Achieving Health Equity and Providing Quality Care

Joseph R. Betancourt, M.D., M.P.H.Director, The Disparities Solutions Center

Senior Scientist, Institute for Health PolicyDirector for Multicultural Education, Massachusetts General Hospital

Associate Professor of Medicine, Harvard Medical School

Outline

Disparities, Equity and Quality

Building the Foundation: Data Collection & Monitoring

Moving to Action: Improving Quality & Achieving Equity

Achieving Spread: The Disparities Leadership Program

Disparities, Equity and Quality

Diabetes-Related Death Rate, 2010Deaths per 100,000 population

22.8

50.1

33.6

50.3

18.4

0

10

20

30

40

50

WHITE BLACK HISP/LTN AI/AN ASIAN/PI

Disparities in Health Care 2002Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for.Many sources contribute to disparities—no one suspect, no one solution• System factors• Provider factors• Patient factors

IOM’s Unequal Treatmentwww.nap.edu

Recommendations Increase awareness of existence of disparities Address systems of care

– Support race/ethnicity data collection, quality improvement, use of EGB’s, multidisciplinary teams, community outreach

– Improve workforce diversity– Facilitate interpretation services

Provider education– Health Disparities, Cultural Competence, Clinical Decisionmaking

Patient education (navigation, activation) Research

– Promising strategies, Barriers to eliminating disparities

Quality Health Care Health care should be

– Safe

– Effective

– Patient-centered

– Timely

– Efficient

– Equitable

8

Linking Disparities to Cost, Quality and Safety Safe

– Minorities have more medical errors with greater clinical consequences

Effective– Minorities received less evidence-based care

(diabetes) Patient-centered

– Minorities less likely to provide truly informed consent; some have lower satisfaction

Timely– Minorities more likely to wait for same

procedure (transplant) Efficient

– Minorities experience more test ordering in ED due to poor communication

Equitable– No variation in outcomes

Also– Minorities have more CHF readmissions,

ACS admissions, and longer LOS

Cost of Disparities

Between 2003 and 2006, the combined direct and indirect cost of health disparities in the United States was $1.24 trillion (in 2008 inflation-adjusted dollars).

Building the Foundation:Data Collection and Monitoring

Achieving Equity

Key ProcessCollect Data

Identify and Report by R/E

Implement Solutions

Evaluate

Strategic Planning

MGH Disparities Committee 2003

Underlying Principle While data specific to disparities at MGH important, not

necessary to begin to take action given IOM Report documented issue nationally

Charge Identify and address disparities in health and health care

wherever they may exist at MGH– Subcommittees: Quality, Pt Experience, Education/Awareness– Present plan and results to Board, Executive Council and other

hospital leadership regularly

Data CollectionPerceived Challenges

Collection of information is illegal

Patients won’t want to provide information

Registrars won’t want to collect information

(have history of just deciding patient info)

Process will take too long, impede registration

Adapting IT systems to collect info costly

Uncertain how information will be used

Data Collection: TimelinePrior to 2003

Collected R/E data in 5 basic categories and

preferred language

Registrars asked basic questions

Little training or quality assurance

No preamble to collection of data

No campaign to inform patients of purpose

Information not linked to quality data

Data Collection: Timeline

2003 Boston Mayor convenes Hosp CEO’s & Community Leaders

– Agree to effort to address disparities in health and health care– Boston hospitals to be required to collect race/ethnicity

2004 Piloted new method of collection

– 3 models among 7000 patients (R/E, subgroup, language, education)– Metrics: Collects key info in timely fashion in way patients could

understand Registrars receive intense training and QA Process

– Includes preamble, methods to respond to questions City releases PR Poster Campaign MGH passes policy that all Quality Data will be stratified by

race/ethnicity and language

Data Collection: Timeline2006 MA Health Care Reform requires race/ethnicity, language,

and highest level of education to be collected MGH begins preparation of Disparities Dashboard

– Poster campaign series and website unveiled – Disparities questions incorporated in Quality Rounds– Patient Experience Survey Conducted– Multicultural Advisory Board Convened– Patient Satisfaction stratified by race/ethnicity, and language

2007 MGH develops first Disparities Dashboard Disparities found, interventions developed2008 MGH begins public reporting via web

