Healthcare providers are realizing that without an intentional emphasis on equity, patient safety cannot truly be achieved—and they’re taking steps to put into practice initiatives that lean into the nexus of those two intertwined goals.
The American Hospital Association has had a plethora of conversations with its members in building the Health Equity Roadmap that it launched in spring 2022 with support from the Robert Wood Johnson Foundation, says Joy Lewis, senior vice president, health equity strategies. “Everyone wants to tether this equity work to the work that’s been done for over a decade now around quality and patient safety,” she says. “Because at the end of the day, it is really hard to say you’re delivering high-quality care if it’s not equitably administered.”
Lewis doesn’t think much needs to be done to raise awareness of the concept, but providers do need to raise their game in parsing data and looking at outcomes by race, gender, ethnicity, age and other factors, Lewis says. “You can start to identify where there are opportunities for really targeted and focused interventions, and what’s the right dosage of interventions that one should bring to bear,” she says.
St. Bernard Hospital and Health Care Center, located in the lower-income Englewood neighborhood on Chicago’s South Side, is well aware of the disparities, says Diahann Sinclair, St. Bernard’s vice president of organizational and community development, and an ACHE Member. “If you want your patients to be safe, … you need to get to know them, and to understand how they operate, what works for them, what doesn’t work, what they are aware of, and what they’re not,” she says.
For example, a healthcare provider who serves an area with low levels of literacy shouldn’t only be giving patients written discharge instructions, Sinclair says. “Maybe you need to deliver that information in a different form,” she says. “When you do, you might find that return rates decrease and the number of instances of that occurrence decreases.”
To guard against such instances, St. Bernard uses the “teach back” method, through which clinicians explain the care plan and then ask the patient to respond with what they understand. This easily assesses comprehension and helps correct any misunderstandings.
Main Line Health, based in the Philadelphia suburb of Bryn Mawr, Pa., places safety, quality, equity and affordability as its top four priorities, says Jack Lynch, FACHE, president and CEO. “If you’re not committed to equity, you’re really not committed to safety,” he says. “Nobody suggests that being committed to safety, or high quality, is for one group of patients. It’s for everybody.”
The correlation is also a no-brainer for William Jahmal Miller, chief administrative officer of Dignity Health’s Mercy Medical Group, CommonSpirit Health, Sacramento, Calif., and an ACHE Member. Miller says that evidence-based research shows that patient safety and outcomes are positively correlated with culturally competent care. “There are significant improvements in outcomes for patient safety when you have more diverse, equitable, inclusive representation.”
That’s happening more often these days, but not often enough, says William “Marty” Martin, PsyD, a professor at DePaul University and an ACHE Member. “We still have far too many people dying unnecessarily within healthcare facilities or suffering from harm they shouldn’t suffer from,” he says. “People, period, but it’s exacerbated in certain groups.”
Successes to Date, Challenges to Face
AHA member organizations have begun to improve their efforts around collecting race, ethnicity and language-related information, Lewis says. “That’s probably a good place to start because of the intersectionality of race and ethnicity across these other variables,” she says. But providers have been less adept at garnering “sexual orientation and gender identity data and other demographic data, like one’s educational or employment status.
“And then how do you use those data to drive action, to really produce improvements in health outcomes?” she adds. “That’s a really important nut to crack. Because if you don’t understand the experience of folks coming into your hospital setting, across different patient populations, how are you going to identify where the gaps are?”
Main Line Health started its focus on equity 11 years ago, when it initiated an annual disparities-of-care colloquium at which physicians, trainees and staff present findings of research they have conducted—roughly 10 per year.
As part of their equity training, employees have been taught to say “ouch” anytime they think someone said something inappropriate or offensive, Lynch says. “You’re not expected to get into
a debate about why what that person says” is wrong, he says. “It’s been incredibly effective at underscoring with our workforce that we don’t think it’s appropriate to treat people in a way that suggests that their difference is not valued.”
To measure disparities, Main Line Health examines quality and safety metrics by age, gender, race, ethnicity, language, ZIP code and payer, Lynch says. “You can immediately see if a gap exists,” he says. “It’s right there in everybody’s face. The metrics are shared with service-line leaders and clinicians, who have to develop plans around measuring gaps.”
