction (ii) and quality improvement without limitations (iii). PP additionally expressed that patients can finally receive their rights (49%). Moreover, HP mentioned PFPC advantages of high-quality care delivery (30%), frontline workers empowerment (22%) and the bolstering of mutual understanding (11%).

The satisfaction with the partnership approach

The majority of PP (94%) and HP (90%) ‎were highly satisfied with the patient partnership experience. HP reported a noticeable change in the QIP (89%) and approved standardizing the PFPC at SGH (93%).

The challenges facing PFPC implementation

All HP identified challenges facing the patient partnership process, and around half of PP (54%) did not identify any. The main two challenges mentioned by both PP and HP were conflicts and time availability. Only PP considered the COVID-19 pandemic as a challenge (17%). The challenges that were solely expressed by HP were confidentiality (11%), PP distraction into personal stories (19%), implementation of the PP suggested solutions (37%) and the PP’s educational level (26%).

The opportunities for PFPC improvement

Only 35% of all participants did not recommend any improvements. The main opportunities for improvement were identified as allocating additional PFPC time and providing pre-PFPC training through workshops and hospital rounds. Recommendations that were solely suggested by PP were post-PFPC follow-up (10%), permitting authorized decision-making (10%) and pre-scheduled meetings (7%). Suggestions unique to HP were catering (15%), PFPC policy development (15%) and implementing directed questions instead of open discussions (15%).

The PFPC coordinator

Both PP (100%) and HP (96%) received the needed support and guidance from the PFPC coordinator. The latter’s role was identified by both groups as the support and motivation to participate (i) and the explanation of unclear concepts (ii). HP considered the discussion management as an additional role of the PFPC coordinator.

The PFPC autonomy boundaries

We assessed the safety of allowing PP to become authorized decision-makers. Participants were asked to choose between healthcare quality concepts and their personal preferences in different decision-making scenarios. Most participants chose concepts directly related to safety and quality ‎over personal preferences (Table 3).

Table 3

The autonomy boundaries of decision-making compared between healthcare professionals and patient partners.

Safety and Quality Concepts	Healthcare Professionals n (%)	Patient Partners n(%)
Responsibility Toward Other Patients	25 (93%)	40 (98%)
Medical Recommendations	18 (67%)	30 (73%)
Resource Utilization	22 (81%)	30 (73%)
Roles and Regulations	23 (85%)	31 (76%)
Quality and Safety Opinion	27 (100%)	34 (83%)
Nurses’ Recommendations	25 (93%)	38 (93%)
Protecting the Common Good	24 (89%)	34 (83%)
Protection From Danger	27 (100%)	39 (95%)
Evidence Based practice	22 (81.5%)	35 (85%)

Discussion

Despite variations in methodology, patient partnership initiatives usually produce favorable outcomes. In this study, we aim to determine the impact and limitations of PFPC implementation in a hospital setting. We assessed the PFPC advantages, barriers for implementation and the opportunities for improvement. Unlike previous studies, we assessed the boundaries of delegating decision-making to the patient partner.

Whether direct or virtual, PFPC meetings were easily accessible for participants in our study. Unlike previous studies [18], pre-training for a long period was not feasible due to the COVID-19 pandemic. ‎Black et al. suggested recommendations to achieve meaningful engagement in successful PFPC meetings [13]. Moreover, certain studies reported the PFPC elements of support solely from the patient partners perspectives [9]. We assessed the engagement factors according to both HP and PP perspectives. We identified seven PFPC team dynamics building blocks: transparency, support, motivation, comfortable ‎communication, mutual understanding, ‎ equity in positions and empowerment to participate.

Similar to previous results [9], participants in this study reported a continuous learning experience. Communication and listening skills were improved in both PP and HP. The education provided to HP before PFPC implementation may have been beneficial in increasing their awareness. The skills acquired by front liners through PFPC bolsters the notion ‎that partnership targets the human and talent management dimension.

We found partnership benefits similar to those reported in literature [3,8,9]. A strong point of this study is that it evaluates the benefits gained by hospitalized patients as well as the PFPC participants. The PFPC advantages achieved were not related to the ‎PP being well-educated, young or involved in the healthcare ‎domain. Thus, our eligibility screening questionnaire was a reliable tool for PP recruitment. Despite the objective selection process, HP still tend to doubt the patient’s ‎knowledge and thinking [19]. In our study, 26% of HP considered the PP education level as a challenge for PFPC implementation. This emphasizes the importance of pre-PFPC training for both PP and HP.

