Health Equity Is a Patient Safety Issue

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Over 250,000 people die of medical errors each year making this the third leading cause of death in the nation.  Poor or inappropriate care is not distributed equally across all patient populations, however. One of the alarming statistics shared about health inequities is that each year over 90,000 African Americans die unnecessarily throughout the nation’s health system. A confluence of factors contribute to this number: Poor access to healthcare, limited health literacy and unconscious bias place people of color at risk—as is also true for low income patients, women or members of the LGBTQ community. US News and World Report recently featured the experience of a black physician who received less than appropriate care during a visit to the ER that serves as an essential case study of the dangers of bias in healthcare service delivery. 

How do these events happen?

Every hospital must follow an enormous array of patient safety standards with clinical and administrative protocols on everything from dispensing medications to conducting surgery. The Joint Commission’s Hospital National Patient Safety Goals provide a framework for these standards and serve as an evaluation process that is part of every hospital’s accreditation process. Most hospitals have also adopted the Institute of Medicine’s standard for quality healthcare that is safe, efficient, effective, timely, patient centered and equitable.

Unfortunately, few hospitals track health disparities as part of a hospital’s quality metrics. The American Hospital Association 2015 Equity of Care Initiative referred to as #123equitypledge was signed by 1760 organizations.  In California, just 22% of the state’s health care organizations have signed.   All this despite a growing body of research suggesting bias does shape the type of care and the quality of care delivered to diverse patients (Special coverage on this can be found in the 2017 Health Affairs Equity Series).

The Institute for Health Improvement and the National Opinion Research Center (NORC) at the University of Chicago recently published Americans’ Experiences with Medical Errors and Views on Patient Safety in which they surveyed 2,546 adults and identified 21 percent of those surveyed have personally experienced a medical error and 59% of those patients pointed to a medical problem that either was not diagnosed at all or diagnosed incorrectly. Among women, 25% reported they had personally experienced a medical error compared to 17% of men surveyed. These gaps were also seen for high versus low socioeconomic status patients, 17% versus 22% respectively. 

The study also reported that 16% of Latinos experience communication related errors versus 2% for Whites when discussing treatment goals. Latinos pointed to discussions without an interpreter or without a provider who spoke the patient’s language as contributing to the medical error. In addition, 43% of Latinos versus 28% of Whites agreed communication errors take place when discussing treatment options.

The rise in the nation’s racial anxiety and growing polarization poses heightened threats for health inequities. Almost on a weekly basis, national media outlets feature examples of people who feel enabled to outwardly act on their racial biases and verbally or physically assault people of color.  This climate has the potential to impact diverse patients’ experiences in healthcare settings because even the anticipation that bias may occur creates emotionally challenging conditions for diverse patient populations.  The US Department of Health and Human Services’ National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care should be updated to integrate into clear patient safety protocols that target the impact of unconscious bias at every stage of the healthcare delivery process. Now more than ever a deeper commitment to health equity is needed. 

It’s a matter of life or death.  

Early Warning Signs of A Health Disparity

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Maybe stories are data with soul—Brenee Brown, PhD

One of the personal stories I often share when I present to hospital leaders and staff is the moment my dad was about to be wheeled into surgery for his first battle with cancer.  My brothers, my mom and I were around him wishing him well and as would be natural for our family we were all conversing in Spanish.  My father motioned to us to stop and said, “Stop speaking Spanish. They are going to think I’m stupid and the doctors won’t treat me right.” 

Amid all the anxiety of what he was facing at that moment in his life, it stunned me that he would think the simple act of speaking something other than English would mean he would not receive the right care.   My brothers and I dismissed his fears reminding him that each of us would trade off staying with him during the days ahead of recovery.   All three of us-- a physician, a psychologist, and state program administrator became his healthcare advocates. His recovery went fine and that surgery gave him another 8 years of life.

During those days I reflected on how many other people in similar circumstances might find the same fears my dad voiced far more consequential—especially for those without the benefit of informed advocates.  I also came to recognize that this moment was an example of an early warning sign for a health disparity.  We did for my Dad what would have been difficult for him to do alone.  We advocated for his pain medication. We asked for physical therapy. We asked for more tests.  We navigated a system of care and an illness that takes enormous effort. 

