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