Achieving Equity in Care
Essential Hospitals Engagement Network
June 25, 2013
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OUR NEW NAME
We’ve rebranded! The National Association of Public Hospitals and Health
Systems is now America’s Essential Hospitals.
Although we’ve changed our name, our mission is the same: to champion
hospitals and health systems that provide the highest quality of service to all by
achieving the best health outcomes for every patient, especially those in
greatest need. The new name underscores our members’ continuing public
commitment and the essential nature of our work to care for the most
vulnerable and provide vital community services, such as trauma care and
disaster response.
This is an exciting time for us and our members, as we lean forward into new
care models, opportunities and challenges of reform, and quality and safety
innovations that often take root in our member systems.
Our new website address: www.EssentialHospitals.org
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“Q&A” AND CHAT
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Essential Hospitals Engagement Network (eHEN)
Achieving Equity in Care
Vickie Sears, MS, RN
Improvement Coach, America’s Essential Hospitals
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TODAY’S AGENDA
•
National Issues and Local Actions
• REAL DATA: the San Mateo Medical Center Journey
• Addressing Quality and Disparities at Truman Medical Centers
• Q&A
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PARTNERSHIP FOR PATIENTS
(PfP)
A public-private partnership to help improve the quality, safety and
affordability of health care for all Americans, funded by CMS
Innovation Center through the Affordable Care Act
PfP Goals:
• Decrease 9 preventable hospital-acquired conditions (HACs) by
40 percent
• Infections (CLABSI, CAUTI, SSI, VAP)
• Morbidity from immobility (falls, pressure ulcers, VTEs)
• Adverse events (drugs, obstetrical)
• Reduce preventable readmissions by 20 percent
Engage patients and families to accomplish harm reduction goals
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ESSENTIAL HOSPITALS ENGAGEMENT NETWORK
(eHEN)
• The PfP funds 26 Hospital Engagement Networks (HENs) to
provide a wide array of initiatives and activities to improve patient
safety.
• HENs represent 3,700 hospitals nationwide.
• Essential Hospitals Engagement Network (eHEN) is the only HEN
in the PfP community focused on serving the most vulnerable
population.
• Special Focus: increasing health equity
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WHAT ARE DISPARITIES IN HEALTH CARE QUALITY?
Differences in quality of health care received by members of different
racial or ethic groups that are not explained by other factors.
• Can occur at every stage in the continuum of care
• Many possible causes and solutions
• Disparities in care represent a failure in quality
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WHY SHOULD WE FOCUS ON DISPARITIES?
Readmissions
• Black patients have a 13% higher odds of readmissions than white
patients for myocardial infarction, congestive heart failure, and
pneumonia1
Pressure Ulcers
• Black residents of nursing homes show higher pressure ulcer
rates compared with white residents (16.8% versus 11.4%)2
Obstetrical Events
• Preterm birth rates are one third higher for Non-Hispanic African
Americans compared to whites3
• Black mothers are significantly less likely (odds ratio 0.31) to
receive prenatal care in their first trimester compared to white
mothers4 1 . Joynt KE, Orav JE, Jha AK. (2011). Thirty day readmission rates for Medicare beneficiaries by race and site of care. JAMA; 305(7),
675-681.
2. Li Y, Yin J, Cai W, et al. (2011). Association of race and site of care with pressure ulcers in high risk nursing home residents. JAMA;
306(2), 179-186.
3. Spong CY, Iams J, Goldenberg R. et al. (2011). Disparities in perinatal medicine: Preterm birth, stillbirth, and infant mortality.
Obstetrics & Gynecology; 117(4), 948-955
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4. Paul I, Lehman EB, Suliman AK, Hillemeier MM. (2008). Perinatal disparities for black m others and their newborns. Maternal
Child Health Journal; 12, 452-460.
DISPARITIES CONTINUE TO EXIST IN QUALITY
Percent of Quality Measures With a Disparity
0%
10%
20%
30%
Black
(Ref: White, n=182)
American Indian or Alaska Native
(Ref: White, n=107)
Hispanic
(Ref: Non-Hispanic White, n=171)
40%
50%
41%
29%
39%
Source: 2011 National Healthcare Quality and Disparities Reports. March 2012. Agency for Healthcare Research
and Quality, Rockville, MD.