Participants in this study recommended several opportunities for improvement to enhance the partnership process, which were beyond our research objectives. The recommendations were not implemented due to circumstantial limitations. The COVID-19 pandemic prevented conducting the pre-meeting workshop. Moreover, it reduced the feasibility of holding direct PFPC meetings. Another pandemic-specific limitation was the fear of hospital-acquired infection, which may have affected recruitment. The poor internet ‎connection faced by under-resourced patients may have also restricted participation. Similar to previous studies [13], our project spanned a relatively short time. Moreover, ‎our evaluation of the partnership approach was based on interviews only. Unlike other studies [9], we did not clinically assess the ‎positive outcomes from partnership. Finally, financial support is a crucial element in partnership studies, but it was lacking in ours.

The PFPC coordinator played an important role in achieving participants’ satisfaction. To maximize the involvement of partners, he motivated and empowered them and managed discussions in the committee. This role was only mentioned in literature by the Montreal university study under the term ‘patient coach’ [9]. Our study emphasizes that the professional and supportive communication of a partnership coordinator is crucial for partnership success.

We assessed for the first time the boundaries of delegating the decision-making power to patient partners. Participants were asked to choose between quality and safety concepts in healthcare and their personal preferences. ‎The PP participants demonstrated responsibility and altruism by adhering to quality and safety concepts. Thus, the PP recruited by objective ‎eligibility criteria can be empowered, supported and authorized. Balance is the key to ‎preserve the beneficial outcomes for everyone.

Patient partnership attains the patient partner and the frontline staff satisfaction simultaneously. When adopted by healthcare organizations, a single process like partnership can achieve major healthcare quality goals without the ‎need for maximizing efforts. Patient partnership needs management support and staff motivation to embed the process in the quality management culture.

Conclusion

Partnership is needed to raise awareness among healthcare organizations and the general public. Developing countries can benefit from our experience to assess implementing PFPC in their healthcare facilities. This study showed that the implementation of PFPC in a Lebanese hospital produced favorable outcomes. The main PFPC advantages were patient loyalty preservation, achieving patient satisfaction and quality improvement without limitations. Partnership can be additionally improved by pre-PFPC training, real PP experience sharing, assigning a PFPC coordinator staff and proper time allocation.

The patient and family members recruited in this study were valued as underutilized resources. ‎They have the potential to directly aid a healthcare organization in achieving favorable outcomes of safe and ‎high-quality care. This study highlights the importance of patient empowerment and ‎its ability to bring changes that expert healthcare providers could not achieve alone. Finally, we recommend standardizing the PFPC in the patient and family rights chapter of the Lebanese accreditation.

Gantt chart ‎representation of the timeline of PFPC implementation at SGH.

(TIF)

Click here for additional data file.

(DOCX)

Click here for additional data file.

7 Mar 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Paavani Atluri

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

4. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The current study focuses on a patient partnership experience in a Lebanese hospital. This is an interesting study relevant to the current qualitative research in the developing low-middle income African countries such as Lebanon, where human and financial resources are limited. The present study was carried out during this challenging COVID-19 pandemic, where a hospital-based study was difficult to conduct.

There are a few points which may improve the present manuscript are enlisted below:

Specific points

1. The whole manuscript (MS), especially the Introduction, needs to be proofread for coherence and grammar. A few examples are page 4, line 66 use of ‘unsurprisingly’ or use of ‘competent’ on page 10 line 180 was not apt.

2. An extended form and the abbreviation in the first encounter and only the abbreviation later on. Some of the abbreviations, such as QIP, the extended form, was missing in the text. [Page 2, line 30]

3. Author should add the ethical committee approval number in the MS. [Page 6, line no 105]

4. On Page 7, lines 119-120, the author should clearly mention the process of study participants, and the denominator was missing in the text. Among how many patients, x number of patients were eligible and among them how many patients were willing to participate, similarly, for the hospital staff.

