Two medical researchers argue in an opinion article published on January 23 in The New England Journal of Medicine that some of the very processes being implemented to improve patient safety could also serve the purpose of improving equal access to quality healthcare for Americans.
Karthik Sivashanker, M.D., M.P.H. and Tejal K. Gandhi, M.D., M.P.H. make that argument in an article entitled “Advancing Safety and Equity Together,” in the Perspectives section of the NEJM. Dr. Sivashanker is the medical director of quality, safety, and equity at Brigham and Women’s Hospital in Boston; Dr. Gandhi is chief safety and transformation officer at the Boston-based Press Ganey.
“There are persistent and widespread inequities in health outcomes in the United States based on race, sex, language, socioeconomic class, and other factors,” the physicians write. “Such inequities have historical roots in structural racism and other forms of systematic discrimination, which have been codified in policies and practices. Our systems have been constructed, usually unintentionally, to deliver outcomes that vary according to factors such as patients’ skin color or their ability to pay for services. However, there is no such thing as high-quality, safe care that is inequitable. Observations like this one frequently provoke a defend-and-deny reaction because of our tendency to personalize critiques of systems. But inequity in health care is a systems-based problem that requires a systems-based approach.”
Still, the researchers write, “The good news is that there is a natural alignment between the framework we use to improve safety and the approach we can take to increase equity. Safety and equity are both fundamental dimensions of health care quality. Both frameworks encourage redesigning systems to make them more reliable and resilient. Both balance this systems focus with individual accountability. Both recognize the role of cognitive, often subconscious, biases in contributing to unintentional harm. Both highlight the importance of psychological safety to support difficult conversations. And both avoid excessive focus on individual or interpersonal blame. The goal isn’t to shame individual clinicians but to build resilient systems around them that support optimal behaviors.”
In that, they note, “The prioritization of patient safety in U.S. health care since 1999 has led to the creation of strong safety programs. These programs have established technology, infrastructure, and resources that health systems can leverage to advance equity.”
Importantly, the researchers write, “A simple first step is to apply an equity lens to existing safety data, such as data generated from safety reporting, root-cause analysis, and efforts to reduce adverse events. Such data can be stratified by patient race, ethnic group, language, sex, gender identity, disability status, and other key social determinants of health. Stratifying data enables health care institutions to identify, study, and address previously hidden inequities.
Going into a detailed hypothetical case study, the researchers write, “Consider a hypothetical case that illustrates the way in which patient-safety processes and infrastructure might facilitate action to address inequities. A safety report is filed regarding a delayed diagnosis of lung cancer in a primary care patient. When the risk manager collects demographic information, she notes that the patient is Latino, his preferred language is Spanish, and he doesn’t speak English. She also learns that the hospital’s standard outreach for follow-up of incidental lung nodules consists of three reminder phone calls, a mailed letter, and frequent notifications on the patient portal.” They go on to explain how some of the processes coming out of the process around that case could lead to broader outreach to patients of all backgrounds, which could increase equity for all patients.
The potential alignment between the pursuit of patient safety and that of equity is already there, the authors note: “[H]igh-reliability teams, such as patient-safety teams, are typically steeped in data, so stratifying by race, ethnic group, and language is a small ask. Second, the widespread use of standardized tools, such as high-reliability algorithms, presents an opportunity for systematically embedding equity concepts and prompts into risk analyses. Existing infrastructure (e.g., case-review meetings that use root-cause analysis) also provides a stage for bringing attention to inequities by using data and stories. Finally, an emphasis on systems-level contributors leads to structural solutions.”
And, they add, “Advancing equity-focused initiatives will probably require blending disciplines and strategies. It’s not easy to facilitate a difficult conversation about discrimination. Staff will have to learn about structural racism as a foundation for current inequities,” they write. “They’ll need practice facilitating psychologically safe conversations and to get comfortable shifting from an identity-blind state that promotes denial to an identity-conscious state that builds awareness. Ideally, they should also develop skills and tools for performing aggregated analyses of equity-related data throughout their institution, rather than just within individual departments. Every department — from human resources to environmental services — should eventually use the same high-reliability, equity-informed approach.”