I am Now Also Blogging on the Patient Voice in Health Care

I have now started blogging on issues relating to the patient voice in health care.  I am proud and happy that my posts will be appearing on the blog of Parent Family Care Centered Partners.

Here is how the organization describes itself (no prizes for noting the huge resonance with the self-represented litigant movement.)

We are a small organization with a large vision for improving the quality, safety and experience of healthcare through the development of authentic partnerships from the bedside caregiving relationship to the boardroom where programs and policies are established.  PFCCpartners is committed to collaborating with patients, families, physicians, healthcare administrators, nurses, therapists, social workers and all those invested in improving health care.

PFCCpartners supports the commitment to collaboration by engaging in Community, Skills Development, Contracted Projects and Patient Family Voice.

 PFCCpartners was founded in 2010 in response to a request by the healthcare community in southern California  for a resource and support network to establish patient family centered care practice in the region.  Founder Libby Hoy, is a Patient Family Advisor with more then 20 years experience in partnering with hospitals, healthcare organizations, national health policy organizations and care teams managing her sons’ chronic illness.  The resources and enrichment programs developed for PFCCpartners come from personal experience in the role of PFA for many hospitals and healthcare organizations.  Therefore, the core values of PFCCpartners are:

Representative Voice
PFCCpartners believes in the value of providing the representative voice of patients, to inform the design of programs, policies and improvement of healthcare systems. 

Teachable Spirit
PFCCpartners values our teachable spirit in our efforts to inform healthcare improvement, constantly seeking to knowledge from all of our partnerships so that together we create a learning health system.  

PFCCpartners values and embraces the diversity of culture, experience, region and socio economic status of all healthcare stakeholders.  

PFCCpartners values authentic, respectful partnerships in which every stakeholder has the opportunity to inform the healthcare system.  
PFCCpartners is committed to building authentic partnership opportunities to every patient and family member across healthcare.

Here is my first blog posting on that blog.

Not Just Patient Centered, But Rather Patient-Partnered Care
By Richard Zorza, Patient Family Advisor

As a patient coming up to four years from my MDS diagnosis, and now getting regular blood transfusions, at the wonderful Johns Hopkins, and as a member of the Hopkins Oncology PFAC, I have been thinking about the right labeling of our movement. (As Libby Hoy and I agreed in a recent phone call, names are important.) I love the phrase “patient-centered,” and think it has been a great way of thinking about changing the focus of the system at every level. But I would like to suggest a modification. The problem for me is that it evokes a picture of multiple providers and caregivers clustered around my bed. Now, that’s much better than having them meeting in another room, with me knowing nothing about it. But somehow in that image, I am still the object of care and healing – very good care and healing and much appreciated care and healing, but still the object on which others focus. I like to offer the phrase “Patient-Partnered.” What I mean by that is that the process includes the patient as a full partner, with our own skill and expertise, as well as direct reportable knowledge. The patient provides information about what they are feeling medically and in terms of how they are being treated, in all senses of the word. They make suggestions about how to improve not only their situation, but that of others. They keep their eyes open and try to see patterns in fellow patients and ask if those may generally be true, or worth researching. They talk to other patients and help build a community that gives feedback. Their input includes everything from their own situation to the overall health care system. In other words, they are partners, not just the beneficiaries of being at the center of care. The first time I sat down with my current oncologist, Amy DeZern, I related to her how even though exhaustion is recognized in the research as the primary symptom issue for MDS patients, noone had ever tried to treat it, until my psychiatrist said something like “Lets think outside the box. Let’s try Ritalin.” Within 30 mins of taking the first pill, I was like: “This is what life was like.” Now, of course, it does not really take me back to before, but it’s a lot better, and I would not be going to meetings, and writing this blog if I was not taking it. (Now, most people think of Ritalin for AHDD, but it also works for narcolepsy. I talk a bit more about getting Ritalin here, on my health updates blog.) Anyway, at the end of the session, I asked Dr. DeZern, “Tell me how I can help you do your job better, and not just for me.” She replied, “You already have.” You can imagine how great that made me feel. Better than a double dose of Ritalin. One way of thinking about all of this is to say that “patient centered” asks what the patient wants and needs, while “patient-partnered” hears the answer that the patients wants to be engaged and useful. P.S. The wonderful Care Map by Cristin Lind, described in the Huffington Post here, has a lot of the same thoughts behind it.

