Improving Quality and Achieving Equity:
A Guide for Hospital Leaders

The Quality Case: Addressing Disparities, Improving Quality and Achieving Equity

“Health disparities and quality are two sides of the same coin…that’s it in a nutshell. If you’re going to provide quality care and services, then you need to address health disparities.” – Kimberlydawn Wisdom, MD, Vice President of Community Health, Education and Wellness, Henry Ford Health System
 
Shortcut Menu Quality
Impact on Safety
Impact on Effectiveness
Impact Patient Centeredness
Impact on TimelinessCrossing the Quality Chasm states that to achieve equity, systems should provide care that does not vary in quality because of personal characteristics such as ethnicity, gender, geographic location, and socioeconomic status. Equity is the only pillar of quality that was seen as ‘cross-cutting’, meaning that it has implications for safety, effectiveness, patient-centeredness, timeliness, and efficiency. A careful analysis of the pillars of quality provides several important examples of how the inattention to disparities can impede quality of care. The following section provides a summary of these key findings, with efficiency given special attention (see also the five mini-vignettes in Appendix A for practical clinical examples).

 Safety – Patients should not be harmed by the care that is intended to help them, and they should remain free from accidental injury, misdiagnosis and inappropriate treatment. Ensuring patient safety also requires that patients be informed and participate as fully as they wish and are able—and that patients and their families should not be excluded from learning about uncertainty, risks, and treatment choices.

“Addressing cultural and linguistic barriers is about saving lives. Any progressive leader can understand that communicating effectively with patients is essential to making healthcare delivery safer. The issue of disparities needs to be embedded in safety policies and procedures.” Pete Delgado, CEO, Los Angeles County and University of Southern California Healthcare Network

Disparities and their Impact on Safety

Communication between patients and health care providers, and the barriers many racial/ethnic minorities face in this regard, has an important impact on patient safety. Communication difficulties may lead to misdiagnosis, inappropriate treatment, and limit the process of truly informed consent. We currently have both direct and circumstantial evidence to support the impact of the root causes of disparities on patient safety. For instance:

• Patients with limited English proficiency (LEP) and racial/ethnic minorities are more likely than their English-speaking white counterparts to suffer from adverse events, and these adverse events tend to have greater clinical consequences (3-5).

• Communication problems are the most frequent cause of serious adverse events as recorded by the Joint Commission. Effective communication is compromised by language barriers, cultural differences, and low health literacy, all of which are particularly important issues for racial/ethnic minority patients (4).

• True informed consent is not possible without effective communication and according to the Institute of Medicine, “an informed patient is a safe patient" (1).

Exploring patient safety issues through the stratification of medical errors by race and ethnicity should yield improvement opportunities that will not only improve quality, but likely provide cost-savings and yield lessons that will help manage risk.

Effectiveness – Patients should receive care that uses evidence-based guidelines to determine whether an intervention (preventive service, diagnostic test, etc.) produces better outcomes. Included in this principle is the integration of research evidence with clinical expertise (skills to identify each patient’s unique health state and diagnosis, individual risks and benefits of interventions, and personal values and expectations) and patient values (unique preferences brought by each patient to the clinical encounter and must be integrated into clinical decisions).

Disparities and their Impact on Effectiveness

There have been hundreds of carefully controlled studies showing that even when clinically appropriate, minorities tend to receive fewer key diagnostic and therapeutic procedures than their white counterparts. For instance:

• Racial/ethnic minority and limited-English proficient patients are less likely than others to receive some of the most effective, evidence-based treatments for certain conditions (2). Racial/ethnic disparities exist in use of thrombolysis for acute myocardial infarction (38), curative surgery for early non-small cell lung cancer (42), renal transplantation for end-stage renal disease,43 and the management of patients with diabetes (71-73), congestive heart failure and community acquired pneumonia (44), among many other examples (74-76).
  
  
• Differences in patient preferences never fully account for the observed racial and ethnic disparities in health care (placement of patients with end-stage renal disease onto the transplantation list is probably the best example in this regard) (2).

Several of the root causes of disparities (e.g. poor communication, stereotyping, mistrust) contribute to this problem and must be attended to if effectiveness is a priority. Stratifying quality measures by race and ethnicity (i.e. the National Hospital Quality Measures), at a minimum, will allow the opportunity to identify disparities that are amenable to intervention, and improve effectiveness overall.

Patient-Centeredness – The key dimensions of patient-centered care include respect for patient’s values, preferences, and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; and involvement of family and friends.

“I think the key ‘selling point’ is patient-centered services. I don’t think that there’s a health care executive in the United States that isn’t thinking about the concept of patient and family satisfaction.  If you want to deliver patient-centered services, you have to think about issues of equity to make those services more patient-centered.” –Rohit Bhalla, MD, MPH, Chief Quality Officer, Montefiore Medical Center

Disparities and their Impact on Patient-Centeredness

The key aspects of patient-centered care are indelibly linked to the issues of provider-patient communication, stereotyping, and mistrust, among others that contribute to racial and ethnic disparities in heath care. For example:

• Racial and ethnic minorities report more communication difficulties with their doctors, less involvement in clinical decisions, more difficulty understanding instructions on prescription bottles and instructions from their doctor’s offices than their white counterparts (77).
  
  
• Racial and ethnic minorities are more likely to feel like they will receive unequal treatment, than their white counterparts (78).

• Racial and ethnic minorities feel less satisfied with the quality of care they receive than their white counterparts (77).

Despite this, not only are routine patient satisfaction survey results (i.e. HCAHPS, Press-Ganey) not stratified at hospitals by race and ethnicity, but often are not administered in multiple languages, and do not include questions specific to issues that are connected to racial and ethnic disparities in health care. Stratification of these survey results by race and ethnicity, administering them in multiple languages, and minor improvements in their content would allow for greater sensitivity in identifying issues related to disparities in patient-centeredness.

Timeliness – Patients should not experience harmful delays in receiving necessary services, and waiting times should constantly be reduced. Health systems must develop multiple ways to meet patient needs.

Disparities and their Impact on Timeliness

Several root causes for disparities have been shown to clearly impact timeliness, and the disparities literature provides several examples where lack of timeliness has led to differences in quality. Overall, minority and limited English Proficient patients receive less timely care in a variety of scenarios than their white counterparts.79-81 For example:

• Patients with limited-English proficiency have longer waiting times to see a physician in the emergency department (81) and delays in time to appendectomy and time to definitive breast cancer surgery (82, 83).
  
  
• Minorities have longer door-to-needle time for community acquired pneumonia than their white counterparts; they also have longer door-to-balloon time for acute myocardial infarction (84).

• African-Americans with end-stage renal disease on hemodialysis are less likely to be on the renal transplantation list than their white counterparts (43).

Active measurement to assure equity in timeliness is critical to high-quality care for all patients. Systems should be developed to assure that the root causes of disparities do not disproportionately impact the ability of minorities to obtain critical health care services.

The Business Case
The Risk Management Case
The Accreditation Case

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