BMJ Qual Saf: first published as 10.1136/bmjqs-2020-012599 on 29 December 2020. Downloaded from EDITORIAL Advancing health equity in patient safety: a reckoning, challenge and opportunity

Marshall H Chin

Section of General Internal COVID-19 and police brutality have emphasising interventions and solutions. Medicine, University of Chicago, simultaneously heightened public aware- The patient safety field should move Chicago, Illinois, USA ness of disparities in health outcomes faster, incorporating major advances that Correspondence to by race/ethnicity, gender, and socioeco- have occurred regarding how to reduce 8 9 Dr Marshall H Chin, Section nomic status, and the underlying struc- health disparities. While equity issues of General Internal Medicine, tural drivers of systemic racism and social in patient safety have been understudied, University of Chicago, Chicago, 1 2 the principles for successfully advancing IL 60637, USA; privilege in the USA. Increasingly major mchin@​ ​medicine.bsd.​ ​uchicago.​ professional associations such as the health equity align well with the culture edu American Medical Association, Amer- and toolkit of the safety field.10 Thus, ican Hospital Association, and Associ- achieving equitable patient safety is a real- Accepted 24 November 2020 ation of American Medical Colleges are istic and important opportunity. decrying racism and inequities, and many My lessons are from the ‘school of hard individual healthcare organisations are knocks’: over 25 years of performing committing to addressing health dispari- multilevel health disparities research and ties. Hospitals, clinics and health plans are interventions locally,11 nationally9 12 13 looking inwards to identify organisational and internationally.14 I have been fortu- biases and discrimination, and developing nate to work with many passionate, inspi- outward interventions to advance health rational staff and leaders from healthcare equity for their patients. Looking in the and the community who have demon-

mirror honestly takes courage; frequently strated that advancing health equity is not http://qualitysafety.bmj.com/ the discoveries and self-insights­ are trou- a mirage—it can be done. bling.3 At their best, discussions about 4 racism and inequities are challenging. A FRAMEWORK FOR ADVANCING Within the quality of care field, dispari- HEALTH EQUITY ties in patient safety are relatively under- The WHO defines health equity as ‘the 5 6 studied. Thus, Schulson et al’s study absence of unfair and avoidable or reme- in this issue of BMJ Quality and Safety, diable differences in health among popu- finding that voluntary incident reporting lation groups defined socially, econom- systems may underdetect safety issues in

ically, demographically or geographi- on September 25, 2021 by guest. Protected copyright. marginalised populations, is an important cally’.15 To achieve health equity, people sentinel event.7 Implicit bias in providers should receive the care they need, not and structural bias in safety reporting necessarily the exact same care.16 ►► http://dx.​​ doi.​​ org/​​ 10.​​ 1136/​​ ​ systems might explain this underdetection I summarise a framework for advancing bmjqs-2020-​ ​011920 of problems. health equity (figure 1). In brief, indi- In this editorial, I summarise the prac- viduals and organisations must commit tical lessons for advancing health equity to the mission of maximising the health © Author(s) (or their sustainably, with the hope of accelerating of diverse individuals and populations. employer(s)) 2020. No equity in patient safety. I present a frame- Their actions, policies and procedures commercial re-­use. See rights work for advancing health equity, describe must intentionally advance health equity. and permissions. Published by BMJ. common pitfalls and apply the frame- This intentional design to advance health work to patient safety to inform research equity consists of two simultaneous To cite: Chin MH. and policy recommendations. The wider tracks: (1) Create a culture of equity in BMJ Qual Saf Epub ahead of print: [please include Day health disparities field has been criticised which the whole organisation—senior Month Year]. doi:10.1136/ for spending too many years describing leadership, mid-level­ management, front-­ bmjqs-2020-012599 the phenomenon of inequities before line staff and clinicians—truly values and