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GROWING U.S. MINORITY POPULATION
Population (Millions)
250
200
150
Non-Hispanic Whites
100
Other
50
0
2012
2020
2030
2040
2050
U.S. Census Projections
Note: Other includes all Hispanics regardless of race and Non-Hispanics whose race is not White
Source: 2012 National Population Projections (Updated May 2013); United States Census Bureau.
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LEGISLATIVE AND REGULATORY ATTENTION
Action
Description / Summary
2001—IOM Report, Crossing the Quality
Chasm: A New Health System for the 21st
Century
2002—IOM Report, Unequal Treatment:
Confronting Racial and Ethnic Disparities
in Health Care
2009—American Recovery and
Reinvestment Act
Named equity as one of six domains of quality that all health care organizations
need to address.
2010—Patient Protection and Affordable
Care Act (ACA)
2011—Standards for Patient Centered
Medical Homes (PCMH)
2011—HHS Action Plan to Reduce Health
Disparities
2011—Equity of Care Nation Call to Action
2012—Joint Commission Patient-Centered
Communication Standards
2013-Enhanced National CLAS Standards
Reviewed 10 years of research and found that minorities are less likely to receive
recommended care and more likely to receive lower quality care, regardless of
insurance status or income level.
Created financial incentives for meaningful use of electronic health records that
included recording patient demographics, such as preferred language, gender,
race, ethnicity, and date of birth.
Requires federally funded programs to collect data on race, ethnicity, primary
language, disability status, and gender.
Allows providers to earn points towards the PCMH recognition process by
collecting and analyzing REL data.
Outlines ways to increase health equity, including expanding access to care and
upgrading collection and analysis of data on REL and other demographic
categories in line with the ACA.
ACHE, AHA, AAMC, CHA and NAPH together call for action to eliminate health
care disparities
Requires hospitals to collect a patient’s race, ethnicity and preferred language for
both oral and written communication regarding their care, beginning July 1, 2012.
Provides a blueprint for individuals and health and health care organizations to
implement culturally and linguistically appropriate services.
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National Call To Action to Eliminate
Health Care Disparities
Launched in 2011, the National Call Action is a national initiative to end health care disparities and promote diversity. The group
is committed to three core areas that have the potential to most effectively impact the field.
Goals and Milestone (2013 – 2020)
Goal1) Increasing the collection and use of race, ethnicity and language preference (REAL),
2011 – 18 percent *(baseline)
2015 – 25 percent
2017 – 50 percent
2020 – 75 percent
Goal 2) Increasing cultural competency training,
2011 – 81 percent (*baseline)
2015 – 90 percent
2017 – 95 percent
2020 – 100 percent
Goal 3) Increasing diversity in governance and leadership.
2011 - Governance 14 percent / Leadership 11 percent (*baseline)
2015 - Governance 16 percent / Leadership 13 percent (or reflective of community served)
2017 - Governance 18 percent / Leadership 15 percent (or reflective of community served)
2020 - Governance 20 percent / Leadership 17 percent (or reflective of community served)
*Survey Questions:
1) Is race, ethnicity and primary language data collected at the first patient encounter and used to benchmark gaps in care. 2) Hospital
educates all clinical staff during orientation about how to address the unique cultural and linguistic factors affecting the care of diverse
patients and communities. 3)Racial/ethnic breakdown for each of the executive leadership positions and members of the hospital’s board in
your hospital.
REAL DATA: THREE KEY ACTIONS
Standardize categories and methods for data collection
 Use Office of Management and Budget (OMB) categories
 Patient self-reports
Stratification and analysis of performance measures
 Compare patients within an organization
 Consolidate data to identify community-level trends
Use stratified data to identify gaps in care and develop quality
improvement interventions to address disparities
Source: (IOM) Institute of Medicine. 2009. Race, Ethnicity, and Language Data: standardization for Health care Quality
Improvement. Washington , DC: The National Academies Press
.