5. Reference for SPSS version was missing. [Page 9, Line 177 ]

6. As this is a qualitative study, the author should mention which other software and techniques have been used for the data analysis, such as NVIVO etc.

7. In the result section, Table 2 QIP topic is unclear; what do they represent?

8. Given the small sample size, in Table 2, Four Age categories may not be useful. I can suggest merging it into two categories less than 40 or More than 40. Also, age as a continuous variable with Median (SD) should be added.

Overall, this is an interesting study; however, it requires major English proofreading and minor edits in the MS.

Reviewer #2: Applaud the attempt, patient participation is key in good outcomes. However, the way the inclusion for patients was set up, there is inherent bias. These appear to be patients that are more willing and capable to participate. This does not detract from the findings but can be a launching point for a follow up study to try and recruit patients that may need more help getting involved.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Isha Shah

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Apr 2022

We would like to thank the reviewers for their thorough evaluation and comments that helped to improve our manuscript. For easier visualization, the reviewers’ comments are formatted in the bold and italic font styles. Please note that the line numbers mentioned in this document are compatible with those of the clean version of the manuscript.

Reviewer 1

The current study focuses on a patient partnership experience in a Lebanese hospital. This is an interesting study relevant to the current qualitative research in the developing low-middle income African countries such as Lebanon, where human and financial resources are limited. The present study was carried out during this challenging COVID-19 pandemic, where a hospital-based study was difficult to conduct. There are a few points which may improve the present manuscript are enlisted below:

Thank you for the positive evaluation and for your comments.

1. The whole manuscript (MS), especially the Introduction, needs to be proofread for coherence and grammar. A few examples are page 4, line 66 use of ‘unsurprisingly’ or use of ‘competent’ on page 10 line 180 was not apt.

The whole manuscript was revised for grammar and coherence.

2. An extended form and the abbreviation in the first encounter and only the abbreviation later on. Some of the abbreviations, such as QIP, the extended form, was missing in the text. [Page 2, line 30]

We added the extended form for each abbreviation upon its first appearance in the text. The abbreviation list was proofread to include all the abbreviations mentioned in the text in alphabetical order.

3. Author should add the ethical committee approval number in the MS. [Page 6, line no 105]

Thank you for your comment. However, an approval number is not applicable in our case. The Saint Georges Hospital’s ethical committee provides written approval letters for qualifying research applications. We noticed from our letter that they do not seem to include a corresponding approval number in such letters. We contacted the hospital for assistance and it appears that a specific approval number is not usually granted for all applicants to the ethics committee.

4. On Page 7, lines 119-120, the author should clearly mention the process of study participants, and the denominator was missing in the text. Among how many patients, x number of patients were eligible and among them how many patients were willing to participate, similarly, for the hospital staff.

The sampling method was a purposeful guided approach, where sample selection was based on preset inclusion criteria for both patient partners and healthcare professionals.

It is important to emphasize on the fact that willingness to participate was one of the inclusion criteria elements. Thus, if a participant met all other elements of eligibility and was not motivated or didn’t have the will to participate, he/she was considered ineligible.

• The requested denominators were added to the materials and methods section, recruitment and selection sub-section, Lines 120-124:

{Out of 1997 hospitalized patients, we contacted 70 candidates. Only 41 patients and family members were eligible and willing to participate as a patient partner. Out of 389 healthcare employees, 121 were multidisciplinary healthcare workers with a minimum of two years of experience and a previous quality improvement expertise. However, only 27 HP were willing to participate and thus considered eligible and included.}

5. Reference for SPSS version was missing. [Page 9, Line 177]

• The SPSS version reference was added to the materials and methods section, data analysis sub-section, Lines 185-186:

‎{The coded data were entered and analyzed using the IBM SPSS statistics software (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.)}

6. As this is a qualitative study, the author should mention which other software and techniques have been used for the data analysis, such as NVIVO etc.

We didn’t use other software for qualitative data analysis. The research team used paper coding for both the open and selective coding phases.

7. In the result section, Table 2 QIP topic is unclear; what do they represent?

Thank you for this comment. We agree that this data needs clarification and have addressed the issue in the manuscript.

One of the study’s goals was to implement a quality improvement process (QIP) through the patient and family partnership committee (PFPC) meetings. For the purpose, the participants had to choose one priority focus area to analyze its root causes, discuss the opportunities for improvement and suggest corrective actions.