Initial Disparities Dashboard Welcome and Purpose

– Definition of DisparitiesFocus on disparities in care

– Purpose of DashboardAnnual ReportEmbedded into Q and S Reporting

– Data and MeasurementHow race/ethnicity data collected

– Process, categoriesData Sources

– IDX, PATCOM, TSI, H-CAHPS survey data, medical record review (Core/NHQM)

Snapshot of diversity of MGH patients– Who they are and where they are seen

Initial Disparities Dashboard Measures

– Clinical quality indicatorsInpatient: National Hospital Core Measures

– AMI, CHF, CAP, SCIPOutpatient: HEDIS Measures

– Mammogram, Pap, CRC Screening– Diabetes, Coronary Artery Disease

– Physician, Practice Linkage– Patient Experiences with Care

Press-Ganey Inpatient satisfaction by r/eResults of Quality RoundsResults of Minority Survey

– Communication with LEP patients

Disparities Dashboard Evolution

H-CAHPS Inpatient satisfaction by race/ethnicity All-cause and ACS Admission by race/ethnicity CHF Readmissions by race/ethnicity Sentinel Measures

– Mental Health– Pain Mgmt in the ED– Wait time for Renal Transplantation

New Minority Patient Experience Survey Interpreter Pilot Project Cross-Cultural Communication Training Report

Disparities Dashboard Executive Summary– Green Light: Areas where care is equitable

National Hospital Quality MeasuresHEDIS Outpatient Measures (Main Campus)Pain Mgmt in the ED

– Yellow Light: National disparities, areas to be exploredMental Health, Renal TransplantationAll cause and ACS Admissions (so far no disparities)CHF Readmissions (so far no disparities)Patient Experience (H-CAHPS shows subgroup variation)

– Red Light: Disparities found, action being takenDiabetes at community health centers

– Chelsea (Latino), Revere (Cambodian) Diabetes Project Colonoscopy screening rates

– Chelsea CRC Navigator Program (Latinos)

Moving to Action:Improving Quality and

Achieving Equity

Culturally Competent Disease Management:The MGH Chelsea Diabetes Program

Collaboration of the Disparities Solutions Center, Chelsea Healthcare Center, and the MGPO

A quality improvement / disparities reduction program with 3 primary components:

• Telephone outreach to increase rate of HbA1c testing

• Individual coaching to address patients’ needs and concerns regarding diabetes self-management to improve HbA1c

• Group education meeting ADA requirements

*Also focus on link between mental health, chronic disease management, and prevention

Diabetes Control Improving for All: Gap between Whites and Latinos Closing

24% 24%

20%

37%34%

29%

0%

10%

20%

30%

40%

50%

2007 2008 2009

Year

% o

f Pat

ient

s w

ith P

oorly

Con

trol

led

Dia

bete

s (H

bA1c

>

8) Whites

Latinos

* Chelsea Diabetes Management Program began in first quarter of 2007; in 2008 received Diabetes Coalition of MA Programs of Excellence Award

*

Chelsea CRC Navigator Program

CRC Navigator Program– Initiated 2005– Use of registry to identify individuals, by race/ethnicity,

who haven’t been screened for colon cancer– Navigator contacts patient (phone or live)– Determine key issues, assist in process

EducationExploration of cultural perspectivesLogistical issues (transportation, chaperone)

– GI Suite facilitates time/spaces issues

CRC Screening Over Time

2005 2006 2007 2008 2009 201025%

35%

45%

55%

65%

75%

Chelsea PatientsLatino White

Year

CR

C S

cree

ning

Com

plet

ion

(%)

Health Care Provider and Staff Training Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI

Incentive in Q3 2009; case-based, evidence-based, interactive e-learning program which allows learners to develop a skill set to provide quality to patients of diverse cultural backgrounds

987 doctors completed; more than 88% said program increased awareness of issues, would improve care they provide to patients, and would recommend to colleagues; average pretest score 51%, posttest score 83%

Training 3000 frontline staff with Healthcare Professional Version

1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

New Initiative: Patient Experience Survey Goal:

– Gain additional insight into the experiences of diverse patients and harder-to-reach vulnerable populations

Methods: – 800 interviews, stratified by R/E, ambulatory, ED, and

inpatient (will include Peds, and possibly mult languages)– Self-administered paper survey and telephone follow-up

Instrument: – MGH 2004 Disparities Survey with modifications– Standard patient experience domains and disparities-

related issues, including experiences of perceived discrimination or unfair treatment

Preliminary results expected Fall 2012

*Funded by the MGH Center for Quality and Safety

New Initiative: Improving Safety in Patients with Limited-English Proficiency

Funded by Agency for Health Care Research and Quality (AHRQ)

Disparities Solutions Center in collaboration with Abt Associates, Inc., Cambridge

Project Years: 2009-2012

Project Goals• A hospital guide on

preventing, identifying, and reporting medical errors due to language barriers and cross-cultural communication problems.