Above all, I hope that this all helps lead to a fruitful sharing of ideas between out movements.  I have previously suggested that legal advocates might both learn and contribute by joining local hospital patient and family councils.

Posted in Access to Justice Generally, Litigant Voice, Medical System Comparision | Leave a comment

Immigration Judges Learn to Recognze and Protect Against Implicit Bias

The NYT has an important piece today on judges and implicit bias.

Now, as the country struggles with how these instinctive judgments shape our lives, the Justice Department is trying to minimize the role of bias in law enforcement and the courts. More than 250 federal immigration judges attended a mandatory anti-bias training session in August, and this summer the Justice Department announced that 28,000 more employees would go through a similar exercise.


When the brain has to process large volumes of information quickly, there is a tendency to rely on past experiences rather than on unique details in the present. In judging people, for instance, this can mean falling back on generalizations about race, age, country of origin, religion or gender.


In August, at the judges’ training session, Ms. [Kelly] Tait went over strategies to counteract bias, like focusing on something as innocuous as the color of an immigrant’s shirt to prevent cases from bleeding together.

She explained that people who know they are biased against a particular group can try to picture an exemplar of that group whom they hold in high esteem. One of the judges she taught said that when he had felt himself tensing up next to a large African-American man on the witness stand, he pictured President Obama. Another judge said that under similar circumstances he had thought of Nelson Mandela.

The simplest and most effective way to combat bias, however, is to avoid rushing and take breaks, Ms. Tait said. But with more than 500,000 cases pending, immigration judges say that slowing down is not an option.

Now Kelly Tait is a long time friend of access to justice and a powerful speaker and trainer, so the immigration judges were very lucky.  See her piece at page 45 of this SRL package.

So, lets hope these ideas spread through the whole system — and not just for judges.


Posted in Access to Justice Generally, Communications Strategy, Immigration, Judicial Ethics, SRLN | Leave a comment

How Not To Bring The Litigant Voice Into the Legal System

Richard Moorhead of University College London has a brilliant blog post here, on a recent attempt by the Solicitors Regulatory Association to impact the process of reforming (or not) the exam process for qualifying as a solicitor. (By the way, those of you who have forgotten what London is, it is the capital city of the now largely forgotten country, the United Kingdom, that voted to leave Europe.)

The SRA’s new consultation on the solicitors qualifying examination (SQE) is now out. I will read it with interest. I note with a little frisson of amused dismay that the SRA is praying in aid of its proposals polling from the general public. It appears, the general public were asked all of three questions:

  • As part of the process of qualifying as a solicitor, solicitor should have some training in the workplace. (87)
  • Everyone should pass the same final exam to become a solicitor, regardless of the type of training they do. (79)
  • I would have more confidence in solicitors if they all passed the same final exam. (76)

To spell it out they have commissioned polling with leading questions, and which the public can be expected to have very limited insight into or informed view on. It’s not that the public’s voice is unimportant, it is just that if we asked a random group of strangers these questions we would almost always expect them to answer in the affirmative.

I have put the actual reported percentages after each offered statement.

Cute, and surely an inspiration to us in our equivalent research brining the litigant voice into the discussion.  How abut the following questions?

  • I would be more comfortable being represented by someone with full legal training rather than someone who has had only limited training.
  • Only lawyers should be allowed to give out information about the law because otherwise people will get wrong information and get badly hurt.
  • It is important that lawyers are not allowed to leave from representing someone in the middle of the case.
  • Court staff must not act like lawyers
  • If a judge asks a question that changes the result of the case, the judge is not being neutral.

