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Using the Johari Window to explore patient and provider perspectives

Alex Berland A. Berland Inc., Vancouver, Canada

Abstract Purpose – The purpose of this paper is to introduce the “Johari Window” as a tool to illustrate how providers and patients differ in their understanding of healthcare quality. Design/methodology/approach – The four quadrants of the Johari Window depict information known by both parties, by providers only, by patients only and by neither party. Findings – By understanding these differing perceptions, clinicians and planners can improve the patient’s experience of service delivery. Research limitations/implications – There has been no formal evaluation of this tool’s performance. It is presented as a heuristic teaching model to stimulate inquiry and discussion. Originality/value – The author has used the Johari Window in various cultural contexts, where its clarity and simplicity help introduce a potentially sensitive subject. Because it has face validity as an easy-to- understand tool, it can be used with students and junior care providers as well as non-clinician governors. Keywords Patient perspectives, Communication, Patient experience, Professional education and development Paper type Viewpoint

Perspective matters. As Evans (1984) notes, “If health could be purchased directly, no difficulty would arise”. We generally recognize that information shared between healthcare providers and their patients, or health service planners and their communities, is asymmetrical. One party knows more than the other about some things but not about other things. What people at large know is the value, or potential value, that programs to promote, maintain or restore health have for them in their everyday lives. What healthcare providers and planners know is more technical in nature. Most people may not be interested in details of healthcare technology or the inner-workings of government; however, most are very interested in effects, in outcomes. Again, paraphrasing Evans (1984), patients want health; they seek healthcare expecting that it will improve their health. Perspective matters because it is fundamental to delivering person-centered care and essential for shared decision making.

The Johari Window model (Wikipedia, 2016) evolved from the field of cognitive psychology, where it was developed by Joseph Luft and Harrington Ingham (1955) to illustrate domains of awareness. While it has found wider application in other settings, it has not been widely recognized as a tool for facilitating improvement in healthcare delivery. The model comprises a two-by-two table of four domains: subject matter that is known to both; what is known only to one party; what is known only to the other; and what is unknown to both. For healthcare, those parties can be labeled as providers (healthcare planners and health service professionals) and patients (individuals and communities) (Figure 1).

Providers and patients may share similar understanding of demographic facts (e.g. age, gender, education and income levels, etc.), and specific concerns (e.g. prevalent healthy or unhealthy habits, disease conditions, social concerns, etc.). These shared perceptions comprise the upper-left quadrant of the model.

In the lower-left quadrant the providers’ perception may be termed “quality of examination.” Providers sometimes refer to this domain as “clinical quality” or “technical quality.” It arises from measurable, usually quantifiable components such as signs,

The Johari Window

Received 26 June 2016 Revised 1 August 2016

Accepted 4 August 2016

International Journal of Health Governance

Vol. 22 No. 1, 2017 pp. 47-51

© Emerald Publishing Limited 2059-4631

DOI 10.1108/IJHG-06-2016-0032

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IJHG 22,1

Figure 1. The Johari Window

Things that patients know

Things that both Things that

patients only and patients

Things providers know that know providers know Things that

Things that neither

only patients providers nor

know providers know

symptoms and test results for individuals, or community health surveillance and survey results for populations. Through a healthcare governance lens, this might include measures like frequency of preventable admissions for hospitalized patients, average number of medications per resident in an elder care program, caesarian section rates in a maternity care program, or management of chronic (e.g. diabetes) or acute conditions (e.g. community- acquired pneumonia) in a primary care setting. It might also include econometric measures oriented toward optimizing cost vs benefit in current policy options.

The individual person’s “quality of experience” occupies the upper-right quadrant. At an individual or aggregate level this is usually based on qualitative sensations (such as pain or fatigue); emotional feelings (such as safety or fear, competence and respect or diminution and humiliation, satisfaction or dissatisfaction). In the literature this is sometimes referred to as “service quality” or “quality of perception.” Superficial satisfaction surveys may elicit reactions to surroundings and friendliness, missing more authentic aspects of the patient experience (Al-Abri and Al-Balushi, 2014) and not always using survey findings to influence changes in practice (Coulter et al., 2014). Similarly, reliance upon quantitative studies (the numbers) without related qualitative research (the context behind those numbers), may elicit solutions that are doomed to fail because of cultural mismatches. Unless formally surveyed, individual providers will know little about the experience of patients or other people in the aggregate or outside their own case-load. Additionally, there is no reason to believe that painful personal stories will be openly shared until sufficient sense of trust and purpose is established in fora intended to hear what aggrieved people have to say.

