The multicultural task force at Heywood Hospital wasn't sure what it would find when it started analyzing patient data to identify inequities in health care. The result was surprising, and it might have remained hidden if the group hadn't honed in on patient diagnoses by race and ethnicity.
All hospital admissions of a small group of Asian patients that year were for chemical exposure. Working with a community minority coalition, the hospital found that many Asian people in the area work in environments that put them at risk for chemical exposure, including nail salons, high-tech chemical companies and cleaning companies.
"We realized we needed to go back and educate the Asian communities working in these areas about health risks," says Barbara Nealon, a social services director who heads the task force at Heywood, a 134-bed hospital in Gardner, Mass.
Make No Assumptions
The discrepancy that Heywood's task force unearthed falls under the broad category of an inequity, a way in which a subgroup's health needs are not met or are handled differently from those of most patients. Addressing the problem falls under the hospital's responsibility to improve the health of its community.
A growing body of research over the past two decades shows that minority populations in the United States fare differently from the majority on many factors of health status. Some of these inequities may result from stereotypes or language differences, or issues that slip under the radar of the health care system. Whatever the reasons, hospitals need to step up to identify those differences and seek solutions.
"I would imagine all our hospitals aspire to excellence and quality of care, and strive to deliver the highest quality of care for everyone who walks in our doors," says Joseph Betancourt, M.D., director of the Disparities Solution Center at Massachusetts General Hospital, Boston. "But we have research that tells us clearly that nationally, we are not providing high-quality care for everyone. As hospital leaders we have to stand by our commitment to quality."
For trustees, there are many good reasons to make sure that your hospital is taking health equity seriously and is collecting and crunching the data about race, ethnicity and language of patients.
The first reason is because it's the right thing to do and the institution's mission requires it. Quality of care is central to most hospitals' missions and strategies, and equity is one of the six pillars of quality, according to the Institute of Medicine, notes Maulik Joshi, president of the Health Research & Educational Trust. "Clearly we've made great progress in this country on all the aims, but the one that needs the most improvement is equity," he says.
Trustees also should be aware that hospital regulators and accreditation bodies have made rooting out disparities a priority, which will mean mandates to collect and analyze demographic information about patients. The Joint Commission has released new standards on disparities and cultural competence, the National Quality Forum has quality standards specific to cultural competence, and the Affordable Care Act includes several provisions to reduce disparities.
There's also the link between the groups of people who are not staying healthy and your organization's bottom line. "Logically, if patients are not getting the same quality of care and do not have the same medical outcomes as the dominant ethnic or racial group, then there's a greater likelihood for medical errors to occur, which can be very costly and embarrassing," argues Frederick D. Hobby, president and CEO of the Institute for Diversity in Health Management, an affiliate of the American Hospital Association. Those patients are more likely to have longer lengths of stay, a disadvantage for the hospital in the increasingly popular reimbursement schemes that bundle payments for a patient's entire illness. Also, they are more likely to be readmitted to the hospital for the same diagnosis, something payers are balking at reimbursing.
The patient population increasingly may include groups whose disparate health outcomes are the result of society's ills rather than anything your hospital is doing in terms of providing care. But it still makes financial sense to help them get healthier, Hobby says. "If you take the financial problems and compound that by volume, then you really have a potential crisis on your hands," he says.
Don't let an assumption that your organization's culture is generally supportive of diversity and quality keep you from a closer examination of the data on patient backgrounds, Hobby urges. "We hear so often, 'Not my hospital, we don't have to ask those questions because we give everybody the same quality of care,'" he says. "But if you don't look and don't ask the question then you can't possibly address the challenge."
There has been some confusion in the past about collecting demographic data about patients. The Institute of Medicine's 2002 report, "Unequal Treatment," noted that some health plans held back from collecting data in the belief that it was illegal in some states.
But the tide has definitely turned: 22 states require reporting, as do a raft of federal agencies related to health care.
In fact, 82 percent of hospitals collect patient data on race and ethnicity, but often the information is not collected in a systematic way, it's not shared among departments and it's not used to root out disparities, according to a report by HRET. Additionally, various agencies define races and ethnicities differently, which poses a challenge to hospitals that want to identify patients in the most accurate and useful way.
San Mateo Medical Center in northern California is working through that issue with other California safety net hospitals that have been part of a statewide collaborative focused on reducing disparities. Inspired by the collaborative's goals, San Mateo's cultural competence leader, Jonathan Mesinger, pulled together a team from around the hospital to work on it.
The group's first task has been to decide the racial and ethnic groups that need to be identified upon admission. This was easier said than done.
"The federal government currently asks us only to collect one ethnicity question, which is whether you are Hispanic or not, and its race question has about five categories," explains Mesinger. "And then the state asks for different data."
"We wanted people to be able to see themselves on the list," he adds. So they made their own list of about 30 races and ethnicities. The team also did a survey to identify languages that should be included.
Incorporating the categories into the hospital's information system has been a job for the IT staff. Mesinger says that other safety net hospitals in the collaborative have had varying success in making that happen, depending on their technology vendors.
San Mateo also has addressed the sticky issue of how to ask registering patients about their cultural backgrounds. "We don't want to insult patients," Mesinger says. So for those who seem reluctant to answer, they will be given a form to fill out on their own, along with an explanation about why the hospital wants the information.
