Patient experience in co-production of care: perceptions about patient safety protocols*

Objective: to analyze the experience of the patient during hospitalization, focusing on the co-production of care related to patient safety protocols. Method: qualitative study, whose data were collected through the triangulation of multiple sources: document analysis, observation of 10 professionals in the provision of care and 24 interviews with patient-families from 12 clinical and surgical inpatient units of a hospital. Thematic analysis was carried out, based on the concept of co-production. Results: safety protocols according to the experience of the patient portrayed the role of patient-families as co-producers of safe care. It was found an alignment between perceptions of the patients, institutional definitions and basic national and international patient safety protocols. However, these protocols are not always followed by professionals. Conclusion: co-production was perceived in the protocols for safe surgery and prevention of injuries resulting from falls. In patient identification, hand hygiene and medication process, it was found that co-production depends on the proactive behavior of patient-families, as it is not encouraged by professionals. The research contributes with subsidies to leverage the participation of the patient as an agent of their safety, highlighting the co-production of health care as a valuable resource for advancing patient safety.


Introduction
For more than a decade, the World Health Organization (WHO) has warned of the need to promote safer practices in the healthcare environment. In the

2008-2009 work plan of the World Alliance for Patient
Safety, there is an action that is the focus of this study, which requires attention from health service providers and managers, called Patients for Patient Safety, whose main purpose is to ensure that the patient's voice is the foundation of the movement for safety (1) . At the national level, this action makes up one of the axes of the National Program for Patient Safety (Programa Nacional pela Segurança do Paciente, PNSP), instituted by the Ministry of Health, which describes actions for the involvement of the patient in their safety (2) .
Considering the direction of health policies towards improvements in patient safety, through their participation, the focus of this research was on the experience of the patient in the co-production of care, from the perspective of quality in hospital service. The interrelation of the conceptual basis presented in this statement reflects the dynamic and interactive nature of the investigated object.
Among the concepts, it is based on patient engagement in the assessment of health quality (3) and patient safety, consisting of reducing the risk of unnecessary damage associated with health care to an acceptable minimum (4) . The concept of patient experience is also emphasized, which involves interactions, organizational culture and patient perceptions throughout the continuum of care (5) .
In line with these conceptions, co-production is integrated, originating in the Marketing Services area, whose application can be transversal to different areas of knowledge. The classic concept of co-production refers to a process in which the user is considered an inherent part of the production of a given service, so that the result depends on a joint effort between providers and users (6) .
In the health field, service delivery occurs through the presence of the actors involved in service meetings.
When this characteristic is not recognized, limitations on the success of partnerships between patients and professionals are incurred, with a view to improving care (7) . An example of these limitations is found in a recent publication, in which the low quality of care was associated, among other factors, with the lack of coproduction in the provision of health care, considering patients and families (8) .
Despite several initiatives, there is a long way to go in favor of patient safety, especially in strategies that consider their involvement in the identification of weaknesses in the health system, which incur health care (9) . Patient participation in safety is still deficient in clinical practice and systematic actions are needed to create a safety culture in which patients are seen as partners (10) .
A multi-center study concludes that patients provide information that portrays the care experienced and, therefore, can contribute with what needs to be changed to improve patient safety and experience (11) .
Scope review about patient engagement in improving hospital services, shows that there is a lack of research on this theme, pointing to the need for future research with a behavioral focus on patient engagement (12) .
These findings from the foray into the literature

Method
The research is part of the qualitative aspect, a design recommended to explore and describe the object under investigation, which applies to the study of the perceptions and interpretations that the subjects produce, making it possible to unveil meanings of the studied phenomenon (13) . It was anchored in the conceptual framework of co-production (6) , which implies the active participation of the patient in their care.
Presearch developed in a public, university, Brazilian hospital, certified by the Joint Commission International. Data saturation has guided the decision that enough has been achieved (14) . Institutional documents were found that guide the care routines, described in the form of care policies and plans, selecting those that contained the explicit description of the patient-family involvement in care.
In addition to these, results were collected from four quality and safety indicators (hand hygiene, patient identification, falls and patient satisfaction) from the 12 units of the study scope. to organize the analysis corpus (13) . Thus, the themes were identified and grouped for the composition of indicated for qualitative research, described in the check list COREQ (16) .