Neither party knows the content of the fourth quadrant. The status quo is frequently taken for granted. Unanticipated consequences of a new policy or action cannot be fully known or understood until after the fact, sometimes long after any change. Therefore, by definition, the contents of this quadrant are as-yet unrecognized, unmeasured, unfelt or hidden contexts and outcomes. For instance, involvement of patients in care decisions is a relatively recent expectation. Once known, these discoveries would move to one of the other three quadrants. For policy and governance bodies, this quadrant may reveal surprises (good or bad) and a realm where intuitive hunches can lead to exploration and insight (or career disasters). Where there exists a significant gap in expectations between providers and patients or between managers and providers, this quadrant may reveal paths to mutual understanding and reconciliation.

Thus, the Johari Window can provide a useful framework to facilitate discussion of health policy and governance topics. Whether the topic involves population health disparities, building healthy communities, measuring and continuously improving healthcare quality, the first step is to examine what is known (raw data transformed into information), all possible explanations for what is known (knowledge) and what works best

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for which groups under what circumstances (stakeholder engagement and knowledge translation) to guide action decisions.

For the last decade, Canadian hospitals have thought a great deal about quality measurement. Specific “clinical quality indicators” are now established as definitive markers in quality measurement. Often summarized in “dashboards,” “balanced scorecards” or “report cards,” these indicators are usually outcome-based performance measures, such as readmission to hospital, waiting times and adverse incidents (BC Patient Safety and Quality Council, 2010). Certainly many hospitals attempt to include patients’ perceptions. Typically though, the high-level indicators refer only indirectly to patient perceptions of quality. This is not a criticism. There is so much work to be done in assessing quality that priorities must focus first on high-yield issues. Presently, the quality indicators movement is just a baby-step in the right direction. Many Canadian teaching hospitals survey patients and staff to assess the quality of care as seen “through the patient’s eyes” (Gerteis et al., 1993; Picker, 2016). It is not uncommon to find that although patients give relatively high ratings overall to their experience while in hospital, many will state that communication, physical care, pain and discharge planning were not well managed. This is increasingly a global problem (e.g. Goodrich and Cornwell, 2008; Wang et al., 2014).

Involving patients in decisions about their own care remains challenging (Richards et al., 2015). Patients’ Charters have been developed in jurisdictions around the world (e.g. Ghana Health Service, 2015). They are printed and widely available so that everyone – patients and providers – is aware of the expected standards. At a major Canadian psychiatric hospital, a Patients’ Charter was developed with extensive consumer, family and advocate involvement (Riverview Hospital, 1998). This became a way of jointly establishing expectations about service quality and patient voice. Monitoring these values-based guidelines is difficult; nonetheless, the visibility of the Charter creates a basis for discussion and the potential for greater provider accountability.

More broadly, Richards et al. (2015) refer to enlisting “patients’ help to reform systems poorly geared to meet current health challenges” (p. 1). What are the priorities for reform? Which metrics best measure appropriate health service for an entire country? Gross domestic product is commonly used but has been criticized (Thoma, 2016). It is not a measure of well-being, just economic output. It also may not reflect the cultural values of all communities within a country. Alternatives have been proposed, but there is no uniquely correct solution. Communication among stakeholders is essential, so a simple visualization tool to promote self-awareness and communication, like the Johari Window, has merit to help frame necessary discussions about choices.

The fourth domain of the Johari Window model is certainly the hardest to think about. Acknowledging that we do not know is an important first step. In preparing for a major fund-raising campaign, a Canadian teaching hospital where the author worked engaged a marketing firm to help develop its strategy (Bradley, 1996). As part of the analysis, we thought it critical to understand consumers’ perceptions and ideals about the hospital and its context in the healthcare system. The marketers created separate focus groups of adults who had been patients, patients’ relatives or never in the hospital. In the focus group sessions, participants were asked to illustrate their responses by choosing from an enormous collection of images. The findings indicated that consumers subconsciously fear hospitals, in fact prefer never to think about hospitals, because they symbolize illness and suffering. Illness and hospitals generally had similar negative associations in the participants’ experience; they chose pictures of jails and military formations to illustrate lack of control, a state of dependence, restriction and loss of freedom. The consumers also feared “the system” and its uncaring, high-tech focus, selecting pictures of steely-eyed executives, shiny machines and dollar bills. Achieving this level of understanding about subconscious fears could provide revelations for both parties.