• A new TeamSTEPPS® training module, focused on team behaviors to improve safety in LEP and culturally diverse patient populations

MGH New LEP Safety Initiatives Interpreter Rounds

– Medical interpreters will conduct rounds to assess quality of care and patient experience of LEP patients

Executive Quality and Safety Rounds – Executive rounds will include manager of interpreter services

to incorporate focus on role of language and cultural factors

Training– Interpreter Training: Patient Safety 101, Reporting,

Communication Tools via TeamSTEPPS® LEP Module– Provider Training: E-Learning Program on partnering with

interpreter services and tools for working with interpreters

New Initiative: MGH Patient Activation Poster Campaign

Launched: June 2011

Languages: English and Spanish

Long Term Plans: Expand to other languages, ideally evaluate impact of poster campaign on patient-provider communication and error reduction

Achieving Spread:The Disparities

Leadership Program

The Disparities Leadership Program One year, Exec Q/S, Distance Learning Program Develop cadre of leaders in health care equipped with

– Knowledge of disparities, root causes, research-to-date– Cutting-edge QI strat’s for identifying/addressing disparities– Leadership skills to implement and transform organizations

Assist individuals and organizations to:– Create a strategic plan to address disparities, or– Advance or improve an ongoing project, and– Be prepared to meet new standards and regulations from

the JC, NCQA, and health care reform

Our Experience: The Disparities Leadership Program

• From 2007 to 2012 (5 Cohorts), the Disparities Leadership Program trained:• 190 participants from 86 organizations

• 43 hospitals• 16 health plans • 17 community health centers • 1 hospital trade organization• 1 federal government agency; 1 city government agency• 7 professional organizations

• Representation from 28 states, along with the Commonwealth of Puerto Rico and Switzerland

AIM Statement

We aim to improve the accuracy and collection rate from 81% to 95% for Race, Language, Ethnicity, Hispanic/Non-Hispanic, and Religious Preference (REAL Plus) data collection for UC Davis Health System within the next fiscal year (July 1, 2012 – June 30, 2013) and pre-work to begin in May 2012.

Project ScopeThe DLP Project Team assisted us in “scoping” our project in specifically on developing strategic plans to achieve the below indicated milestones:

Development of system-wide curriculum and ongoing training program for all staff with competencies in collection of REAL dataDesign of efficient infrastructure to measure patient experience outcomes with REAL Data Collection REAL Data using CG CAHPS Cultural Competence Survey Integration Ability to VALIDATE “accuracy” of collection of REAL Data with Coaching and Improvement Plan Implemented

Project Description

DISPARITIES LEADERSHIP PROGRAM 2012

Disparities Leadership Program 2012-2013

GoalThe goal of our project is to research and develop a disparities dashboard to identify and strategically address AnMed Health’s most vulnerable, underserved and costly patient populations. The disparities dashboard will be adjunct to our system-wide quality management strategies.

Project Objectives• Establish dashboard implementation team • Establish dashboard framework• Establish priority populations• System engagement• Project Evaluation & Phase II Assessment

National Hospital Quality Measures 1-White 1-Hispanic 2-Black 3-American Indian 4-Asian 7-UTD Total

Heart FailureDischarge instructions 97.34% 100.00% 96.52% 0.00% 100.00% 100.00% 97.16%Evaluation of LVS Function 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%ACEI or ARB for LVSD 99.33% 0.00% 100.00% 0.00% 100.00% 0.00% 99.50%Adult smoking cessation advice/counseling 100.00% 0.00% 100.00% 0.00% 0.00% 0.00% 100.00%HF Appropriate Care Score (ACS) 97.76% 0.00% 97.18% 100.00% 0.00% 0.00% 97.64%