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NATIONAL SNAPSHOT OF REAL DATA USE
Source: AHA Diversity & Disparities: A benchmark study of U.S. hospitals, June 2012
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COLLECTION OF PATIENT REAL DATA IN eHEN
HOSPITALS
Hospitals (%)
100%
96%
96%
96%
75%
65%
55%
50%
25%
45%
52%
Collected at Registration
16%
Required Data Field
0%
Race
Ethnicity Spoken Written
Language Language
Patient Characteristics
Source: 2012 Organizational Assessment Tool (OAT) – over 90% of eHEN hospitals reporting
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METHODS FOR COLLECTING PATIENT REAL DATA
AMONG eHEN HOSPITALS
Staff
Observation
of REAL
Used at
Times
43%
Patient SelfUses Staff Observation
Identifies
at Times
Every Time
(43%)
57%
Source: 2012 Organizational Assessment Tool (OAT) – over 90% of eHEN hospital reporting
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Hospitals (%)
COMMON LANGUAGES SPOKEN BY PATIENTS
IN eHEN HOSPITALS
100%
100%
75%
50%
25%
48%
39%
35%
22%
22%
13%
13%
13%
13%
9%
0%
Source: 2012 Organizational Assessment Tool (OAT) – over 90% of eHEN hospitals reporting
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THE OPPORTUNITIES IN eHEN HOSPITALS
Source: 2012 Organizational Assessment Tool (OAT) – over 90% of eHEN hospital reporting
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MOVING TOWARDS ACTION
• Disparities in care are far to common
• Some are under our control
• We must start with actionable data (REAL)
“Effective data collection is the linchpin of any comprehensive
strategy to eliminate racial and ethnic disparities in health.”
– Thomas Perez, JD MPP, Current Assistant US Attorney General for the Civil
Rights Division, from Unequal Treatment: Confronting Racial and
Ethnic Disparities in Healthcare, March 2002
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MOVING TOWARDS ACTION: eHEN 6 MONTH PLAN
• Next Equity Webinar: September 5th at 2:00pm ET
» Topic: Exploring Health Literacy
• Mid-September: eHEN data feedback report on outcome
measures stratified by race and ethnicity
• Offer training to hospital staff on standardizing self-reported REAL
data
• Disseminate “bright spots” in achieving equity
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SAN MATEO MEDICAL CENTER
Jonathan S. Mesinger, PhD
Cultural Competence Leader
Clinics Manager
San Mateo Medical Center
Email:[email protected]
Phone: (650) 578-7187
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Jonathan Mesinger
Cultural Competence
Coordinator
San Mateo Medical
Center 2013
[email protected]
Concepts
• Disparities in medical outcomes and provision of
healthcare services, based on cultural and language
differences, are a pervasive problem
• Identifying the nature and extent of these disparities
at the local level requires careful analysis of patient
demographic data and core measures
• The accuracy and relevance of the demographic
information can determine the success of this
analysis
• The organization must be committed to making
changes in data collection needed to guarantee
accurate, useful data
Race, Ethnicity and Language Data
THE PROBLEM
• Patient demographics were collected using a list of
categories and responses that were archaic and not very
useful
• Staff did not understand the importance of the
information, so were collecting data that were inaccurate,
incomplete or based on assumptions
• No attempt had been made to link this inadequate
patient cultural data to health outcomes for disparities
analysis
• Information on patient language did not indicate the level
of English proficiency or the patient’s language
preference.
Race, Ethnicity and Language Data
REPORTING LIMITATIONS
• Federal and State reporting requirements dictate the
structure and response set for patient demographics
• Staff responsible for reporting are resistant to change
that might interfere with their adherence to reporting
requirements
• Changes in the data fields and responses need to
preserve the integrity of the required data, while
improving the ability of the organization to acquire
meaningful patient cultural information
• Reporting staff need to be convinced that these
changes are possible and non-threatening
Race, Ethnicity and Language Data
THE REAL DATA INITIATIVE
• Obtain the blessing of executive management for the
project and include it in the organization’s DSRIP goals
• Work with key stakeholders within the organization
and the community to develop standards for cultural
data collection
• Create a new set of race, ethnicity and language
categories and responses
• Align the new data elements with federal and state
reporting requirements, as well as CLAS and Joint
Commission standards
• Revise policies and procedures to reflect the new
process
Race, Ethnicity and Language Data
RACE
• Categories are defined by OMB and cannot be changed
• Hispanic or Latino not listed as a race
• Many patients are multiracial or do not know their race
• Accuracy based on patient self-report, not assumptions
• Is race a meaningful way to differentiate our patients?
Race, Ethnicity and Language Data
ETHNICITY
• The only federal “ethnicity” question is “Are you
Hispanic?”