The Johari Window

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When asked about the ideal relationship between a patient and a hospital, the answers were surprising. For many of the participants, it was captured in the phrase, “an atmosphere of drunken intimacy,” where the patient could ask about anything at all, based on a healthy exchange of information. Some referred to a teacher/student relationship where the ultimate goal is to guide the student to independence. These consumers wanted a respectful partnership. They recognized their reliance on providers’ expertise; hence it could not be an equal partnership. But they also recognized that trust could be abused. Therefore, they saw communication as the biggest indicator of respect and one that would in turn lead to their trust.

Choosing pictures to illustrate this ideal relationship, they selected a friendly senior professor coaching a student; a pair of ballet dancers, one balancing the other in a graceful pas de deux pose; two rowers in a light scull, straining for an unseen goal; and a team of baseball players swarming around their captain, spontaneously celebrating a victory. No white coats; no machines that go “ping!” Perspective matters. The Johari Window can be a powerful tool in understanding other’s viewpoints and developing the trust needed for collaboration toward improvement.

References

Al-Abri, R. and Al-Balushi, A. (2014), “Patient satisfaction survey as a tool towards quality improvement”, Oman Medical Journal, Vol. 29 No. 1, pp. 3-7.

BC Patient Safety and Quality Council (2010), “Measurement strategies for improving the quality of care: a review of best practice”, available at: https://bcpsqc.ca//documents/2013/06/ measurementstrategies.pdf (accessed February 29, 2016).

Bradley, C.F. (1996), In Pursuit of Quality, Vancouver Hospital, Vancouver.

Coulter, A., Locock, L., Ziebland, S. and Calabrese, J. (2014), “Collecting data on patient experience is not enough: they must be used to improve care”, British Medical Journal, Vol. 348, p. g2225, available at: www.bmj.com/content/348/bmj.g2225.full?ijkey=a747dab3d134fb0c45e7628580 13aa46b9cea4fd&keytype2=tf_ipsecsha (accessed January 13, 2017).

Evans, R. (1984), Strained Mercy, Butterworths, Toronto, p. 73.

Gerteis, M., Edgman-Levitan, S., Daley, J. and Delbanco, T.L. (Eds), (1993), Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care, Jossey-Bass Publishers, San Francisco, CA.

Ghana Health Service (2015), “The patients charter”, available at: www.ghanahealthservice.org/ghs- subcategory.php?cid=2&scid=46 (accessed March 2, 2016).

Goodrich, J. and Cornwell, J. (2008), Seeing the Person in the Patient: The Point of Care Review Paper, Kings Fund, London.

Luft, J. and Ingham, H. (1955), “The Johari Window, a graphic model of interpersonal awareness”, Proceedings of the Western Training Laboratory in Group Development, UCLA, available at: https://en.wikipedia.org/wiki/Johari_window (accessed January 13, 2017).

Picker Institute (2016), “Picker principles of patient centered care”, available at: http://cgp. pickerinstitute.org/?page_id=1319 (accessed February 28, 2016).

Richards, T., Coulter, A. and Wicks, P. (2015), “Time to deliver patient centred care”, British Medical Journal, Vol. 3 No. 50, p. h530.

Riverview Hospital (1998), “Patients Charter of Rights”, Coquitlam, author.

Thoma, M. (2016), “Why GDP fails as a measure of well-being”, CBS Moneywatch, January 27, available at: www.cbsnews.com/news/why-gdp-fails-as-a-measure-of-well-being/ (accessed June 8, 2016).

Wang, S., Zhao, Y. and Zang, X. (2014), “Continuing care for older patients during the transitional period”, Chinese Nursing Research, Vol. 1, December, pp. 5-13.

Wikipedia (2016), “Johari Window”, available at: https://en.wikipedia.org/wiki/Johari_window (accessed February 29, 2016).

Further reading Kennedy, G. (2010), From Creation to Compliance: Accreditation Canada’s Required Organizational

Practices, Accreditation Canada, Ottawa, available at: https://bcpsqc.ca//documents/2012/11/ Accreditation-Canada-Background-on-Required-Organizational-Practices.pdf (accessed February 29, 2016).

The Johari Window

Corresponding author Alex Berland can be contacted at: [email protected]

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