AMIAspirin at arrival 99.56% 100.00% 100.00% 100.00% 99.64%

Aspirin Prescribed at discharge 100.00% 100.00% 100.00% 100.00% 100.00%

ACEI or ARB for LVSD 100.00% 0.00% 100.00% 0.00% 100.00%Adult smoking cessation advice / Counseling 100.00% 0.00% 100.00% 100.00% 100.00%Beta Blocker prescribed at Discharge 100.00% 100.00% 100.00% 100.00% 100.00%Inpatient Mortality *Not tracked in 2011 2.63% 0.00% 3.57% 0.00% 2.80%

Primary PCI Received Within 90 Minutes of Hospital Arrival 100.00% 0.00% 100.00% 100.00% 100.00%AMI Appropriate Care Score (ACS) 99.58% 100.00% 98.21% 100.00% 99.32%AMI-T1a LDL Cholesterol Assessment 100.00% 0.00% 91.67% 0.00% 97.62%AMI-T2 Lipid-Lowering Therapy at Discharge (Test) 93.33% 0.00% 100.00% 0.00% 95.24%

PneumoniaPneumococcal vaccination 99.80% 100.00% 100.00% 0.00% 100.00% 100.00% 99.82%Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital 99.45% 100.00% 96.34% 100.00% 100.00% 100.00% 99.05%Adult smoking cessation advice / counseling 100.00% 0.00% 100.00% 0.00% 100.00% 100.00% 100.00%Influenza vaccination 100.00% 100.00% 100.00% 0.00% 100.00% 0.00% 100.00%Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU 100.00% 0.00% 100.00% 100.00% 0.00% 0.00% 100.00%Initial antibiotic received within 8 hours of hospital arrival 97.16% 100.00% 97.26% 100.00% 100.00% 100.00% 97.20%Initial antibiotic selection for CAP in immunocompetent - ICU patient 95.45% 0.00% 100.00% 0.00% 0.00% 0.00% 95.92%Initial antibiotic selection for CAP in immunocompetent - Non ICU patient 97.60% 100.00% 97.22% 0.00% 0.00% 100.00% 97.56%Initial Antibiotic Received Within 6 Hours of Hospital Arrival 97.16% 100.00% 97.26% 100.00% 100.00% 100.00% 97.20%PN Appropriate Care Score (ACS) 96.99% 100.00% 94.87% 100.00% 100.00% 100.00% 96.75%

Surgical CareProphylactic abx within 1 hr prior to surgical incision-Overall Rate 98.01% 100.00% 99.15% 0.00% 98.20%Prophylactic abx selection surgical patients-Overall Rate 98.48% 100.00% 99.16% 0.00% 98.60%Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate 98.03% 100.00% 99.11% 0.00% 98.21%Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose 99.19% 100.00% 93.75% 0.00% 98.58%Surgery Patients with Appropriate Hair Removal 100.00% 100.00% 100.00% 100.00% 100.00%Surgery Pt on BB Therapy Received BB During Perioperative Period 97.25% 100.00% 95.24% 100.00% 96.97%Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 98.60% 100.00% 98.89% 0.00% 98.66%Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg 97.66% 100.00% 96.67% 0.00% 97.51%SCIP Appropriate Care Score (ACS) 91.93% 100.00% 91.25% 100.00% 91.89%Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero 93.84% 100.00% 94.12% 0.00% 93.95%Surgery Patients with Perioperative Temperature Management 100.00% 100.00% 100.00% 0.00% 100.00%

National Hospital Quality Measures 1-White 1-Hispanic 2-Black 3-American Indian 4-Asian 7-UTD Total

Heart FailureDischarge instructions 97.34% 100.00% 96.52% 0.00% 100.00% 100.00% 97.16%Evaluation of LVS Function 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%ACEI or ARB for LVSD 99.33% 0.00% 100.00% 0.00% 100.00% 0.00% 99.50%Adult smoking cessation advice/counseling 100.00% 0.00% 100.00% 0.00% 0.00% 0.00% 100.00%HF Appropriate Care Score (ACS) 97.76% 0.00% 97.18% 100.00% 0.00% 0.00% 97.64%

