Ingraining Equity into Quality and Safety: A System-Wide Strategy

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Photo by Emma Gossett | Unsplash

When addressing equity and inclusion, there are many things to be said and done. But all too often much more is said than done. To help prevent this, we highlight a purposeful, iterative, and lasting strategy that health systems can use to fundamentally advance their equity agenda.

NYC Health + Hospitals (NYC H+H) is the largest integrated municipal health care system in the United States, serving over 1 million patients annually. As a safety net system, tackling systemic injustice such as structural racism has always been central to our mission. In New York City, we have the privilege of serving a diverse patient population where nearly 3 million New Yorkers were born outside of the US. Of NYC H+H’s registered patients, less than 9 percent racially self-identify as White non-Hispanic.

COVID-19’s disparate health effects among racial and ethnic groups and the recent civil unrest following the brutal killings of George Floyd and many others have helped our nation focus on health and racial inequities as never before. Given the gravitas of this work and our experience, we propose a comprehensive 4-step strategy that health systems can utilize to ingrain equity into quality and safety work:

• Conduct a departmental needs assessment. To deliver on the promise to improve health care quality for all, a health system must first review the equity knowledge and needs of its workforce because quality and safety are inextricably linked. Similar to work done by some public health departments, like the Hartford Department of Health and Human Services through their Health Equity Action Training (HEAT) project, it’s important to begin with a needs assessment conversation with system-wide Quality & Safety (Q & S) leaders to ascertain current state. 
  
  Ideally in-person, such discussions familiarize staff with standard definitions of subjects like equity, justice, racism, and health disparities and establish a baseline of knowledge. More importantly, these sessions should create a psychologically safe and brave space to discuss difficult topics that have often been considered taboo in the workplace setting. In partnership with the Office of Diversity + Inclusion (D + I) or Human Resources (HR), this needs assessment should be extended to listen to employees across the health system. 
  
  Professionally facilitated, digital town halls allow for anonymous participation in real-time polls and free-text responses during the sessions. We suggest sampling at least 5 percent of the total workforce, with diverse representation from every service line within the enterprise. This purposeful cultural shift, education, and analysis allows more data-informed, rather than emotionally reactive, next steps.
   
• Focus on departmental workstream mapping and capacity building. To assess current work structures, complete a departmental organizational chart. Every division working on quality and safety should share their current workstreams and identify areas for opportunities to make their work more equitable. Consider creating a survey to collect anonymous self-reported data on race, ethnicity, language, sexual orientation, gender identity (REaL SOGI), country of origin, age, religion, disability, and zip code to assess the current demographic makeup of your office. Q & S departments should partner with HR and D + I and ensure their recruitment, retention, and promotion practices are aligned with the system’s equitable hiring strategies. This information can lead to the creation of an equity dashboard like the one the municipal government of New York City uses to display its diversity data to increase transparency and accountability. 
  
  To ensure sustainability of this cultural shift, health systems should consider further capacity building with the development of a Director of Equity, Quality & Safety leadership role. Modeled after the equity leadership position within the Q & S team at Brigham and Women’s Hospital, the person in this role helps to guarantee that equity and inclusion principles are explicitly represented and fundamentally ingrained into the core of all Q & S initiatives. The Director of Equity, Quality & Safety can also help the Office of D + I or HR set up a diverse Equity and Access Council to be the governing body for equity, diversity, and inclusion initiatives within the organization. By leveraging existing departmental structures, like those utilized at health systems such as Northwell Health’s Center for Diversity, Inclusion and Health Equity, organizations can identify where equity initiatives can be woven into key daily functions, and the structure through which they are analyzed.
   
• Apply equity lenses to key existing Q & S workstreams through iterative PDSA cycles. Strategic priorities for core quality and safety functions will be identified through the needs assessment and departmental workflow mapping. For example, re-envisioning the Root-Cause Analysis (RCA) process through an equity lens can more effectively identify inequities and bias. A standardized toolkit, which encourages investigators to analyze contributing factors at the interpersonal (explicit bias), human behavioral (implicit bias), institutional (policies and practices), and structural (societal determinants of health) levels, helps to ingrain equity into this process. 
  
  A second method is the inclusion of mandatory bias “triggering” questions into the real-time incident reporting system, including a drop-down list of qualitative contributing factors for reporters to choose from. These will address potential underlying causes of bias that led to the adverse patient safety event. If the triggering question is answered either yes or no — depending on the prompt — or bias is listed as a contributing factor, risk managers should address bias-related concerns explicitly in their investigations. This will allow frontline staff to identify and easily report equity-related concerns for further elucidation by Patient Safety and Risk Management teams. The number of RCAs conducted with equity- or bias-related concerns, as well as incident reports that trigger positive for potential bias, should be collected and analyzed. 
  
  Performance improvement (PI) teams, who often implement and monitor system-wide quality improvement (QI) projects, can also ingrain equity into their activities. The UCSF Center for Health Professionals’ use of a disparities lens for QI, includes tenets of selecting diverse multidisciplinary teams and should inform a system-wide PI charter. A system’s PI goals should include a focus on equity and access. During needs assessment, it may surface that current patient-reported REaL SOGI data collection practices need revision to ensure accuracy and completeness. A process to improve the system-wide collection and validation of self-reported REaL SOGI  data in the electronic health record through iterative PDSA cycles is crucial to informing this work. This stratified high-fidelity REaL SOGI data will help PI teams identify and improve identified health disparities and inequities.
   
• Use data visualization with transparent milestones and measures. Systems should track the impact of their equity and inclusion strategy on Q & S work over time. These metrics should be established early and include tiered process and outcome measures at the patient, facility, and system levels. These metrics should be updated and refined as the health system’s approach matures. Examples of initial measures include percentage of patients in the patient self-reported REaL SOGI data who choose “Other” or “Prefer to not disclose,” the number of RCAs conducted during which equity- or bias-related concerns were discussed, and the percentage of PI projects presented to the board that look for differences using REaL SOGI stratified data. Available on an equity Q & S dashboard, these metrics should be reported back to staff at regular intervals.

Together, we need to not only reimagine change, but take purposeful action to ingrain equity into every facet of quality and safety.

Louis H. Hart III, MD, is Director of Equity, Quality & Safety at New York City Health + Hospitals (@DrLouHart).  Eric K. Wei MD, MBA, is Chief Quality Officer at New York City Health + Hospitals (@EricKaihwanWei). Mona Krouss, MD, is Senior Director of Patient Safety at New York City Health + Hospitals (@KroussMD).  Jeremy Segall, MA, RDT, LCAT, is Chief Wellness Officer at New York City Health + Hospitals (@JCSegall). Matilde Roman, JD, is Chief Diversity and Inclusion Officer at New York City Health + Hospitals. Kwame Sheehy, MPH, MBA, is Director of Performance Improvement at New York City Health + Hospitals. Komal Bajaj, MD, MS-HPEd, is Chief Quality Officer at NYC Health + Hospitals/Jacobi (@KomalBajajMD).