A Health Equity Lens on Patient Safety and Quality

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UCSF Center for Vulnerable UCSF School UCSF Department Populations at Zuckerberg of Medicine of Epidemiology San Francisco General and Biostatistics Hospital

A Health Equity Lens on Patient Safety and Quality

Kirsten Bibbins-Domingo, PhD, MD, MAS Lee Goldman, MD Endowed Chair in Medicine Professor of Epidemiology and Biostatistics and Medicine Vice Dean for Population Health and Health Equity

10/26/2018 Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017. Partnering for Health Equity . The fierce urgency of now Can we advance patient safety AND equity at the same time?

4 YES!

Deliberate action, Informed choices, Creating a culture of quality and safety for all

5 The inequality paradox

6 Frohlich and Potvin, AJPH 2008 Number and percentage of quality measures for which income groups experienced better, same, or worse quality of care compared with reference group (high income), 2014-2015

7 AHRQ 2016 National Healthcare Quality and Disparities Report Number and percentage of quality measures with disparity at baseline for which disparities related to income were improving, not changing, or worsening (2000 through 2014-2015)

8 AHRQ 2016 National Healthcare Quality and Disparities Report Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group (White) in 2014-2015

9 AHRQ 2016 National Healthcare Quality and Disparities Report Number and percentage of quality measures with disparity at baseline for which disparities related to race and ethnicity were improving, not changing, or worsening (2000 through 2014-2015)

10 AHRQ 2016 National Healthcare Quality and Disparities Report Number and percentage of quality and access measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group in 2014-2015, by geographic location

11 AHRQ 2016 National Healthcare Quality and Disparities Report 1. The inequality paradox Inequities in quality and safety exist Without an focus on equity, these may not improve 2. We only know what we measure

12 10/26/2018 13 10/26/2018 14 DIFFERENCES MATTER We Ask Because We Care. By knowing your race, ethnicity, and language, we can review the treatment patients receive and ensure that everyone gets the highest quality of care. Your information is PRIVATE, and you can DECLINE to answer. Your individual responses are not shared outside the health care system. If you choose not to answer, you will still receive the highest quality of care.

15 DIFFERENCES MATTER 1. The inequality paradox Inequities in quality and safety exist Without an explicit focus on equity, these may not improve 2. We only know what we measure Don’t let perfect be the enemy of good Engage staff, clinicians, patients in why this is important 3. Don’t just measure - do something!

16 10/26/2018 17 Zuckerberg San Francisco General Hospital TRUE NORTH

Zuckerberg San Francisco General 9/22/2017 2 Hospital and Trauma Center WORKFORCE DEVELOPMENT CARE EXPERIENCE • Staff confuse equity with equality • Culture that equates working at a safety net with • Workforce population does not reflect patient majority minority population as being equitable. population • Organizational discomfort of discussing or ZSFG’s • No consistent support to meet training needs addressing disparities. fragmented • No Equity Executive sponsor. • Cultural competency needs vary and not coordination of • No follow-up work after completion of trainings monitored. Equity like racial humility or cultural competency. • Highly reactive environment of firefighters and Initiatives, limits • No operational and governance infrastructure to meeting regulatory requirements. our workforce’s oversee and coordinate ZSFG equity efforts • Organizational policies not aligned to meet needs ability to reduce of vulnerable staff and patient populations disparities in a measurable way. Currently, only QUALITY & SAFETY FINANCIAL STEWARDSHIP 6% of ZSFG • Inconsistent staff and patient experience metrics • ZSFG cultural competency and implicit bias Depts have • Homegrown data programs developed in trainings just started. No need was forecast countermeasures response to division needs, not systematic • Equity work driven by mandates (e.g. PRIME, to Advance • In transitional period for EHR deployment. SOGI Ordinance) instead of institution mission – Equity. • Disparity data not tracked in a centralized this impacts resources/rollout location • Uncertainty over impact of political climate on • No consistent venue for staff and patients to ability to address equity long term. voice concerns regarding equity or social justice 20 10/26/2018 Wasserman, et al. Identifying and preventing errors in patients with limited English Proficiency J Healthc Qual. 2014 ; 36(3): 5–16 22 Wasserman, et al. Identifying and preventing errors in patients with limited English Proficiency J Healthc Qual. 2014 ; 36(3): 5–16 1. The inequality paradox Inequities in quality and safety exist Without an explicit focus on equity, these may not improve 2. We only know what we measure Don’t let perfect be the enemy of good Engage staff, clinicians, patients in why this is important 3. Don’t just measure - do something! 4. Engage community resources outside of healthcare setting

23 10/26/2018 THE FULL REPORT IS NOW AVAILABLE FOR FREE DOWNLOAD AT: iom.edu/ehrdomains2

Also summarized in Adler NE, Stead WW. N Engl J Med 2015;372:698-701.