A review of patients who have averaged at least four annual ED visits led Main Line Health to note patterns at two of its campuses that are being addressed:
On one campus, such patients were mostly from four ZIP codes, 90% were Black, 64-71% were female, who mostly ranged from 18-44 years of age. Many were presenting with urological or pregnancy-related issues.
On the second campus, two ZIP codes stood out. The patient group in one of those was 90% white, 57% female, and mostly 65 and older; that cohort presented primarily with respiratory concerns. In the second ZIP code, patients were 84% Black, 79% were female, and most were ages 18 to 44, and they presented mostly with urological and pregnancy-related concerns, similar to the four ZIP codes on the other campus.
Main Line Health has worked to ensure equity for the LGBTQ+ community as well, Lynch says, by opening LGBT-inclusive practices, switching to gender-neutral restrooms, and changing language to ensure that same-sex couples and transgender people feel welcomed, Lynch says. “We’re not going to make everybody happy [with our approach],” he says. “But we need to make all groups of people who receive care from us feel good about the care they received.”
CommonSpirit developed a health equity blueprint under Miller’s leadership, which was finalized in the spring of 2021. Among the strategic imperatives under the vision are to transform the system from within, “walk the talk” and identify how to address equity-related challenges and create effective diversity, equity, inclusion and belonging efforts, he says. CommonSpirit also has pledged to review how to build its data analytics to promote and support equity in a way that produces a measurable and sustainable impact. “Achieving equity is still aspirational in many instances,” he adds. “We still have a journey ahead of us.”
One area CommonSpirit has concentrated on is healthcare services to the homeless, given that having a roof over one’s head is a key social determinant of health, Miller says. “Long-term success is predicated not just on good medical care, hospitals and doctors,” he says. “It’s how can that patient go back to where they live, learn, work, play and pray and have proper social supports and continuum of care in addressing their needs?”
CommonSpirit has launched a health equity research project on peripheral artery disease, which Black Americans are twice as likely to contract as the general population, Miller says. “We’re identifying those at risk … making sure folks are adequately screened, and moving forward with clinical and nonclinical efforts that will ultimately yield improved outcomes,” he says. “That will ultimately improve patient safety, save lives, improve quality-of-life, and show us what’s possible when we think about equity.”
DePaul’s Martin has co-led efforts to reduce health disparities on the West Side of Chicago in a partnership with Rush University Medical Center, known as the DePaul/Rush Center on Community Health Equity. They reexamine scenarios like a patient who has a heart attack and lives in a high-crime area; when they go to cardiac rehab, the provider suggests they try to walk a half-mile a day. “Great, but I’m going to be at risk of being mugged or shot,” the patient might respond. “Do I keep my clogged arteries, or do I get head trauma?”
That community focus starts before someone becomes a patient, Martin says. “One of the ways to decrease patient harm is to see why people are becoming patients,” he says. “We focus on community health workers who keep people healthy.” And the system next works to try to ensure that patients can be seen in an ambulatory setting if at all possible rather than resorting to more complicated inpatient care.
A core tenet is that while DePaul and Rush bring subject matter experts with formal education and training, they are not experts on what’s happening on the ground, Martin says. Academic researchers partner with “key informants” like nonprofit executives, educators, religious leaders and small businesspeople. “We have an expertise, you have an expertise. Let’s co-create and co-design,” he says, “rather than being paternalistic.”
The Role of Leadership
Organizational commitment to equity that advances patient safety has to start with the board, CEO and others in the C-suite, Lewis says. “You can then begin to really build out and flesh out what does that accountability across the organization look like?” she says. “How do you cascade and catalyze the workforce to see that they each have a role in being what I would describe as ‘equity influencers?’”
Leaders themselves might first have to shore up their skills and acknowledge any biases, as well as ensure that their own ranks are diverse, Lewis says. “Leadership that reflects those individuals from historically marginalized groups can make more informed decisions,” she says. In addition, “Leaders may consider attending community meetings, not because they have an ask, but to be present on the community’s turf,” she says. “There is a power dynamic we need to be very sensitive and conscious of. ... A hospital is often the largest employer [and] really the anchor institution of the communities we serve.”
As the largest employer in its neighborhood, St. Bernard’s takes its community leadership role seriously—and because it’s a relatively small hospital, it’s easy to make quick decisions, Sinclair says. “The decision-making is mainly at the senior team level, informed by what managers and practitioners are seeing,” she says. “But we also partner with community groups, so whatever we deliver is done so in a manner that we know the community will receive, and also we have a trusted partner with us.”
Leaders also can be receptive to hearing from people at all levels of the organization, Sinclair says, because nutrition workers, for example, who go into patients’ rooms every day might get more information that may be helpful to doctors and nurses. “We’ve got to learn that if we’re really serious about equity and safety, we’ve got to start listening to all the touch points, not just the ones who have certifications behind their names,” she says.
Lynch believes it’s important for leaders to push past divisive political rhetoric and do what’s right for patients. “Why should somebody who doesn’t look like me, who doesn’t have the sexual orientation I have, who isn’t white—why shouldn’t they all get the same level of care, the same compassion, the same empathy, the same timeliness, the same access to healthcare that I get?” he says. “When I decided to go into this business, I didn’t look at the mirror and say, ‘Make sure you take care of people who look like you really well.’ I went into this business to deliver safe, equitable, high-quality care. People who don’t think this is important don’t belong in this business.”
Leaders at CommonSpirit show a visible commitment to DEI so that women and minority groups always feel like they are part of the organization, Miller says. “We’re focused on implementing routine discussions around implicit bias and being an anti-racist organization,” he says. “The better we are doing that, the better able we are to treat more diverse populations.”
Every organization is in a different place on that journey, Lewis says. “But we do have to be serious, and diligent, and hold each other accountable for this work,” she says. “This is the long game, right? If it were easy, we would have figured it out by now.”
To figure it out, providers need to move from the performative aspect of taking pledges and turn the corner to action, Lewis says. “That is really where the field is going,” she says. “I know our members are chomping at the bit and are asking for the how-to’s. How do I write a strategic plan that has equity embedded in it? How do I ensure that my board leadership and my executive leadership are diverse?”
Sinclair says that leaders need to be prepared to face resistance to change, although St. Bernard’s has been fortunate to have staff excited about equity work and who, often, have driven it. “You have to have your team members understand what you’re doing, why you’re doing it and why it’s important,” she says. “And once you have them connected in that way, I think you can step out of the way, and equity will move forward.”
“This is a journey that will never end,” Lynch says. “The first thing you have to do is be comfortable talking about it. The second thing is you have to measure it. People who say, ‘We treat everybody the same,’ I say, ‘How do you know?’ If you don’t measure it, you don’t know.”
Ed Finkel is a freelance writer based in the Chicago area.
Equity Standard Requirements Begin
Hospitals and healthcare centers that weren’t already moving toward a more equitable culture to promote patient safety faced a few more reasons to do so as of Jan. 1, 2023, notes Joy Lewis, senior vice president, health equity strategies for the American Hospital Association.
The Joint Commission on Accreditation of Healthcare Organizations launched two standards related to equity work that took effect at the beginning of this year, Lewis says. One requires a designated equity leader “whose day job it is to be accountable for leading the equity agenda,” she says. The second covers new requirements around data related to social determinants of health, including questions like, “What are your reporting mechanisms? How are you sharing those findings, whatever the data reveal, both internally and to the board?”
On top of that, the Centers for Medicare & Medicaid Services finalized a rule last August, which also took effect on Jan. 1, that related to quality reporting requirements and equity for the Inpatient Prospective Payment System, Lewis says.
“They’ve layered on requirements around what you’re reporting out on those quality metrics,” she says. “How do you apply an equity lens to them? … There is more momentum and energy around our members trying to figure out, ‘What is the role of hospitals and health systems in dismantling the structural barriers that impede some segments of our population from pursuing their health goals?’”