Chin MH. BMJ Qual Saf 2020;0:1–6. doi:10.1136/bmjqs-2020-012599 1 BMJ Qual Saf: first published as 10.1136/bmjqs-2020-012599 on 29 December 2020. Downloaded from Editorial

Figure 1 Framework for Advancing Health Equity.9 18 buys in to the mission of advancing health equity.17 daily jobs with an equity lens and reform the struc- Developing a culture of equity requires an inward tures in which they work, regardless of whether they personal look for biases as well as examination for are working in clinical care, data analytics, quality systematic structures within the organisation that bias improvement, strategic operations, finances, patient against and oppress marginalised groups. (2) Imple- experience, environmental services, health informa- ment the Road Map to Reduce Disparities.9 18 Road tion technology or human resources. Leadership needs map principles are the tenets of good quality improve- to provide front-­line staff with the training and support ment, emphasising an equity lens that tailors care to necessary for success. The wider environment requires meet the needs of diverse patients rather than a one-­ payment reform that supports and incentivises care size-­fits-all­ approach. Key steps of the road map are transformation that advances health equity.20–22 Part- to: identify disparities with stratified clinical perfor- nerships across health and social sectors need to align mance data and input of clinicians, staff and patients; goals and efforts to address the medical and social http://qualitysafety.bmj.com/ do a root cause analysis of the drivers of the dispar- drivers of health, both drivers for individual persons as ities; and design and implement care interventions well as the underlying systematic structural drivers.23 that address the root causes in collaboration with the affected patients and populations. These actions will COMMON PITFALLS ultimately improve individual and population health (1) Not being intentional about advancing health equity. and improve health and healthcare equity. Relying on magical thinking. When I ask healthcare Creating a culture of equity and implementing the leaders what they are doing to advance health equity, concrete actions of the road map are equally important I frequently hear well-­meaning statements such as:

for change. Management consultant Peter Drucker’s ‘We’re already doing quality improvement.’ ‘We’re a on September 25, 2021 by guest. Protected copyright. famous aphorism that ‘Culture eats strategy for break- safety-­net organization that cares for the most vulner- fast’ applies to equity work. Technically sound disparity able persons. It’s who we are.’ ‘The shift from fee-for­ -­ interventions and strategies will not be implemented service payment to value-based­ payment and alterna- or sustained unless equity is an organisational priority tive payment models will fix things.’ Such statements among all workers. Similarly, well-meaning­ intentions are variants of the ‘rising tide lifts all boats’ philos- will not take an organisation far unless accompanied ophy and the belief that the ‘invisible hand’, whether by concrete actions. The key bridge between a culture it be general free market principles, a general system of equity and road map principles is that every worker of quality improvement and patient safety, or general in the organisation, from the chief executive officer to commitment to serving marginalised populations, will front-­line staff, must know how to practically oper- suffice in reducing health disparities. Yet, disparities ationalise advancing health equity in their daily jobs. stubbornly persist in quality of care and outcomes by Successful application of these lessons is in part inter- race, ethnicity and socioeconomic status.24 acting effectively with diverse persons, as classically Culturally tailored care interventions that address taught in cultural humility classes.19 However, oper- the underlying causes of disparities often work better ationalisation goes beyond interpersonal relations to than default one-­size-­fits-­all approaches.25 However, each worker knowing how they should perform their the ‘invisible hand’ incentives in general quality

