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This introductory course introduces the framework for embedding equity into quality and safety, which was developed by Brigham and Women's Hospital and the Institute for Healthcare Improvement. This activity will provide an overview of the five focus areas and how the framework was implemented at Brigham and Women's Hospital.
This video excerpt was taken from the official Kick-Off of the AMA's Advancing Equity through Quality and Safety Peer Network in January of 2022.
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Education from AMA Center for Health Equity
AMA’s online education to empower individuals and organizations, in health care and beyond, in advancing racial justice and equity.
Karthik Sivashanker, MD: [00:29] What we want to cover now is the tracking systems that you're using. We use a very simple system; we use an Excel spreadsheet to track these cases. So it doesn't have to be fancy. And when we first started the work, we were not tracking demographics consistently. So that was one of the first things that we started to implement. So I'm going to hand this over to Nadia to speak to it. You'll notice that like, it's just the header for the spreadsheet. We're just doing that to protect patient confidentiality for the time being. But Nadia, do you want to take it away?
Nadia Huancahuari, MD: [01:03] Yes, I'm Nadia Huancahuari. I know I met a lot of you in the breakouts but just wanted to say hi, and wanted to also say how excited I am to be here. We thought that we would bring you into our equity tracker and share a few details of it. Again, this is just a way in which we're doing it and you can certainly customize it to make…for your own needs. I do want to start by saying that this has been an amazing team effort by the—we have three directors of quality, safety, and equity, Dr Gershanik and Dr Marsh, who are here and who have been faculty, and two program coordinators who support this work, as well. So in terms of the tracker, this is an example of the beginning of the headings. We usually want to assign—as Karen had mentioned, we usually have a risk manager or patient safety specialist—and we'll assign that person based on the area where the event occurred. We assign ourselves, one of us, to lead that particular case, and then we'll include the patient's name, the date of the event, the date we learned about it—because some of these events might have happened months ago, but we maybe just got notified about it—the medical record number, the age of the patient, the gender, the race, and ethnicity. Next slide, please.
[02:30] We also capture the insurance, the preferred language, and disability service line location. And the next couple ones…we use it in a certain way and I want to talk a little bit about that. The case titles are basically key words that we use among ourselves to address a particular case or to know a particular case. So a case title may be, for instance, a denial of monoclonal antibody due to race, or maybe MRI rescheduling due to language barriers, or maybe misgendering in allergy clinic. So whatever it is that makes sense for you to think about this case and talk amongst yourselves about it, that's how we typically use the case title. And then we try to collect themes, and those are more general, and I'll show some data around that in a couple of slides. But the themes are more general in terms of…so it might just be a communication, it might…the whole thing may be about a miscommunication. It might also be about language barriers. But you can customize this for your own needs. The summary section, most typically, is just copied and pasted directly from the safety report. Next slide, please.
Sivashanker: [03:46] Oh, and can we just pause for a moment? I want to just elaborate a little bit more. So why those demographics? So one of the things that we looked into was, you know, why not SOGI, for example, sexual orientation? So we looked into the data, and we just did not have complete enough data for it to be usable. So some of these choices are purely based on, do we have enough complete data and reliable enough data to track it. So a goal remains to add sexual orientation and gender identity, and that requires more system-level work. So there was a question about how we're doing data collection and getting folks to understand race, ethnicity, all these other categories. So we did education with our registration staff, but updating all the patients and their demographic information that's a years-long process. So the point here is look at what variables you have enough data for—and say, 60 to 70% completeness is pretty average—so if it's, as long as it's somewhere around there, it's enough to start the work.
Huancahuari, MD: [04:51] Next in the tracker we'll have “follow-up steps taken” and this part really functions as almost a notepad and our frame for how we're going to address the case. And typically, we'll have weekly meetings with the entire team when we're reviewing new cases or following up on cases, and this is how we really just keep track of what we're doing. And then the next section is action items where we actually collect and actually write down all of the various interventions and what we're learning and what we're doing with a particular case. So if a case went, for instance, to a collaborative case review we'll include in there, what are the things that we're supporting that we learned from that case. And then we count the action items, and then any of the other headings there help us just keep track of this, like what we're waiting on and what else we need to do and at the end, we'll…most of these will be in progress status. And when we closed it, it may…they drop off our tracker, and they remain stored. The other thing I wanted to highlight here is that depending on what other committees this case may be referred to, that's something that you can customize for yourself. So for instance, if we're requesting that a case be reviewed at a larger forum, like a collaborative case review, we do have a way in which we'll track that for ourselves as well. Next slide, please.
[06:16] So we wanted to take you inside a case so you see how we do this work. I'm just going to briefly go through this. But as you can imagine, this is just a screenshot of a case that has been de-identified and a few details have been changed. But if you start with a case title, our case title is Delay and Initiation of Lactation. The theme after all this is done, we ended up calling a racial disparity in breastfeeding, and the summary is directly from the safety report. I just wanted to highlight a couple of things. So this particular reporter described a case of a patient who was interested in breastfeeding, but had not been given the supplies to start that and had not received the appropriate support to start that and it had been about eight hours since the event. And so just like Andrea said, they reported the event in the safety reporting system, and then they checked off that flag, the equity concern, and within that box, they wrote the following: “Patient is a Black woman. We know that our breastfeeding rates are lower for Black moms. And by not offering a Black mom a breast pump immediately, we're not following our policies, and we're contributing to this inequity.”