AMIAspirin at arrival 99.56% 100.00% 100.00% 100.00% 99.64%

Aspirin Prescribed at discharge 100.00% 100.00% 100.00% 100.00% 100.00%

ACEI or ARB for LVSD 100.00% 0.00% 100.00% 0.00% 100.00%Adult smoking cessation advice / Counseling 100.00% 0.00% 100.00% 100.00% 100.00%Beta Blocker prescribed at Discharge 100.00% 100.00% 100.00% 100.00% 100.00%Inpatient Mortality *Not tracked in 2011 2.63% 0.00% 3.57% 0.00% 2.80%

Primary PCI Received Within 90 Minutes of Hospital Arrival 100.00% 0.00% 100.00% 100.00% 100.00%AMI Appropriate Care Score (ACS) 99.58% 100.00% 98.21% 100.00% 99.32%AMI-T1a LDL Cholesterol Assessment 100.00% 0.00% 91.67% 0.00% 97.62%AMI-T2 Lipid-Lowering Therapy at Discharge (Test) 93.33% 0.00% 100.00% 0.00% 95.24%

PneumoniaPneumococcal vaccination 99.80% 100.00% 100.00% 0.00% 100.00% 100.00% 99.82%Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital 99.45% 100.00% 96.34% 100.00% 100.00% 100.00% 99.05%Adult smoking cessation advice / counseling 100.00% 0.00% 100.00% 0.00% 100.00% 100.00% 100.00%Influenza vaccination 100.00% 100.00% 100.00% 0.00% 100.00% 0.00% 100.00%Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU 100.00% 0.00% 100.00% 100.00% 0.00% 0.00% 100.00%Initial antibiotic received within 8 hours of hospital arrival 97.16% 100.00% 97.26% 100.00% 100.00% 100.00% 97.20%Initial antibiotic selection for CAP in immunocompetent - ICU patient 95.45% 0.00% 100.00% 0.00% 0.00% 0.00% 95.92%Initial antibiotic selection for CAP in immunocompetent - Non ICU patient 97.60% 100.00% 97.22% 0.00% 0.00% 100.00% 97.56%Initial Antibiotic Received Within 6 Hours of Hospital Arrival 97.16% 100.00% 97.26% 100.00% 100.00% 100.00% 97.20%PN Appropriate Care Score (ACS) 96.99% 100.00% 94.87% 100.00% 100.00% 100.00% 96.75%

Surgical CareProphylactic abx within 1 hr prior to surgical incision-Overall Rate 98.01% 100.00% 99.15% 0.00% 98.20%Prophylactic abx selection surgical patients-Overall Rate 98.48% 100.00% 99.16% 0.00% 98.60%Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate 98.03% 100.00% 99.11% 0.00% 98.21%Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose 99.19% 100.00% 93.75% 0.00% 98.58%Surgery Patients with Appropriate Hair Removal 100.00% 100.00% 100.00% 100.00% 100.00%Surgery Pt on BB Therapy Received BB During Perioperative Period 97.25% 100.00% 95.24% 100.00% 96.97%Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 98.60% 100.00% 98.89% 0.00% 98.66%Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg 97.66% 100.00% 96.67% 0.00% 97.51%SCIP Appropriate Care Score (ACS) 91.93% 100.00% 91.25% 100.00% 91.89%Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero 93.84% 100.00% 94.12% 0.00% 93.95%Surgery Patients with Perioperative Temperature Management 100.00% 100.00% 100.00% 0.00% 100.00%

Appropriate Care Scores

Alameda County Medical Center

Measuring Equity: Lessons Learned

Annette Johnson, MBA Quality Analyst

Alameda County Medical Center

“To measure is to know”…“If you cannot measure it, you cannot improve it”Lord Kelvin, William Thompson, 1824-1907

Alameda County Medical Center

GraphData for Visual Impact

Eliminate Excessive Nuance Highlight

Asks and Actions

Anatomy of a Dashboard

Alameda County Medical Center

Balance What is

Measured Aim for quick wins

Highlight Bright Spots

Dashboard Strategies

Summary

There is a significant body of evidence that has identified

racial/ethnic disparities in health care, and impact on cost,

quality and safety

Hospitals can play a major role in their elimination through

quality improvement

– Essential elements include data collection, monitoring, quality

improvement, provider and patient interventions

Efforts to improve quality and achieve equity will improve the

care not only of minorities, but of all patients

Thank You

Joseph R. Betancourt, MD, MPH

jbetancourt@partners.org

www.mghdisparitiessolutions.org

www.qualityinteractions.org