Results
As a characterization of the participating patients, Regarding the preventive measures of falls observed, it was found that the professionals, when finishing the service, repositioned the bed in the low position and raised the bed rails (O7, O16, O18, O19).
It is also possible to follow the reinforcement of the guidelines on care to prevent falls, emphasizing the high railings, the low bed and the request for help to get out of bed accompanied (O26, O27, O28, O29).

Discussion
The assistance guidelines analyzed are in line with the global challenges proposed by WHO more than a decade ago. The first challenge directs care to prevent infections through hand hygiene (17) . The second, deals with safety barriers for harm reduction associated with surgical interventions, including the participation of the patient-family in the consent regarding the type of planned procedure, confirmation of the surgical site and verification of the identification of the patient before anesthetic induction (18) . The third, more recently launched, aims to reduce preventable adverse events related to the medication process (19) .
The safety protocols identified refer to international targets for patient safety. These goals guide barriers to the occurrence of adverse events in situations of higher hygiene, surgery and fall prevention (20) . In addition to this care, patient-families also expressed perceptions about care related to transfer between sectors (2) .

Results of research that assessed the impact of
Accreditation programs on Brazilian health organizations, highlighted greater patient involvement when the institution has Accreditation status (21) . In line with this result, in this research it was found that patient-families demonstrated knowledge about the purpose of patient identification, whose meaning of such practice, in the view of patient-families, is equivalent to health care in first world countries.
Regarding medication administration, perceptions of the patients showed fragility in the process, considering the important safety barrier of checking identification before the medication administration, which is only followed by some professionals. It was found that there is variability in the behavior of professionals, compared to the standard of quality and safety defined by the institution. In addition, it was found that the patient considers the way medication administration takes place, when there is a relationship of trust established with the care team, making identification checking unnecessary.
The concern with correct identification, as an important barrier for the prevention of adverse events, has been published since the theme became a global issue, as a result of the initiatives of the World Alliance for Patient Safety (1) . A study evaluated the use of the identification bracelet in patients in the same field, at the time they were made manually by nursing professionals, found that 11.9% of patients had the identification bracelet with errors, with incomplete names, record numbers differences, lack of data legibility and problems with integrity (22) .
Still in the same scenario, another study found an increase in the rate of adherence of professionals to verify the identification of the patient before the highest risk care after changes in the process, with the inclusion of computerized labels for making the bracelets, sensitizing the teams (23) . A study carried out at another university hospital, also in the south of the country, found that adherence to patient identification is deficient, considering that, in 71.6% of the analyzed cases, patients were identified, and the authors considered that the result should be close to 100% (24) . Research carried out in Turkey, in a JCI certified hospital, the results were alarming, in relation to the lack of knowledge of the patient about the use of the identification bracelet, as well as of the professionals about when it is essential that the conference is held, so that the care provided is safe in that concern (25) .
Regarding the involvement of patients in safety actions, it was found that co-production for patient safety is still incipient, when the participation in the mandatory moments of checking their identification is analyzed, in the sense of depending on the patient's inherent posture. If the patient-families are proactive and knowledgeable, it was found that they feel free to participate, getting involved about which medications they are receiving, checking the identification labeled on the medication. However, it was not identified that there is a stimulus of this practice, on the part of professionals, in the production of care and the relationship of trust that patients place in professionals is considered sufficient by patient-families so that there are no failures.
One study, which sought feedback from patients on safety, found that 35% of the reports were classified as a patient safety incident, with the most frequent incident being the medication error, which was present in the speeches of one in 10 interviewed patients (11) . Research that analyzed the preparation and administration of drugs in the same field in which this research was developed found that one of the current problems concerns the verification of patient identification at the time of administration, since it is performed only with the visual resource of the professional, not counting with technology support, such as bar code reader (26) .
In Canadian research, an innovative visual tool on patient safety was proposed, guiding postures and behaviors so that they participate in the care, which is available in the users' circulation environments. The assessment of the tool by patients and family members indicated that they felt more confident to ask questions of professionals, by stimulating the materials used (27) .
In addition to finding strategies to influence patients to ask questions, in order to promote their involvement in the safety of their care, it is also necessary to prepare professionals for this participation. In this sense, a study analyzed government policies and programs in five countries, and in Canada, the actions were directed towards monitoring patient engagement, stating the need to invest in the training of professionals, through education programs, to develop co-production strategies in healthcare (28) . Other results demonstrate barriers to be overcome in this sense, due to the lack of skill of the health team and cultural issues present in the hospital service environment related to the lack of knowledge about how the patient can collaborate with safety (12) . In addition to cultural differences, the reduction of gaps in communication between patients-families and teams requires time organization, for investment in such a strategy (29) . The education of professionals and patients for co-production in health is highlighted as a need to train agents of change in this context (7) , becoming urgent due to the occurrence of preventable adverse events related to health care (9) .
Another protocol described in PNSP (2) is consolidated in the documents and care practices of the studied field, through a fall prevention plan, whose care was present in the perceptions of patients-families study participants and the behavior of professionals on a constant basis.
The results demonstrate that professionals encourage the patient and family to co-produce care in service meetings, in relation to preventive measures during hospitalization.
In a national study about this care, there are no aspects on the involvement of the patient and family in the prevention of falls (30) . On the other hand, we found the description of 11 actions to prevent falls, with the participation of the patient and family in it (31) . The implementation of an intervention, to promote the participation of the patient and family in the fall reduction plan, resulted in a significant reduction in falls in general and falls with damages (32) . Studies demonstrate that patient and family involvement in care is relevant, which must be implemented systematically in hospital health services.
Another action related to patient safety, marked Regarding the limitations of the study, it is considered that the interviews, since they were carried out during the hospitalization period, may not have contemplated the entire experience lived during the hospitalization. Another issue refers to the possible fear of participants expressing delicate situations, while they still depend on the assistance that is offered to them, which may have influenced the content of the reports.