Despite access to health insurance, Latinos, Asians and African Americans remain at risk for poor health outcomes when they seek care for anything ranging from diabetes to child birth. At the heart of these challenges is an enormously complex set of factors—access to primary care providers with cultural competence is just the beginning.  Much can be done to address the challenge by creating a stronger culture of inclusion throughout a hospital---among both the clinical and administrative staff.  That philosophical shift can allow staff to see every encounter through the lens of diverse patients.  While healthcare often strives to treat all patients the same—a commitment to standards of care—it is not a one size fits all endeavor.  Cultural competence, inclusion and stronger ties to community networks can set the stage for engaging diverse patients with greater responsiveness to the different social determinants of health, different beliefs and values that impact health.  Now more than ever—as healthcare reform and disruption are constant--every hospital’s equity playbook must increase its sensitivity to the root causes of health disparities that continue to shape lives each day.  -Maria Hernandez, PhD  President and COO Impact4Health, LLC

 

Notes from a PFS Journey: Three Years Later

Three years ago I attended the White House Convening on Civic Engagement and Social Innovation with about 70 other participants. We were called pioneers in social impact investing.  My invitation came as a consequence of the work I had done with support from the California Endowment to explore a Pay For Success Initiative to reduce Asthma related emergencies in Fresno, California and now in Alameda County.  For anyone curious about the nature of Pay for Success initiatives, Social Finance has just released its analysis of their six year history as a financial intermediary in this emerging field.  While the candor of their report is notable,  there's more to be seen from the front lines. 

But firstwhat is a Social Impact Bond (SIB) or Pay for Success Initiative (PFS)?

The idea in short: private investors fund evidenced based interventions to address major social problems that eventually save taxpayer dollars for which a state, city or county pays for successful outcomes from those savings.  The unique strategy in both Fresno and Alameda County is to draw the attention of a different set of payors: health insurance companies and self insured employers that would see reduced health care costs for asthma related hospitalizations and emergency room visits. At long last, the initiative in Alameda County has begun enrolling its first round of participants.

Why the time lap? It's complicated.

Throughout Social Finance's report the words complexity, evidence, and measured impact are emphasized in every section looking at how PFS are crafted, the challenges they face, and their potential for solving major societal problems.  Social Finance reports 60 projects total on the global scale. Only 6 of these are in some stage of implementation in the US and 1 has already closed without a payout to investors. The structure of an initiative requires bringing several players to the table--an intervention provider, a willing payor, and of course the investor.  In the middle of this there is the need for an evaluator, a financial intermediary to structure the deal and a knowledge intermediary like Impact4Health to address the protocols leading to a successful intervention. What has not been stated clearly enough, is that initiating a PFS hinges entirely on finding an intervention that already demonstrates the potential for measurable financial savings.  Social Finance suggests that the approximately 350,000 human service nonprofits in the US are largely ready for that kind of operational rigor. 

In my past work with nonprofits, public agencies and faith based organizations, I have found few are measuring the results of their programs with the precision needed to enter into a PFS agreement.  Instead the daily struggle takes precedent: meet the needs of their community, engage other agencies or providers to coordinate other kinds of care or services and, oh yes, find more funding!

Why aren't we talking about metrics?  

For anyone who has worked as a service provider, the challenge of meeting the mission with limited resources is nothing new.  Finding metrics to prove the impact of your services---now that's definitely a harder sell.  Evaluation is expensive.  Metrics can only happen if there is a consistent service delivery process and that only happens with constant training--all hard to do with small, ever changing staff. Part of the journey in Alameda County was to craft a phase of work that allowed us to first gather that data on health care costs so there is some indication about what kind of return on investment a potential investor might see.  There is no easy way around that requirement. 

Unfortunately, the drive for PFS initiatives---at least in the US--was largely the work of experts in finance, venture capital, or banking and not so much in social services delivery. nonprofit management or program evaluation. No doubt this is an inherent element of the financial modeling necessary for a PFS.  But as one PFS initiative has already demonstrated, the financial structure is not the determinant of success. It's the intervention.  If the financial requirements of a PFS are to be met, the US ecosystem in this nascent field needs a major reset on how to prepare nonprofits or public agencies for the demanding evaluations necessary to measure impact.  That work--capacity building of intervention providers--must be funded with the same determination that SIB enthusiasts have demonstrated about promoting and publishing volumes on the deal structure itself.   The future of PFS in the US rests on building the capacity of service providers to demonstrate impact and while that may not make the headlines or a white paper, it's the right kind of worthy investment indeed.  @drmghernandez