[07:31] I wanted to go back to this idea of adding a box. We used to get a number of cases where the “yes” was checked, but we had no idea what the actual inequity was, or what was the concern that they were trying to raise. And so this really changed how we could focus on the specific concerns if it was not clear within the body of the safety report. And you can see there the follow-up steps taken. So we came together as a team, we discussed who we needed to contact, and we also actually learned that there was a similar case that had happened very recently. So actually wanted to address both cases of potential delays in initiation of lactation at the same time. We had…we met and we discussed how we wanted to approach that collaborative case review, to ensure that we were creating a safe space, that we were mindful of various concerns and emotions that may come up during it, and then we held a collaborative case review. Now in terms of some of the action items, we just tracked specifically what we're doing. So for instance, number one discussed with risk management, requested local lactation leadership review of the case, we talked about that collaborative case review.
[08:46] Now the collaborative case review didn't specifically reveal discrimination against one particular group of patients. It actually showed us how, globally, we could do much better in terms of initiation of lactation within a certain period of time, so we actually discovered a lot of other issues in which we could support this department and this team. And I think that really highlights the point that this isn't an equity issue, right? Like, perhaps if this wasn't…if this had not been thought of as an equity concern, that delay in lactation which probably happens more often than not would not have been highlighted. But the opportunity to come in, to do a collaborative review, and to understand things like the fact that it is much difficult to initiate lactation for moms that deliver in the middle of the night and how it's so much more…so much more easier to have these delays of eight or nine hours. There was something that it was really good to talk about and to implement processes toward addressing those vulnerable periods of time. And so it was just a really, really great opportunity to talk about these issues openly and move forward from that. I do want to say that it is the particular department or division or group that will be responsible for addressing these things, as it should, that this doesn't become the job of the medical directors of equity or any one particular person. As has been said again and again, this is just part of quality, safety and equity all together. So we move that work forward, together. Next slide, please.
Sivashanker: [10:40] And I want to highlight just how important of a point that is, because what you will find is that there are a number of cases where it's…or at least there are going to be some cases where it's not a obvious example of discrimination or bias against one group, but it's a general problem that's getting identified. And that gets back to equity is not a zero-sum game. So that's an important tool to keep in your arsenal as you face resistance in getting, in moving this work forward, right? Because there's going to be folks who need to see what's in it for themselves to be invested. And so being able to say, you know, we thought there might be a differential impact here turns out that everyone's getting negatively impacted here and we need to address this. That just points to how when you're developing resilient, reliable systems for one group, you end up making care better for everyone. And also, just a quick note, technical note that we also have a separate tracker that is specific for the action items where each action item is separately listed and tracked. So just something to keep note of, because you want to make sure that you're actually completing those actions as much as you can. So I'm going to pass it back to Nadia.
Huancahuari: [11:56] For the next few slides, I do want to credit Dr Gershanik for looking at our data for 2021 and giving us the following insights. So one of the biggest benefits of having this tracker is that it really allows you to look for trends and to see how you're doing in terms of these cases. So in this particular graph, you'll see that the numbers increased through the year. In total, there were approximately 150 cases that were flagged for equity, leading for 2021 to 334 action items that were completed for those cases. Next slide, please. Dr Gershanik looked at these and broke them down, and so I wanted to share some of that with you. The average age for these, for this cohort of patients was 46. And they ranged from newborns to 88 years old. We broke it down by gender, and it does, and we do have the opportunity to look at patients who identify as transgender, as well. If you'd look at the breakdown by race, the majority of the patients were identified as African American or Black. And there, and like Karthik mentioned earlier, too, there are a number of patients who do not answer that question. So if it's not in the medical record, then it shows up as unknown or other. Next slide, please. The—
Sivashanker: [13:31] Can we get back to the last slide just for a moment? [background noise] This is an important point in just understanding this data, in terms of context. So, and this is about transparency, right? So I'm just going to be transparent that Brigham and Women's, we don't take good care currently of a representative share, or a fair share of our Black and brown and Medicaid patients, our patients who speak other languages. So when you see that the white and Black counts are almost the same, you have to keep in mind that we mostly take care of white patients and Black patients are very, a relatively small percentage of that population. And yet they make up a larger percentage of the events, which—this is a small sample size and this is where it's going to be really interesting to see—as we bring all of our systems data together, what are the bigger themes that are emerging? Are we under reporting in certain areas? Are we over reporting in other areas? It's hard to know based on one system, but just want to give you that context.
[14:34] Yes, thank you for highlighting that. The next slides here show the insurance carriers of those patients and as you can see, 65 of those patients have Medicaid and 32 commercial, 26 Medicare. The language breakdown as well--the majority of the patients are English speaking. We do have a portion that are non-English speaking whose preferred language was not English, and who…in the majority of those patients, whose preferred language was Spanish.
[15:13] In terms of racial discrimination, I wanted to piggyback on what Karen has said before about the impact and intent. And that's something that I learned from her, that there is this perception that patients will have this perception that they were treated differently because of their race or because of their preferred language, and you'll go and you'll review—and that's one person's experience. And you'll go and you'll review how it happened, what happened, and then you'll often arrive to, you know, that care was appropriate, all the things were done, the way it would have been done otherwise, but yet you're left with this mismatch, right? And so a lot of it has to do with understanding that impact. So by racial discrimination as a theme I do not mean that there was overt and clear and confirmed racial discrimination, but there certainly was that impact.
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