• OMB has a suggested granular list of ethnicities, but
this list can be tailored to the reflect the patient
population
• The granular list provides a more vivid, robust and
meaningful characterization of the organization’s
patients
• The ethnicity list provides information beyond what is
reported and allows the patient to self-determine
• Ethnicity data help us understand who are patients are
and how we can improve their care
Race, Ethnicity and Language Data
LANGUAGE
• In California, acceptable language reporting responses are
determined by OSHPD (Office of Statewide Health, Planning
& Development)
• HRSA requires a question about English proficiency
• In REAL Data, staff are trained to ask the patient what
language they prefer to use, not just their primary language:
“What language do you feel most comfortable speaking
with your Doctor or your Nurse Practitioner today?”
• Meaningful, accurate patient language data are useful for
o Identifying and addressing disparities in health care
o Determining the need for interpretation
o Improving patient services and satisfaction
o Meeting Joint Commission standards
Race, Ethnicity and Language Data
THE REAL DATA INITIATIVE
• Work with IT staff to change the data entry fields in the
patient registration system (Invision)
• Create a data survey form to collect the data for the new
system
• Create scripts for staff use in obtaining information from
patients
• Train staff at all points of patient demographic data
collection on the new way of collecting and entering this
information
• Implement the new REAL Data initiative
simultaneously, organization-wide.
• RACE
• Hispanic?
• ETHNICITY
• English Proficiency
• Preferred LANGUAGE
Race, Ethnicity and Language Data
BASIC DISPARITIES ANALYSIS
Race, Ethnicity and Language Data
FOLLOWING UP:
• Monitor data regularly for accuracy and completeness
• Retrain staff as needed to improve data quality
• Produce REAL Data reports for the organization
• Check individual patient’s preferred language and
English proficiency to determine interpretation needs
• Quality Department uses REAL Data and core
measures/health outcomes/service provision data, to
illuminate any disparities and develop initiatives to
address them
TRUMAN MEDICAL CENTERS
John W. Bluford, MBA, FACHE
President & CEO
Truman Medical Centers
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America’s Essential Hospitals
Equity Webinar
John W. Bluford
President/CEO Truman Medical Centers
2012
Diversity in Governance
Makes Good Business Sense
Diversity in
Governance
Diverse
Perspectives
Better Decisions!
Better Outcomes!
Good Governance is Important!
2012
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Truman Medical Centers: Diversity OnBoard
Paul Black
Jon Gray
Peggy Dunn
Joanne Collins
Juan Rangel
Mark Steele
Rev. Eric Williams
Phil Richter
Sarah Chavez
Leo Morton
Peter Levi
Joy Wheeler
Dennis O’Leary
Ryan Watson
2012
T RUMAN M EDICAL C ENTERS
Bucky Brooks
2012
T RUMAN M EDICAL C ENTERS
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2012
T RUMAN M EDICAL C ENTERS
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Hospital Hill Pneumonia (PN) Measures
Q4 2011
PN-2
PN-3a
PN-3b
PN-4
PN-5c
Freq
90.00%
90.00%
100.00%
90.00%
90.00%
White
Q
100.00%
100.00%
62.50%
100.00%
90.91%
Black/African American
Q
100.00%
100.00%
85.71%
100.00%
93.33%
American Indian/Alaska Native
Q
Asian
Q
Native Hawaiian/Pacific Islander
Q
Unable to Determine
Q
Race Code Data Not Supplied
Q
BY RACE
100.00%
50.00%
0.00%
100.00%
100.00%
75.00%
100.00%
100.00%
100.00%
By Ethnicity
Hispanic
Q
Not Hispanic
Q
Unavailable
Q
100.00%
85.71%
80.00%
100.00%
86.67%
By Gender
Male
Q
100.00%
75.00%
84.62%
100.00%
82.35%
Female
Q
100.00%
100.00%
76.92%
100.00%
92.86%
THANK YOU FOR ATTENDING!
• Save the Date: Exploring Health Literacy – Sept. 5
2-3 pm Eastern
• Evaluation: Following the webinar, when you close out of WebEx, a yellow
evaluation of the webinar will open in your browser. We greatly appreciate your
feedback!
• Essential Hospitals Engagement Network website:
http://tc.nphhi.org/Collaborate
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Achieving Equity in Care