2 Chin MH. BMJ Qual Saf 2020;0:1–6. doi:10.1136/bmjqs-2020-012599 BMJ Qual Saf: first published as 10.1136/bmjqs-2020-012599 on 29 December 2020. Downloaded from Editorial improvement and pay-­for-­performance approaches community. One organisation we worked with sought are frequently too weak to drive organisations to tailor advice from Latinx (gender-neutral,­ non-­binary term approaches to advance health equity,13 and can even to indicate of Latin American descent) healthcare be counterproductive. Rather than implement indi- workers to design an intervention to reduce disparities vidualised, tailored care that can improve outcomes in the outcomes of their Latinx patients with depres- for diverse minority populations, some organisations sion, rather than speaking with actual patients. The perceive that it is easier to improve their aggregate organisation designed a telephone intervention that patient outcomes or clinical performance per dollars failed, partly because their patients frequently had spent by investing resources in the general system of pay-­by-the-­ ­minute cellphone plans rather than unlim- care, or by intentionally or unintentionally erecting ited minute cellphone plans that were probably more barriers that make it harder for marginalised popula- commonly used by the Latinx employees. Few patients tions to access their system of care. For example, persons agreed to enrol in the intervention because of cost. living in zip code areas that have higher percentages of (4) Marginalising equity efforts rather than involving African Americans or persons living in poverty have the whole organisation. Frequently healthcare organi- less access to physicians practising in accountable care sations will do an isolated care demonstration project organisations.26 27 Moreover, inadequately designed to reduce disparities or appoint a siloed chief equity incentive systems can penalise safety-­net hospitals that officer rather than mobilising the whole organisa- care for marginalised populations, leading to a down- tion to advance health equity. It helps having health ward spiral in quality of care and outcomes. The initial equity leaders with dedicated resources to catalyse iteration of Medicare’s Hospital Readmissions Reduc- reform, but meaningful sustainable change only occurs tion Program (HRRP) reduced Medicare payments when everyone makes it their job to improve health to safety-­net hospitals by 1%–3% and increased read- equity. Most organisations do not engage in substan- mission rates for black patients in these hospitals.28 tive discussions with payers regarding how to support Directed by legislation passed by Congress, the Medi- and incentivise disparities reduction, nor consider how care programme intentionally addressed this equity cross-sector­ partnerships can be organised in effective problem in the HRRP in 2019 by stratifying hospitals and financially sustainable ways. by proportion of patients dually enrolled in Medicare (5) Requiring a linear, stepwise process for reducing and Medicaid, so that a given hospital’s clinical perfor- disparities and allowing the ‘perfect to be the enemy of mance would be compared with that of hospitals with the good’. For example, some organisations get stuck a similar prevalence of poverty when calculating finan- collecting race/ethnicity/language data so they can cial rewards and penalties.29 stratify their clinical performance measures by these (2) Focusing exclusively on cultural humility or factors. Such stratified data are valuable but it can be implicit bias training and avoiding looking for systemic, time consuming to establish the initial data collec- http://qualitysafety.bmj.com/ structural drivers of inequities. Many organisations tion systems. While those efforts are ongoing, other institute cultural humility or implicit bias training as projects could occur. These additional projects could their equity intervention.19 While an important and include creating a culture of equity, and identifying essential component of creating a culture of equity, disparity problems based on clinician, staff and patient such training must be accompanied by hard examina- input, and then designing and implementing interven- tion for structural processes that lead to inequities. For tions to mitigate them.34 example, in a project designed to decrease hospital length of stay, the University of Chicago Medicine RECOMMENDATIONS FOR THE PATIENT SAFETY

data analytics group discovered that the process the FIELD TO ADVANCE HEALTH EQUITY on September 25, 2021 by guest. Protected copyright. organisation had proposed for developing and using I offer several recommendations to inform research, machine learning predictive algorithms to identify policy and practical action. patients for intervention would have systematically (1) Broaden collaborators to include experts on shifted resources away from African Americans to racism, intersectionality and systems of oppression.3 4 35 more affluent white patients.30 31 This inequitable A great strength of the patient safety field is its inter- process was caught before implementation, and now disciplinary team approach. However, it is difficult the data analytics group is proactively building analyt- for even the most well-meaning­ people to understand ical processes to advance health equity. what they have not experienced. A recent powerful (3) Insufficiently engaging patients and community. formative experience for me was living in Aotearoa/ Too often perfunctory or no efforts are made to mean- New Zealand for several months and writing a paper ingfully engage patients and community in quality with diverse international colleagues comparing what improvement and patient safety efforts. Patients and Aotearoa/New Zealand and the USA were doing to families frequently feel they have not been heard advance health equity.14 After dozens of frank conver- and that their experiences and preferences are not sations with my Maori coauthors, I began to under- adequately valued.32 33 A common mistake is using stand in depth the devastating nature of colonialism, proxies for the community rather than the actual and the overt and insidious ways power structures