Now, I am not sure how some of these might come out, but you see the picture.



Posted in International Models, Legal Ethics, Non-Lawyer Practice, Political Support | Leave a comment

Serving Self-Represented Litigants Remotely A Resource Guide Is a Must Read

Serving Self-Represented Litigants Remotely A Resource Guide, prepared by a team led by John Greacen and including SRLN members from across the country, has just been published by SRLN.  It is a “Must Read,” to use a much over-used word.  Anyone considering integrating remote services into their access delivery system, anyone convinced that they should not do, anyone involved in thinking about how to respond to the Conference of Chief Justices 100% access resolution, and indeed anyone already delivering any such services, and interested in expanding needs to read it fully very soon.

The SJI Newsletter (SJI provided funding) summarizes the Guide and Executive Summary as follows:

Delivery of services using telephone and internet-based technologies is an effective and efficient means of providing information and assistance to self-represented litigants, and should be a part of the service delivery strategy of every entity interacting with this customer group.

Use of multiple remote services (e.g., telephone, e-mail, live chat, videoconferencing and text messaging) is advantageous to the service provider and the user.

Service providers save resources in these ways: 1) remote services delivery staffing can be centralized; 2) staff/customer interaction time is shorter using most remote methods than face-to-face communications; 3) it easier for staff to establish boundaries for a re- mote conversation; 4) staff are better able to control the pace and demands of their work; 5) facilities costs are reduced; 6) security issues and costs are minimized, but not eliminated; and, 7) how merging technologies used in limited jurisdiction courts, such as those identified in Nebraska and Orange County, California, continue to maximize underutilized staff resources.

Benefits to customers and the ways in which remote services are exceeding internal and external expectations are described. The SRLN, conducted extensive in-person interviews, observational analysis, focus groups, and assisted each contributing state partner in completing a program characteristics spreadsheet. The Guide contains information from state-level programs in Alaska, Idaho, Maryland, Minnesota, Montana, and Utah ,and county-level programs in Butte, Lake, Tehama, and Orange Counties in California.

While the Report is careful to emphasize that there is no one size fits all approach, the practical reality is that the Report effectively answers most if not all of the worries and reluctance about these ways of providing services.

The Report includes detailed findings, comparisons, and descriptions of the programs studied, and any summary will fail to do it justice.  It has to be read.
However, perhaps most dramatic to me is the following chart, which shows the views of surveyed users about alternatives to the remote systems they were using.  While some people, from 10% to 47 % depending on location, would have preferred a different service than the one they received, even among that number, many more would have preferred a different non face to face service than a face to face service.  Indeed, almost half as many again.  So much for the idea that remote services are seen as second best.

The following chart is perhaps even more dramatic in terms of the potential breadth and impact of these programs.  It shows the percentage of state residents served each year by the four statewide programs.


Now, these numbers are indeed somewhat inflated because some people will be double counted.  But, remember that the base is not poor people, not middle income people, not the self-represented, not all litigants.  No, it is the entire adult population.  In other words, these programs are having a statewide impact, measured not just in terms of the legal system, but in terms of the whole population.

What about cost?

Well, on average, close to 4,000 people a year are served by each full time equivalent.


That is an astonishing number, and underlines that these services have huge potential to make the difference in getting to 100%, perhaps in a shorter term than many of us have feared.

Finally, the efficacy results, based on two programs, are impressive, and will be the subject of a future blog post.

At the risk of stating the obvious, this is all very highly relevant to the leveraging of the triage idea, and to strategic choices to be made in Justice for all strategic planning processes, pursuant to the Chiefs Resolution.

SRLN, whose coordinator Katherine Alteneder is arguably the leading national expert on delivering remote services for self-help services, is available for consulting.  Katherine played the major role in setting up the remote self-help services system in Alaska.


