About this series
A social network site (SNS) is a web-based service that allows individuals to: “1) have uniquely identifiable profiles that consist of user-supplied content, content provided by other users, and/ or system-level data; 2) can publicly articulate connections that can be viewed and traversed by others; and 3) can consume, produce, and/or interact with streams of user-generated con- tent provided by their connections on the site.”1 SNSs, a sub-set of social media tools, allow for users to engage with other people based on common interests to share, co-create or ex- change information, ideas, photos or videos.1,2 There are hundreds of SNS platforms globally and there has been a steady rise in usage since the first SNS was launched in 1997.3 In 2016, the most popular SNSs in Canada were Facebook, YouTube, Twitter and Pinterest, with Snap- chat and Instagram becoming increasingly popular among younger users. Facebook continues to be the most popular social media site internationally, with 18 million users in Canada and 70 per cent of users engaging with the site daily.4
This multi-part Social Media and Mental Health series by Canadian Mental Health Association, Ontario Division will explore some of the current literature about internet and SNS use, mental health and addictions, as well as highlight promising practices both within Ontario and inter- nationally. In particular, this second installment of the series focuses on how SNSs, because of their high numbers of users, can be used to improve quality of services within health care, including mental health and addictions organizations.
Introduction to quality improvement
Quality improvement (QI) in health care is defined as the activities that provide better patient outcomes (improved health), better system performance (improved care) and better profes- sional development (improved learning and application of current professional knowledge) across health care systems and within health care organizations.5,6 In the early 2000s, a series of reports was released in North America highlighting the prevalence of medical errors across health care systems. A ground-breaking report from the Institute of Medicine estimated there are up to 98,000 deaths a year across the United States as a result of medical errors, the fifth-leading cause of death in the country.7 In Canada, the Canadian Adverse Events Study found that 7.5 per cent of hospital admissions resulted in an adverse event (totaling approx- imately 185,000 events) and it was estimated that 70,000 of these events were preventable.8 These findings caused alarm for those working in and relying on health care systems. Service planners shifted focus to strategies that could improve these shocking levels of poor patient outcomes.9 Modern QI initiatives in health care are based on the realiza- tion that sustained and effective improvement efforts are the result of changes to systems and processes. This contrasts with the previously-held assumptions that quality is the responsibility of designated leaders and issues are caused by a few individuals. As such, QI frameworks and methods such as Lean Six Sigma and the Model for Improvement have been adapt- ed and widely implemented in hundreds of health care settings in various countries as they focus on improving processes and systems.10 Approaches to implementing the adapted QI methods for health care have originated from individual champions for change, organizations that have made QI a priority, and large-scale, system-level efforts that aim to improve quality across regions, sectors and systems.
Quality improvement and social media
Understanding how social media networks can be used to improve the quality of care clients re- ceive is a growing area of research and exploration. Much of this current research and thinking dis- cusses the intersection of social networking sites and health care quality broadly. However, in this paper, mental health and addictions examples and the Ontario context will be used where possible. As this is a developing area of exploration, there are few definitive answers about how social media is impacting health care outcomes, but many ideas and potential opportunities are emerging.11
The purpose of this paper is to provide an overview of current thinking and trends re- garding how social networking sites may be used to improve the quality of care received in health care settings. We hope to inspire men- tal health and addictions service providers to explore options for leveraging social media for service and program improvement. This paper was sparked by a review of a useful re- source that explores this topic in more detail; Using Social Media to Improve Healthcare Quality: A Guide to Current Practice and Future Promise, released by the Change Foundation and the Health Strategy Innovation Cell of Massey College, University of Toronto.