Conclusion
It is possible to verify an alignment between the perceptions of the patients, the institutional definitions of the studied field and the basic protocols described in the National Program for Patient Safety. However, although these basic protocols are part of the perceptions of patient-families, they are not always followed by professionals, incurring risks for the safety of care, when important safety barriers are not remembered or ignored. It is also noted that this behavior was perceived by the patient-families, with no warning signs on the part of them to the professionals, a condition that indicates fragility in the care process, due to the lack of active participation, mainly in the patient identification conference mandatory moments and hand hygiene.
With that, it was observed that co-production for patient safety is still incipient in relation to this care.
Despite the fact that patients-families show the potential to co-produce, the professionals did not stimulate this practice.
The relationship of trust between patients and professionals, although it is a positive factor in the hospital environment, interposes itself as fragility to safety, when it justifies the passive attitude of patientsfamilies towards care, as they consider that there will be no failures in the face of such relationships.
In the experience of patients undergoing surgery, co-production was present, at the time of consent and marking of the surgical site, when the intervention required laterality. Also, there was a stimulus for coproduction of care related to the prevention of falls.
Co-production for safety in drug administration was found to depend on the proactive behavior of some patient-families. Its initiative in checking and asking questions led professionals to adopt a favorable attitude towards co-production, stimulating interaction through clarifications, enabling the patient to check the type of medication, dose, time and identification.
The research contributes with subsidies to leverage the participation of the patient as an agent of safety actions in their care. Therefore, it was considered that the co-production of care oriented to patient safety is a valuable resource for advances in favor of patient safety. Furthermore, co-production is a viable solution for health services that aim to continuously improve care practices, with a view to developing effective partnerships between health teams and patient-families, for the benefit of patient safety.