Unchecked assumptions can have a negative impact on health care outcomes. Built into the processes and tools used in everyday clinical and health care settings are unchecked assumptions about people and groups. It is particularly important for practice managers to spend time thinking about the unchecked assumptions they have designed into their patient interaction processes and systems, and to correct these as required.
But first, what do we mean by unchecked assumptions?
Opinions (rather than verifiable facts) and implicit bias (unconscious beliefs about a social group) contribute to unchecked assumptions about the people who are our patients. Unchecked assumptions percolate through how we expect a patient to interact with us in a clinical or health care consultation setting, where that interaction happens, what resources are needed for that interaction, how long it happens for, and when it happens.
To illustrate what we mean, the following slide, taken from one of our training presentations, attempts to show an eye health care practice's unchecked assumptions about how a new patient "should" behave when they arrive at the practice.
Focus on the second step (above) involving a new patient receiving and completing a new patient registration form. Millions of people, every single day, are asked to fill in a patient registration form when they arrive at a clinic or practice or hospital. It is such a common task that we often forget to look at it critically and ask ourselves: what are the unchecked assumptions about the ideal / idealised patient? Let's dive in.
When you hand over a new patient registration form to a new patient, ask yourself: what are you assuming they can and cannot do? What are you assuming about the relationship of power between the patient and you, the health care professional?
- Does the patient have adequate reading skills to read and understand what is being asked of her on that form?
- Does the patient have adequate writing skills to respond, in writing, with the necessary information?
- If the patient is literate, are they able to physically see the text on the form or screen? Is it too small? Too light? Too full of jargon?
- Is the form designed with font face, font size and font colour (and, if printed, is it printed on matte paper) that offers optimum legibility?
- Is there enough space in the form for the patient to write out her responses? Remember: handwritten text often takes up much more space than typed text.
- Is the form available in languages other than English? If it is not, is there a staff member who can act as a translator?
- Is the patient expected to complete the new patient registration form in private or in public? Think about this: if a person feels shame about her ability to read or write, she may choose not to answer certain questions on a patient registration form because she's uncertain about how to spell a particular term from her medical history. Instead of disclosing something important about her medical history, she may leave that bit of information out entirely because she doesn't want to appear ignorant in front of a health care professional.
- Is there adequate lighting in the physical setting in which the patient completes the form? Task lighting is essential for reading and writing when a person has low vision. Without task lighting (e.g. a desk or reading lamp), a patient might not be able to see the form's contents clearly.
- Is there enough time allocated to the task of completing the form, especially in an optometry setting where vision is likely to be less than perfect? It is common to ask a patient to arrive 10 minutes ahead of their appointment so that they can, during this time, complete the registration form. But is 10 minutes truly enough time for this task for a patient with low vision? Often, it is not.
- In instances where implicit bias about a particular social group exists, the nurse or receptionist or optometrist holding these biases can communicate non-verbally and verbally their assumption that the patient has lied in their responses on the form. For example, a receptionist was overheard asking a new patient the following: "Are you sure that is your actual home address? You need to bring a utility bill to prove that it is really your home address."
The list above is not exhaustive. We encourage you to think about the unchecked assumptions that have been built into your practice's processes, workflows, assigned physical spaces and tools, particularly those tools that are as mundane as a new patient registration form.