Providing a unique opportunity to gather feedback from clients and family members of health care services and programs
With the rise of social media, users have additional methods of communicating to service providers in a very public way and on various platforms to discuss experiences with access to services and programs.11 Research suggests that using the internet and social media platforms to engage service users is a unique opportunity for health service providers to capture signs of problematic care or areas of strength in program delivery.12 Beyond common social networks like Facebook and Twitter, rating system sites like Yelp and Rate MDs can play an increasingly important role in how clients and family members select the care they require.13 Areas of health care like primary care, hospitals, and private clinics can often be found on these types of rating sites, though they are not networking sites by definition. For a true QI culture that is present within an organization’s SNS accounts, it is necessary to monitor, listen, and communicate back to the platform’s users who are providing the feedback.12 A study across the hospital sector in the US also suggested that the more active a hospital was on social media, the higher the likelihood for receiving patient experience-related tweets.13 For those organizations looking to use SNS as a means to collect client feedback, this may pose good rationale for increasing activity on SNS platforms to receive higher quantities of comments pertaining to experiences.14
An advantage of leveraging social networks to gather feedback from clients and family members is that data is gathered in real time, which is an important aspect of effective quality improvement within organizations.12,14,14 Other benefits to using social media to gather feedback are that it pro- vides a low-cost method of gauging how users are experiencing services on an ongoing basis and it has potential to provide initial data on the impact of new initiatives and programs.13 This is not to say that SNSs would replace existing experience surveys or more traditional means of getting feed- back such as focus groups or interviews. But SNSs can be used as an ongoing tool to flag potential issues in care delivery in a timely manner and determine if action is required.12,13 It has also been suggested that data gathered online should be validated with other means of getting information, like client-care surveys, to check for accuracy. Still, SNSs do provide a novel data source when looking for ways to measure perceptions of care and experiences.12 A “deeper dive” into the issue and causes of concerns/comments would likely be required to fully understand the circumstances that led to a positive or negative experiences for the SNS user sharing feedback.
SNSs may also provide a means of communicating opportunities for online feedback (e.g. surveys) and in-person opportunities aimed at gathering client experiences with the intent of improving care (e.g. focus groups, calls for advisory committees). CMHA Ontario has observed that the community mental health and addictions sector has leveraged social media as a means to share opportunities for feedback.
Advancing client-centredness, a key domain in a quality health care system
Health Quality Ontario recognizes that a high-quality health care system is one that is safe, effective, patient-centred, efficient, timely and equitable.15 These domains are consistent with the globally-recognized six dimensions of health care system improvement developed by the Institute of Medicine in 2001. Of these key domains, client centredness may be the category that is impacted most by social media. This is because SNSs can empower individuals and family members to seek certain health care services based on the experiences of others who’ve shared their experience online. The general use of the internet to assist in learning about health care needs has been shifting the power from health care service pro- viders to clients as clients become more involved in their care and active participants in their treatment/care trajectories.11 The British Columbia Patient Safety & Quality Council notes an advantage of social media is access to information, such as health-related news, up-to-date resources, public service announcements and health promotion/awareness campaigns, in a way that is meeting clients where they are online.16
A systematic review by Smailhodzic et. al. discovered that the most common reason for cli- ents seeking health care information online was for emotional support.17 Getting this support online can improve an individual’s belief in his or her own ability to handle the problem or take important steps for his or her own care (e.g. visit a health care professional). Further to getting emotional support from others, clients may go online to express their emotions of working through a health care challenge without fear of the consequences of judgment from others not experiencing the same issue.
Through this review, the most common effect of using SNSs to get information and share experiences is empowerment of individuals to take control over this aspect of their lives and enhance communication with health service providers. In this study, it’s important to note that clients do not seek information online or connect with others using SNSs to replace the clinical perspective, but rather to complement it.
Understanding the reasons for people seeking support and learning from other experiences on- line and the potential positive impacts on a person’s health care challenges opens an avenue to ensure that client-centred care be made available to those living with mental health challenges.
Sharing stories and outcomes of QI methods working in mental health and addictions services and programs
Social networking sites provide a great opportunity for sharing knowledge of applying improve- ment methods and tools within health care settings that may otherwise not have a venue to be shared broadly and in a timely way. In Ontario, we know there is a growing interest and use of QI methods across the sector and SNSs provide a unique means to share learning and pro- vide motivation for others to use QI tools to improve outcomes for clients. Resources, lessons learned, improvement-related discus- sions and outcome data can all be shared through social networking sites. A survey conducted by CMHA Ontario and Addic- tions and Mental Health Ontario in 2017 showed that across Ontario, community mental health and addiction organizations struggle with sharing improvement work with external stakeholders, such as cli- ents and the research community, who may benefit from learning of this infor- mation (see Figure 1). Both personal and organizational accounts may be used to strategically follow others that share QI work and who may be interested in further developments in the QI field.