Posted in Access to Justice Generally, Budget Issues, Court Management, Forms, Metrics, Remote Services, Research and Evalation, Self-Help Services, SRLN, Systematic Change, Technology, Triage

Harder and Harder to Separate Access to Justice and Election Politics

It is getting harder and harder to separate access to justice and politics.  So I feel that it is not inappropriate to share a link to my politics and humor blog, in which I ask those Republics who might, in the event of a Trump victory, consider joining the administration to think through very carefully, given Trump’s unpredictability, what their red lines would be.

Of course, such thoughts are relevant to anyone considering any job about which they have doubts of any kind, but they are just particularly important here, both for the person and the country.

Please share with anyone these thoughts might become relevant to.

Posted in Access to Justice Generally, Judicial Ethics, White House

More Dramatic Statistics on Representation Imbalance for Collection, Landlord/Tenant, and Small Claims

Recently, I blogged about some numbers derived from NCSC data for representation status and imbalance.  The numbers are stunning, here, and here.  As I put it then:

We Now Have the Data That shows That The One-Side-Self-Represented Case is the Dominant Case Situation in US Civil State Courts and That We Need a Fundamental Rethink of The State Civil Justice System.

With some additional data generously provided by NCSC, I can now break this out further (methodology here) and show, with this broad urban court national sample, how this imbalance works out in certain case types.  This will surely help prioritize strategic planning priorities.  These three charts are shockingly self-explanatory:


As an aid to strategic planning here is a blunt comparison of the percentage with an unrepresented person going against a represented one:


Case closed as to need for intervention, redesign, etc.

Posted in Bankruptcy, Chasm with Communities, Debt Collction, Evictions, Small Claims, SRL Statistics | 3 Comments

Integrating “Roles Beyond Lawyers” into Court Improvement Strategies

A recent paper by Colleen F. Shanahan, Anna E. Carpenter and Alyx Mark makes a very important point that, as the abstract puts it:

Access to justice interventions that provide a little representation, including nonlawyer representation and various forms of limited legal services, may be valuable solutions for low- and middle-income Americans. However, a thoughtful approach to improving access to justice efforts should recognize that a little representation may have risks. In particular, one potential risk of a little representation is that while it provides assistance with a discrete legal need in a specific moment, the nature of the assistance is incompatible with challenging the law. As a result, individual litigants do not have the benefit of legal challenges in their own cases, and our legal system develops devoid of law reform that reflects the needs of low- and middle-income litigants. (Links added by this blog.)

The core idea, based on detailed analysis of hearings in the Washington DC unemployment insurance system, focuses on the actual evidence techniques used in the hearings, and the costs of lack of strategic judgements.  The more detailed analysis is in this parallel paper from the same authors.

To me, this suggests a two pronged approach to improving courts that thinks about the system as a whole, rather than individual cases.  In the first phase, you make heavy use of experienced counsel who can essentially “clean up” the court’s practices, including where necessary taking up the appeal to change the law or make sure that it is followed in the court.  When that process has been successful, then you move in with nontraditional services, in which those providing them are trained in the skills needed to make sure that facts and law are presented to the court.  You keep traditional legal representation in a small number of cases, and make sure that referral is both available, and known to be available for those having to rely on those without full legal training.

A sophisticated triage system would actually be designed to adjust recommendations based on an analysis of where the court or forum was in this reform and support system.

Similarly, a sophisticated access to justice strategy would be designed to develop such a multi-state approach, test and modify it in a few forums, and then apply it statewide.

Different stakeholders would play different roles, with advocacy organizations providing representation, and the courts providing parallel staff training and perhaps support systems for the new forms of assistance.

Let’s think strategically here.

P.S. I should note that it was reading these papers that also got me going on the analysis and suggestions in my earlier post here about the relationship between triage and court simplification redesign.

Posted in 100% Access Strategy and Campaign, Access to Counsel, Court Management, Non-Lawyer Practice, Referral Systems, Research and Evalation, Triage, Unbundling | 2 Comments