Coming up with a registration procedure that is respectful of patient privacy is an issue for any hospital that is serious about collecting racial and ethnic data, says Betancourt. At Massachusetts General, data collection is owned by the registration department. The data are analyzed by the hospital's Center for Quality and Safety.
Registrars at Massachusetts General are trained to be sensitive to patients' concerns about identifying their backgrounds and work from a script. It's important that they understand why the information is important to gather. "We've communicated to them that this is about quality of care and clinical excellence," he says. "They get it and they are committed to it."
Massachusetts General also has worked through the issue of patient categories, focusing on race, ethnicity, language and, most recently, highest level of education. The list is a work in progress, Betancourt says, starting with the quality measures already in place. "We focus on racial and ethnic disparities because there's the strongest evidence for them," he notes. "But we know there are disparities on socioeconomic status, people with disabilities and sexual orientation." The list may grow with the evidence.
What Data Reveals
Once the data on race and ethnic background are available, they can be plugged into existing quality measures or research projects throughout the hospital, offering fresh perspectives on provision of care and patient outcomes. The board can get that process started by asking for data on a few simple quality measures stratified by patient demographics, points out Hobby.
"It can begin with simply selecting a diagnosis or two, such as pneumonia or advanced cardiac disease," he suggests. "Ask the question, 'Are my patients of color receiving the same therapeutic drugs, are they getting the same surgical procedures, are they experiencing the same length of stay as nonminorities with the same diagnosis?' A good cost-accounting system or a utilization review program can often uncover these simple aspects of disparities."
The board also can ask for these types of measures to be added to its quality dashboard for regular review.
When equity problems are identified, the hospital needs to think about how it will share the information with the community. At Massachusetts General, the quality staff has found that transparency is generally a good thing, but also tries to package a solution at the same time it is communicating a problem, says Betancourt.
For example, quality improvement staff at Massachusetts General looked at patients with diabetes by ethnic group and found that Cambodian patients, in particular, were having trouble managing the disease. After some focus groups with patients and discussing the problem with physicians, they determined that coaching programs designed for those patients could close the gap.
The solutions to serving all patients equally can be small-scale, like hiring diabetes coaches, or they can involve the board's biggest, most expensive choices. For instance, Bronson Healthcare Group in Kalamazoo, Mich., for years has factored in the needs of its diverse client base in facilities planning. In the 1990s, the system was looking at replacing its urban hospital campus and had to decide whether to move outside the urban core. "The board decided to build in the urban core because they were concerned about access problems for individuals who did not have transportation," says James Greene Jr., a Bronson trustee.
Later, when the downtown hospital's emergency department was overflowing with uninsured and Medicaid patients with limited access to primary care, the board chose to expand it. Twice. And it's looking at a third expansion, he says.
Bronson has focused on providing culturally competent care, expanding its Spanish-speaking workforce and training providers to ask patients three basic questions about their diagnosis or care to ensure that the information has been understood. Bronson partners with a local, federally qualified health center to provide resources such as physician coverage.
These choices start with the board, Greene says. "Equity is a strategic issue," he says. "We're crunching a lot of demographic data to be sure that every patient gets quality care."
Reflect the Community
It's much easier to find inequities if members of those minority groups are included in the conversation, says Hobby. There are several ways to do this.
One is to create a multidisciplinary team from the hospital staff, which includes people from different departments as well as racial and ethnic backgrounds, economic levels and every other way people might differ in your community.
Having that group was key at Heywood Hospital, says Nealon, the social services director. "We've had plumbers, nurses, clergy, IS, food and nutrition. It was really diverse and really interesting," she says. "All that diversity really helped us to say, 'Hey, what about this? What about this?' coming from the team members' own perspectives and experience. I realized that the way I thought was not the way everyone thought."
Another way to tap into the minority groups' perspectives is by connecting with groups in the community that include their members. Nealon's team found there were no established community groups representing the small subpopulations in their town, so they reached out to a neighboring city to pull in minority perspectives, which helped them identify the work-related chemical exposure, among other things.
Outreach is even more effective if it's done by staff members who belong to that group, advises Hobby, who argues for a workforce that reflects the diversity of the community. "There is a greater likelihood we will understand these unique patient populations' challenges and have a comfort level in asking those pertinent questions," he says.
He also suggests recruiting new trustees from the community's minority groups. "You need to develop connections with the minority business, civic, social and religious organizations and recruit from them," he says.
When getting a program started, look to the work that's already been done by others. Betancourt's Disparities Solutions Center is happy to help. "Don't start from scratch; there are plenty of organizations that have done work in this area," he says.
Despite being a relatively small hospital without a big budget for cultural competence programs, Heywood has accomplished a lot through Nealon's enthusiasm and creativity in leaning on colleagues within the hospital. She relies heavily on the IS department to analyze data when she gets requests. Patient registration and nursing also are allies and she has good support from top management.
Nealon's team already has found a number of hidden problems in Heywood's community, but she knows there are more to be discovered. "We can track by zip code, by age—we're always looking for opportunities for positive change," she says. "We've just hit the tip of this."
Jan Greene is a freelance writer in Alameda, Calif.
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