28 BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE BENEFITS

Benefits of including recommended measures in all EHRs include:

MORE EFFECTIVE MORE EFFECTIVE DISCOVERY TREATMENT POPULATION OF LINKAGES MANAGEMENT

25 CORE DOMAINS & MEASURES WITH SUGGESTED FREQUENCY OF ASSESSMENT

DOMAIN/MEASURE MEASURE FREQUENCY

Alcohol Use 3 questions Screen and follow up Race and Ethnicity 2 questions At entry Residential Address 1 question Verify every visit Tobacco Use (geocoded) Screen and follow up 2 questions Census Tract-Median Income 1 question Update on address change Depression (geocoded) Screen and follow up Education 2 questions At entry Financial Resource Strain 2 questions Screen and follow up Intimate Partner Violence 1 question Screen and follow up Physical Activity 4 questions Screen and follow up Social Connections & Social Isolation 2 questions Screen and follow up Stress 4 questions Screen and follow up 1 question

NOTE: Domains/Measures are listed in alphabetical order; domains/measures in the shaded area are currently frequently collected 26 in clinical settings; domains/measures not in the shaded area are additional items not routinely collected in clinical settings. Examples of how census tract–level information can be linked to health outcomes in a staged manner by displaying geomarkers.

Andrew F. Beck et al. Pediatrics 2012;130:831-838

Andrew F. Beck et al. Pediatrics 2015;135:1009-1017

©2015 by American Academy of Pediatrics Andrew F. Beck et al. Health Aff 2017;36:999-1005 1. The inequality paradox Inequities in quality and safety exist Without an explicit focus on equity, these may not improve 2. We only know what we measure Don’t let perfect be the enemy of good Engage staff, clinicians, patients in why this is important 3. Don’t just measure - do something! 4. Engage community resources outside of healthcare setting 5. Recognize the urgency of addressing healthcare disparities

33 10/26/2018 Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Smedley et al. (eds), Washington D.C., National Academy Press, 2003 Evidence Shows Disparities Exist

• The evidence is “overwhelming” • Disparities exist even when insurance status, income, age, and severity of conditions are comparable • Minorities are less likely than whites to receive needed services • Disparities contribute to worse outcomes in many cases • Differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities • Institute of Medicine Report, 2003

35 Source: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, March 2003. Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Clinical Appropriateness and Need Patient Preferences

Difference The Operation of Health Care Systems Health Minority - Care

Non Discrimination: Disparity

Minority Biases, Stereotyping, and Uncertainty Populations with Equal Access to Health Care

Gomes and McGuire, 2001 How do Fragmented Systems of Care Contribute to Disparities?

. System deficits affect all segments of society, but especially non-white patients

. Disadvantaged patients “fall through the cracks” in complex system of care

. Small disparities in multi-step processes create moderate to large disparities overall

. Disparities arise even when providers well intentioned

Ayanian, 2009 Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Clinical Appropriateness and Need Patient Preferences

Difference The Operation of Health Care Systems Health Minority - Care

Non Discrimination: Disparity

Minority Biases, Stereotyping, and Uncertainty Populations with Equal Access to Health Care

Gomes and McGuire, 2001 Provider bias

“…biases may exist…often unconsciously, among people who strongly endorse egalitarian principles and truly believe that they are not prejudiced. There is considerable empirical evidence that even well- intentioned..…who do not believe that they are prejudiced demonstrate unconscious implicit negative racial attitudes and stereotypes [which] significantly shape interpersonal interactions….Evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.”

39 Ayanian, 2009 Ayanian, 2009 Why focus on health equity in quality and safety?

. Diversity of the US population is increasing

. Financial gaps are widening

. Moral, economic, social imperative

. Without a focus on equity – may ultimately limit ability to achieve the improvements in safety and quality we seek

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