Chin MH. BMJ Qual Saf 2020;0:1–6. doi:10.1136/bmjqs-2020-012599 3 BMJ Qual Saf: first published as 10.1136/bmjqs-2020-012599 on 29 December 2020. Downloaded from Editorial can oppress marginalised populations. Increasing the implementers frequently have a seat at the table when diversity of lived experiences and expertise on patient strategic planning is occurring regarding institutional safety teams is critical, and requires a hard look for priorities, system reform, financing and relations with systemic biases in hiring practices and procedures. external stakeholders such as payers. A strength of the (2) Examine safety criteria and systems for bias. patient safety field has been its ability to understand Design and implement equitable systems for identi- and shape culture, and its awareness of how inner and fying, measuring and eliminating safety problems. outer contexts affect systems change.43 These perspec- Patient safety is an inherently complex field that will tives need to be intentionally viewed through an equity require explicit and implicit criteria to capture and lens to reduce disparities.44 45 For example, American monitor problems.36 37 Schulson et al’s paper high- organisations need to honestly ask themselves to lights how voluntary reporting systems can introduce what extent they will advocate for payment policies bias.7 In practice, automatic and voluntary reporting that incentivise maximising population health and systems have different strengths and weaknesses that equitable patient safety rather than current payment will require careful integration to maximise the chance systems that support too much low value care.38 46 that equitable safety outcomes will be attained. Auto- (6) Ride and nurture the moral wave for equity mated measures are explicit review measures that are in patient safety. Intrinsic motivation is the most objective but can be relatively crude and limited for powerful driver of behaviour.47 People want to do capturing safety issues. In general, voluntary measures the right thing, and they will do so if supported and are implicit review measures that are subject to a provided the training and tools for success.48 Seize variety of personal and judgement biases but which are the opportunity presented by the heightened public more comprehensive and potentially richer. Given that readiness for addressing racism and inequities. Keep individual discretion is used in voluntary reporting, the momentum going. Now is the time for us to make reports could be grouped into different categories strong, bold choices.49 We can make a difference and based on degree of legitimate discretion. Such cate- advance health equity, providing hope and the oppor- gorisation could help identify whether variation across tunity for a healthy life to all.50 different patient groups in rates of reported safety defects occurs primarily among criteria with legitimate Competing interests None declared. discretion versus ones where variation likely reflects Patient consent for publication Not required. implicit bias. Diverse workers and patients should be Provenance and peer review Not commissioned; internally empowered to help create and implement the safety peer reviewed. systems and report potential safety problems.33 (3) View failures in treatment plans due to social REFERENCES determinants of health as safety issues. A treatment 1 Peek ME, Simons RA, Parker WF, et al. COVID-19 among http://qualitysafety.bmj.com/ plan that is likely to fail because of social challenges African Americans: an action plan for mitigating disparities. is a safety problem. Discharging a patient from the Am J Public Health 2020:e1–7. hospital when they are medically stable but likely 2 Vela M, Blackman D, Burnet D, et al. Racialized violence and to have poor outcomes because of homelessness is a health care’s call to action. MedPage Today’s K​ evinMD.​ safety problem. If the purpose of healthcare is to maxi- com: Social media’s leading physician voice, 2020. Available: mise health, then healthcare organisations must collab- https://www.​kevinmd.​com/​blog/​2020/​06/​racialized-​violence-​ orate with community partners to address medical and and-​health-​cares-​call-​to-​action.​html [Accessed 19 Nov social issues.38 2020]. 3 Peek ME, Lopez FY, Williams HS, et al. Development of a

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