We thank the 14 brain injury patients who are members of the "Amazing" Brain Injury Survivor Support Group in Framingham, MA or accessing outpatient services through Spaulding Rehabilitation Hospital for participating in the study that led to this paper. Funding and other support for the study were provided by the Brain Injury Association of Massachusetts, the Statewide Health Injury Program of the Massachusetts Rehabilitation Commission, and the Agency for Healthcare Research in Quality and the Schneider Institutes for Health Policy at the Heller School for Social Policy and Management, Brandeis University, through a doctoral training fellowship in health services research and policy analysis.

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The first author provides trainings in photovoice and photo-elicitation through medical schools and other educational venues. The second author has nothing to disclose.

Respondents become partners and play the role of "co-expert" role in the clinical setting when their lived experience is sought only the patient can really know what it is like to live with brain injury and experience related care. Further, the health care goal for many brain injury survivors appears to be healing, not recovery. Recovery implies a desire to return to a pre-injury status. Newly injured patients may be hoping to recover from their injuries, but long-term survivors have accepted that they will not be able to return to their prior status. They see healing as cognitive, physical, emotional, and even spiritual (Lorenz 2010a). They perceive that they continue to progress over time, even many years after their injury. Discussing photographs of their lives may help patients and clinicians to identify person-centered areas of concern and recognize and appreciate patient progress over time.
Applying fair process to clinical care means the patients are deeply engaged, exploring the way that their experience can be improved, understanding the rationale for all clinical decisions, and accepting their role and responsibility. Fair process activates patient motivation to adhere to rehabilitation strategies and take action to progress in their healing. When providers apply fair process to clinical care, patient and provider expectations and goals may be better aligned. The photograph becomes the focus of the interaction and engages the professional as well as the patient in exploring experience and building relationships. The therapeutic relationship may be improved. Further, according to the Kim and Mauborgne model, resulting attitude and behavior changes could lead to improved outcomes. 
With fair process, power in the clinical interaction may become more balanced as patients feel that they are being heard. Discuss photographs and their meaning can help patients to become part of the solution, not just the problem. Using cameras is not the only way to achieve fair process, and it is not an approach for every patient or every clinician. It is a tool and methodology to engage patients, improve communication under difficult circumstances, and achieve person-centered care.

using visual and narrative methods to achieve fair process in clinical care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

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23.3K Views.  Brandeis University. This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.