Health Quality Ontario

Primary Care

Patient Involvement

Best Practices

Created on August 21, 2017

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Patient involvement in decisions about their care and treatment in primary care is a priority indicator for the QIP. This is the percentage of people in Ontario aged 16 and older who report that their primary care provider (i.e. a family doctor, a general practitioner GP, or nurse practitioner) always or often involves them as much as they want in decisions about their care and treatment. In Ontario 85.9% of people aged 16 or older report being involved as much as they want in decisions about their own care in the primary care setting.

Below are best practices for patient involvement in primary care. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice refer to Health Quality Ontario’s Patient Engagement Framework and guide on Engaging with Patient and Caregivers about Quality Improvement or browse the interactive table below for a quick summary of how to better involve patients in care and decision making in your practice.

  1. Barry MJ, Edgman-Levitan S. (2012).
    Shared decision making--pinnacle of patient-centered care.
    New England Journal of  Medicine; 366(9): pg. 780-781.

  2. Crocker, J. E., Swancutt, D. R., et al. (2013).
    Factors affecting patients’ trust and confidence in GPs: evidence from the English national GP patient survey.
    British Medical Journal (BMJ) Open 2013; 3.

  3. CMPA. (2013).
    Medication management, quality healthcare.
    Retrieved from:

  4. Dang, B.N., Westbrook, R.A., Njue, S.M., and Giordano, T.P. (2017).
    Building Trust and Rapport Early in the New Doctor-Patient Relationship: A longitudinal qualitative study.
    BMC Medical Education, 17(1):

  5. Goold SD, Lipkin M.(1999).
    The doctor–patient relationship. Journal of General Internal Medicine;14:26–33.

  6. Dwamena, F. et al. (2012).
    Interventions for providers to promote a patient-centred approach in clinical consultations (Review).
    Cochrane Library. Cochrane database of systematic reviews.

  7. Laurence, J., Henderson, S., Howitt, P.J., Matar, M., Al Kuwari, H., Edgman-Levitan, S., and Darzi, A. (2014).
    Patient Engagement: Four case studies that highlight the potential for improved health outcomes and reduced costs.
    Health Affairs, 33(9).

  8. Naylor, C., Imison, C et al. (2015).
    Transforming our Health care System.
    Retrieved from:

  9. The Health Foundation. (2011).
    Helping People Help themselves. ISBN 978–1–906461–26–3. United Kingdom: London.
    Retrieved from:

  10. Vahdat, S., Hamzehgardeshi, L., et al. (2014).
    Patient Involvement in Health Care Decision Making: A Review.
    Iran Red Cross Medical Journal: 16(1).


Created on August 21, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How will we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Patient involvement in decisions about their care and treatment
Topic Patient Reported Measures
Quality Dimension Patient-Centred
Type of Indicator Process
Measure Percentage (%)
Data Source Health Care Experience Survey (HCES)
Data Collection Instrument Collected by the Ministry of Health and Long-Term Care (MOHLTC)
How to Calculate

(Numerator/Denominator) x 100

Numerator: Number of positive responses to “being involved”

Denominator: Total number of survey respondents

Target Higher is better (current provincial average 85.9%)
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

To read more about general measurement in QI refer to Measurement for Quality Improvement.


Created on August 21, 2017

“If it currently takes 2 weeks to get a non-urgent appointment –but it always takes 2 weeks – then the practice is meeting its demands…just 2 weeks late. The challenge is getting that demand met today.”
Vineet Nair, MD CCFP, Lead Physician London Centre Family Health Organization


With Regulation 187/15 coming into effect under the Excellent Care for all Act, 2010 on September 1, 2015, the increasing importance of patient engagement is now reflected in the legislation in Ontario. Patient involvement in decisions about care is one aspect of patient engagement and experience (HQO, 2017 i). Across Ontario, health care professionals, policy-makers, and organizations are actively engaging with patients, their families, other informal caregivers, and members of the public to understand their needs, experiences and preferences to improve health care quality. In Ontario 85.9% of people aged 16 or older report being involved as much as they want in decisions about their own care in the primary care setting.

FIGURE 1 Percentage of people aged 16 and older who report that their primary care provider always or often involved them in decisions regarding their care, in Ontario, by LHIN region, 2015.

Source: Health Care Experience Survey, provided by the Ministry of Health and Long-Term Care.

Engaging with patients and their caregivers transforms care. The evidence tells us that supporting patients to be actively involved in their own care, treatment decisions and support can improve outcomes and experiences, and potentially yield efficiency savings for the system (HQO, 2017i; NHS,2016). There are a variety of ways to involve patients but at the level of individual care, one theme stands out: the capacity of patients to discuss issues with their care provider, to generate options for treatment and management, and to share in decision-making. Providers and patient working together to build a productive relationship is the ultimate goal (Health Council of Canada, 2011; HQO, 2017 I; NHS,2016).

Call to Action

In the QIPs patient experience is measured using three distinct but related indicators including:

  • Patient Involvement in decisions about care
  • Primary care providers spending enough time with patients, and
  • Opportunity to ask questions

Performance on these indicators is correlated and overall performance on patient experience in primary care is high (median 92% to 93%). However, in the 2016/2017 QIPs 10% of organizations providing primary care set retrograde targets to worsen their performance over the coming year (HQO, 2017). This might be due to a “ceiling effect”, where organizations may not believe that there is room for improvement (HQO, 2017). In order to maintain the excellent results on this indicator creative change ideas and best practices must to be upheld.

  1. Health Council of Canada. (2011).
    How Engaged are Canadians in their Primary Care? Results from the 2010 Commonwealth Fund International Health Policy Survey.
    Toronto, ON. ISBN 978-1-926961-09-5.
    Retrieved from:

  2. Health Quality Ontario. (2016).
    Engaging with Patients and Caregivers about Quality Improvement A Guide for Health Care Providers.
    Toronto: Queen’s Printer for Ontario; 2016.
    Retrieved from:

  3. Health Quality Ontario. (2017).
    Insights into Quality Improvement: Primary Care Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Queen’s Printer for Ontario; 2017.
    Retrieved from:

  4. Health Quality Ontario. (2017 i).
    Ontario’s Patient Engagement Framework: Creating a strong culture of patient engagement to support high quality health care.
    Toronto: Queen’s Printer for Ontario; 2017.
    Retrieved from:

  5. NHS. (2016).
    Involving people in their own health and care: Statutory guidance for clinical commissioning groups and NHS England.
    ISBN: 0113 825 0861.
    Retrieved from: