health quality and disparties in the US

S A F E T Y

The Three-Legged Stool: Why Safety, Quality, and Equity Depend on

Each Other Jack Lynch, FACHE, president and CEO, Main Line Health, Bryn Mawr, Pennsylvania

In 2015, the American Hospital Association (AHA) launched its #123forEquity pledgecampaign to eliminate healthcare disparities. Since then, nearly 1,500 organizations have committed to increasing

• the collection and use of race, ethnicity, language preference, and other sociodemographic data;

• cultural competency training; and • diversity in leadership and governance.

This powerful commitment to addressing disparities in care holds promise, but it is also nonnegotiable. By 2050, according to the U.S. Census Bureau (2017), minorities will make up 54% of the American population. This could mean that at least one of every two patients who walk through our hospital doors will be at risk for suboptimal care if we do not accelerate efforts to achieve systematic and sustainable delivery of equitable care. As healthcare leaders, we must address disparities in care with the same intensity and passion with which we have unequivocally embraced patient safety and quality.

Main Line Health (MLH), like other systems across the country, is working to create a future state where—without question or exception—every single patient receives the same level of safe, high-quality care. This means that, in every patient encounter, safety and quality outcomes are considered a direct reflection of equitable care delivery.

We at MLH are always learning from others, and three approaches in particular have been critical to our pledge to achieve equity:

1. A focus on the STEEEP principles established by the Institute of Medicine (now the National Academy of Medicine) to deliver care that is safe, timely, efficient, effective, equitable, and patient centered

2. Robust cultural competence education for healthcare teams 3. An organizational culture that rewards those who speak up for safety

For more information about the concepts in this column, please contact Mr. Lynch at [email protected]. The author declares no conflicts of interest.

© 2017 Foundation of the American College of Healthcare Executives DOI: 10.1097/JHM-D-17-00109

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SAFETY

STEEEP: EVERYWHERE, EVERY TIME, EVERYONE As the U.S. health system transforms to a value-based model focused on population health, providers must continue to develop innovative approaches to addressing the social determinants of health and improving access to care. Although this community wellness work represents a critical piece in tackling disparities in care, perhaps the biggest challenge in preventing inequities arises when some of these community members become patients.

Research from the past decade underscores a simple fact: Racial and ethnic minorities, LGBTQ patients, and the uninsured and underinsured face an increased risk of adverse safety events in hospitals. It is not simply social determinants of health, comorbidities, or complex health factors that cause negative patient safety outcomes in these groups. Rather, it is the failure to care for each of these patients as individuals by taking the time to understand how to communicate with them and how to care for them within the context of their support system and social environment (Betancourt, Corbett, & Bondaryk, 2014).

Some disparities exist because of the inherent structure of the U.S. medical system. For instance, one study found that hospitals serving a high number of minority or underinsured patients demonstrate a higher prevalence of adverse patient safety events. The researchers suggested that these hospitals could potentially achieve better outcomes “through the implementation of evidence-based protocols and investment in technology” (Metersky et al., 2011, p. 510). However, given their quality and safety performance, these hospitals risk decreased reimbursement, which would only exacerbate the lack of resources needed to support investments in technology and education for staff.

If we all fixate on the complexity of our nation’s health system infrastructure, the contentious political landscape, or institutionalized inequities that continue to drive disparities, then this injustice seems insurmountable. However, if we look at each patient encounter as an opportunity to effect change by ensuring a high-quality, safe, and therefore equitable patient experience, we can fulfill our commitment to the AHA’s #123forEquity pledge to act.

One way to drive this experience consistently is to adopt the STEEEP principles of the National Academy of Medicine as an expectation and standard for treating every patient. When organizations create an accountability structure to ensure all patients receive care that is STEEEP—safe, timely, efficient, effective, equitable, and patient centered—they can ameliorate disparities in care, one patient at a time. As part of an initiative at MLH called Performance Excellence 2020, we have made it our vision to deliver a STEEEP experience everywhere, every time, to everyone across our system by 2020.

CULTURALLY COMPETENT CARE Although evidence suggests that several complex factors contribute to healthcare dispar- ities, the data show that unconscious bias and a lack of cultural competence are con- tributors. One research study examined how ethnic backgrounds influence patient safety and concluded, “Disparities in safety do not merely exist because of ethnic characteristics of patients. Often because health organizations and health professionals have not acquired cultural competence (e.g., cultural knowledge, attitudes, skills and resources), ethnic dis- parities in patient safety occur” (Suurmond, Uiters, Bruijne, Stronks, & Essink-Bot,

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2010, p. S116). Other research confirms that unconscious bias and other factors that contribute to disparities in care lead to “medical errors with greater clinical consequences, prolonged length of hospital stay, avoidable hospitalizations and readmissions, and overutilization and underutilization of procedures for minority patients” (Betancourt et al., 2014, p. 144). It is the responsibility of healthcare leaders to develop, share, and continually evolve best practices in cultural competence education to ensure that our pa- tients know we are taking the time to understand them and care for them as individuals.

Safety events driven by healthcare disparities come at a cost—to the tune of $1.24 trillion between 2003 and 2006 (LaVeist, Gaskin, & Richard, 2009). Investing in effective cultural competence education for staff is therefore not only the moral thing to do but also a fiscal responsibility of leaders. Overwhelmingly, effective training is directly corre- lated to improved patient safety and quality indicators among minority patients. It also improves providers’ knowledge and attitudes and increases patient satisfaction (Betancourt et al., 2014, p. 144).

Several national organizations, including the AHA’s Institute for Diversity, the Dis- parities Solutions Center, and the Institute for Healthcare Improvement (2017) with its Pursuing Equity initiative, can help organizations enhance their cultural competency and align the tenets of quality and equity. In addition, the American College of Healthcare Executives, in partnership with the National Patient Safety Foundation’s Lucian Leape Institute (2017), released Leading a Culture of Safety: A Blueprint for Success as a resource to help leaders create a culture of safety that is built on a foundation of inclusion and respect.

MLH engages all of its managers in a Diversity, Respect, and Inclusion learning ex- perience. The 2-day, interactive class includes discussions of historical social movements that have shaped perceptions; a detailed exploration of various types of racial, ethnic, socioeconomic, and sexual orientation disparities; and exercises that ask participants to reflect on their personal unconscious biases. The response from our managers has been positive, and anecdotal evidence indicates that the class is helping to create a safer, higher- quality experience for patients and team members, too. Through 2019, we will roll out a similar version of this training to all staff, including physicians, and we will track how these efforts enhance our patient safety and quality indicators.

A SAFE AND RESPECTFUL PLACE TO WORK In a Harvard Business Review article, Andrew Winston (2017) discusses the genesis of most public relations crises and notes how—if one person had spoken up a bit sooner—a public problem could have been avoided. He makes the case that executives need to regularly “assess whether their cultures allow their own employees the power and safety to stand in front of the train of fast-moving stupidity and say, ‘You shall not pass!’ And they need to have executives who will listen to them.”

We are all human. Mistakes are inevitable when we work alone, so we must work together. Merriam-Webster (n.d.) defines culture as “the set of shared attitudes, values, goals, and practices that characterize an institution or organization.” At MLH, we have worked diligently to create a culture in which everyone feels empowered and encouraged to speak up for safety and “have each other’s back.” We frequently talk about the power gradient and ways staff can voice concern with team members in positions of higher

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SAFETY

authority. So, for instance, if a nurse feels a physician is making a decision without ap- propriately receiving consent from a non-English-speaking patient, the nurse should “stop the line” until an interpreter service is activated and the patient is consulted.

On an Agency for Healthcare Research and Quality survey administered to staff, MLH received a grade of 80% for our safety culture. However, despite our efforts, only 19% of staff indicated that they always felt free to question the decisions of those with more authority. That score is unacceptable, and we are actively working to address it with tactics such as consistent rounding, visual reminders for staff (e.g., uniform buttons), and unstructured face-to-face meetings with hospital leaders for staff at all levels.

To achieve a safe, high-quality experience for our patients, we must commit to cre- ating a safe, high-quality environment for our teams. Healthcare leaders should enforce organizational standards that hold all employees, physicians, and volunteers—everyone, at every level of the organization—accountable for demonstrating mutual respect to their colleagues. If we can establish trust and respect in our organizations, we can then be sure every healthcare worker will be that much more committed and sensitive to providing compassion, respect, and an equitable experience to every individual who gives us the privilege to serve and care for them.

R E F E R E N C E S American College of Healthcare Executives and National Patient Safety Foundation Lucian Leape

Institute. (2017). Leading a culture of safety: A blueprint for success. Retrieved from www.npsf.org/ page/cultureofsafety

Betancourt, J. R., Corbett, J., & Bondaryk, M. R. (2014). Addressing disparities and achieving equity. Chest, 145(1), 143–148. doi:10.1378/chest.13-0634

Institute for Healthcare Improvement. (2017, April 3). Pursuing Equity: IHI brings together leading health care organizations for two-year initiative to advance equity (Press release). Retrieved from http:// www.ihi.org/about/news/Documents/IHIPressRelease_PursuingEquityLaunchAnnouncement.pdf

LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Washington, DC: Joint Center for Political and Economic Studies.

Merriam-Webster. (n.d.) Culture. Retrieved from https://www.merriam-webster.com/dictionary/culture Metersky, M. L., Hunt, D. R., Kliman, R., Wang, Y., Curry, M., Verzier, N., … Moy, E. (2011). Racial

disparities in the frequency of patient safety events. Medical Care, 49(5), 504–510. doi:10.1097/ mlr.0b013e31820fc218

Suurmond, J., Uiters, E., de Bruijne, M. C., Stronks, K., & Essink-Bot, M.-L. (2010). Explaining ethnic disparities in patient safety: A qualitative analysis. American Journal of Public Health, 100(Suppl 1), S113–S117.

U.S. Census Bureau. (2017). Table: Projections of the population and components of change for the United States: 2015–2060. Retrieved from https://www2.census.gov/programs-surveys/popproj/ tables/2014/2014-summary-tables/np2014-t1.xls

Winston, A. (2017, April 12). Pepsi, United, and the speed of corporate shame. Harvard Business Review. Retrieved from https://hbr.org/2017/04/pepsi-united-and-the-speed-of-corporate-shame

New Safety Resource for Healthcare Leaders

Leading a Culture of Safety: A Blueprint for Success shares tools to create a culture that puts safety at its core. The guide is a collaboration of the American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation Lucian Leape Institute. Download it at www.npsf.org/cultureofsafety.

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