Three topics were suggested by the research team: conversation time with patients (i), work place violence (ii), and hand hygiene compliance (iii). These priority focus areas are actually common quality measures that are sustainably monitored by the healthcare quality staff and policy makers in the healthcare field.

All 68 participants (27 HP and 41 PP) in the PFPC chose to discuss the ‘‘conversation time with patients’’ quality measure.

In summary, healthcare practitioners are not able to provide sufficient time for a meaningful conversation with patients when providing care. As a result, patients and their families may lack the important health education needed for an effective self-management of their illnesses. Both patients and healthcare practitioners had realized the hazardous effects of conversation time decrease during healthcare service delivery. They eventually agreed to enhance this process for a safer care through partnership.

Introduced changes:

• To clarify the idea for the reader, a footnote was added to Table 2 listing the QIP topic choices. Moreover, a short abbreviation list was added beneath the table to demonstrate the extended form of QIP.

• Information in the text can be found in the materials and methods section, methodology sub-section, Lines 147-148:

{ The participants selected a QIP topic to discuss in the PFPC among three options: conversation time with patients (i), workplace violence (ii) and hand hygiene compliance (iii). }

8. Given the small sample size, in Table 2, Four Age categories may not be useful. I can suggest merging it into two categories less than 40 or More than 40. Also, age as a continuous variable with Median (SD) should be added.

We agree with the reviewer and thank them for the insightful comment.

• The corresponding changes are shown in Table 2:

Age was categorized into two categories: less than 40 years (i) and more than 40 years (ii).

A row was added to represent age as a median with standard deviation (SD).

Overall, this is an interesting study; however, it requires major English proofreading and minor edits in the MS.

Thank you for your comments which helped to increase the manuscript’s quality. We hope that the major English proof-reading request and the minor manuscript edits were addressed successfully.

Reviewer 2

Reviewer #2: Applaud the attempt, patient participation is key in good outcomes.

Thank you for the constructive feedback and encouragement.

We support your notion that patient participation is key in good outcomes. This study is a light of hope in the journey to the implement patient and family partnership as the most advanced model of care in a low-income country. Patient partnership emphasizes on the crucial empowerment and authorization of the patient and his experiential knowledge. It engages patients in all aspects of healthcare system design, delivery and monitoring, rather than just the treatment plan.

However, the way the inclusion for patients was set up, there is inherent bias. These appear to be patients that are more willing and capable to participate. This does not detract from the findings but can be a launching point for a follow up study to try and recruit patients that may need more help getting involved.

We agree about the bias that can be introduced by the selection criteria. One of the major barriers that we faced during implementation was the healthcare practitioners’ presumption of the incapability of patients to decide (due to their lack of academic knowledge and expertise in healthcare). Thus, if we have not selected partners with specific characteristics, this new phenomenon would have faced major barriers in its implementation for a first time in a healthcare setting.

Moreover, this was a preliminary investigation to explore the patient partnership phenomenon and its specific benefits and barriers in an under-resourced developing country. The identified elements of the partnership experience will be indispensable for effective and reliable future investigations. After this successful implementation, we are currently preparing for a follow-up study that will widen the aspect of participation from different patient groups, including patients with barriers and difficulties. We hope that by the end of our investigation, Lebanese hospitals will be encouraged to consider patient partnership in their quality improvement approaches.

• We reported the bias in the sampling method in the materials and methods section, data analysis sub-section, Lines 188-189:

{The research team focused on identifying and minimizing potential sources of bias. The sampling method may constitute a potential source of bias by only recruiting patients who were more capable or willing to participate.}

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

15 Jun 2022

Impact, obstacles and boundaries of patient partnership: a qualitative interventional study in Lebanon

PONE-D-21-25886R1

Dear Dr. Dayekh,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Paavani Atluri

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors have successfully addressed all the major and minor comments. Best wishes to the authors for their further research. I have no further concerns.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prabal Chourasia

**********

28 Jun 2022

PONE-D-21-25886R1

Impact, obstacles and boundaries of patient partnership: a qualitative interventional study in Lebanon

Dear Dr. Dayekh:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Paavani Atluri

Academic Editor

PLOS ONE