There are risks for leveraging social networking sites to enhance quality of care within health care settings. Some of these risks include:
- That non-clinical professionals may share unreliable or inaccurate information on SNS ac- counts belonging to healthcare service 12,17
- SNS users may experience an increase in levels of negative emotions due to harmful feed- back from others 17
- Feedback from an online community may not be representative of everyone and lead to selection bias of users accessing SNSs for health care 12
- There is an unpredictable nature to online comments (e.g. people posting at all times of day, comments that may be unrelated to services, requests for information irrelevant to the health care provider) that can bring either positive or negative attention to a SNS 16
- Information can spread more rapidly than ever Reputational risks may occur if false information is spread across SNS platforms about a health care organization’s services or pro- grams.13 However, there is also evidence to suggest that by having an active online presence, an organization may increase their level of trust with their community.13
The increase in popularity of social networking sites globally allows for discussions and explo- ration of how these platforms can be used to enhance the quality of health care services. The use of SNSs for providing feedback from users of health care services and supports appears to be an inevitable opportunity for professionals to gain timely access to data that can provide in- sight into how clients are perceiving their care. Feedback provided online may be best viewed as a signal to dive deeper into negative or positive issues being expressed by SNS users. And a quality improvement approach can then be taken to leverage the feedback for improvement. SNSs can also be used to share opportunities for clients to provide feedback (e.g. client ex- perience surveys, open focus groups, calls for advisory committee members etc.). The ability for clients to connect with others, empower themselves to seek care or be active in their own care pathway can enhance client centredness, a key component to a quality system. Finally, SNSs are a great way for organizations to share what they’re doing to improve outcomes for clients accessing their care. Sharing information on successes and lessons learned in using improvement methods may contribute to promoting a culture of quality improvement across health care systems.
The Excellence through Quality Improvement Project (E-QIP) is a provincial initiative dedicated to improving the ability for Ontario’s community mental health and addictions sector to learn and apply quality improvement methods and tools. The hashtag #EQIPON follows the E-QIP journey online. The project’s online community of practice, hosted through HQO’s quorum, provides a platform for people to share their experiences using these tools and methods across this sector of Ontario health care.
Below are useful Twitter accounts to learn about recent publications and knowledge on quality improvement in health care:
Mental health and addictions in Ontario:
Common hashtags on twitter for exploring quality improvement in healthcare:
1 Ellison, N.B., & Boyd, D.M. (2013). Sociality through social network sites. In H. Dutton (Ed.), The Oxford handbook of Internet studies (pp. 151–172). Oxford, England: Oxford University Press.
2 Naslund, J.A., Aschbrenner, K.A., Marsch, L.A., & Bartels, S.J. (2016). The future of mental health care: peer-to-peer support and social media. Epidemiology and Psychiatric Sciences, 1-10.
3 Kuss, D & Griffiths, M. (2011). Online Social Networking Addiction – A review of the Psychological International Journal of Environmental Research and Public Health. 8:9.
4 Insights (2016). 2016 Canadian Social Media Monitor. Retrieved from: http://www.insightswest. com/wpcontent/uploads/2016/05/Rep_InsightsWest_CDNSocialMediaMonitor_2016.pdf
5 Batalden, B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? BMJ Quality and Safety in Health Care, 16(1), 2-3.
6 Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Washington, D.C: National Academy Press.
7 Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. (2000). To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US).
8 Baker, R., Norton, P.G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., et al. (2004). The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 17, 1678-1686.
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10 Berwick, D. M. (2008). The science of improvement. Jama, 299(10), 1182-1184.
11 Greaves , Ramirez-Cano D., Millett C., et al. (2013). Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Quality and Safety Journal. 22:251-255.
13 Rozenblum R., Bates W. (2013). Patient-centred healthcare, social media and the internet: the perfect storm? BMJ Quality and Safety Journal. 22:183-186.
14 Hawkins J.B., Brownstein J.S., Tuli , et al. (2016). Measuring patient-perceived quality of care in US hospitals using Twitter. BMJ Quality and Safety Journal. 25:404-413.
15 Ranney M.L., Genes N. (2016). Social media and healthcare quality improvement: a nascent field. BMJ Quality and Safety Journal. 25:389-391.
16 Health Quality Ontario. (2019). Quality Matters: Realizing Excellent Care for All. Retrieved from: http://www.hqontario.ca/portals/0/Documents/pr/realizing-excellent-care-for-all-en.pdf
17 Smailhodzic, E., Hooijsma, , Boonstra, A., & Langley, D. J. (2016). Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals. BMC health services research, 16(1), 442. doi:10.1186/s12913-016-1691-0