Health equity should be a part of all aspects of a healthcare facility’s patient safety planning, Tejal Gandhi, MD, MPH, said on Monday at the Society to Improve Diagnosis in Medicine annual meeting. .
“There is no such thing as high quality, safe care that is inequitable,” said Gandhi, head of security and transformation at Press Ganey Associates, a health analysis firm in South Bend, in the Indiana. “And when you think of fairness, that is really a fundamental goal of quality.”
“We certainly know that there are persistent inequalities in health care and health outcomes, and these inequalities can be based on race, sex, language and gender,” she continued. , adding that recently, “there has been a lot more awareness of structural racism and other systematic discrimination that has really led to these inequalities in the health care system, and much more widely in our society.” This has been true. even before the pandemic, but “COVID has certainly brought this to the fore – we’ve seen great inequalities in rates of infection, hospitalization and death in the United States, across the continuum of care.”
However, issues such as fairness and prejudice are not always easy to discuss, Gandhi said. “The issue of prejudice must be resolved for both safety and fairness,” she said. “We need to stress the need for psychological safety, for difficult conversations and to avoid an excessive focus on shame and blame, and then focus heavily on leadership and culture.” Gandhi added that over the past year and a half she has led a massive equity effort across the country, “and I have had many conversations with health systems that are just starting to think about this. what their equity strategies should be, and I had a lot of moments that felt like déjà vu, ”she said. “It reminds me of conversations I had 20 years ago when we were just starting to focus on patient safety.”
The data needs to be stratified by racial and ethnic groups so that inequalities can be discovered, “and we’ve certainly started doing that with various kinds of quality and safety measures,” Gandhi said. For example, research has shown that maternal mortality rates for non-Hispanic black women are 2.5 to 3 times higher than for non-Hispanic white women and Hispanic women.
Standardizing the procedures of a healthcare system can work very well from a patient safety point of view, “but we have to make sure that whatever we do does not unintentionally increase inequalities,” Gandhi said. , noting that a Robert Wood Johnson Foundation study found that giving everyone the same procedure can actually widen the treatment gaps. “With equity, you potentially have to have a personalized solution to really achieve what you’re trying to achieve. There is a tension between normalization and personalization that we need to be really aware of. “
What steps can organizations take to improve equity in patient safety? Recognizing the role of bias in misdiagnosis is part of the solution, Gandhi said. She and her colleague Hardeep Singh, MD, wrote about the eight types of diagnostic errors they see during the pandemic, and how prejudice may contribute to some of them. Here are examples of the types of errors and the role of bias in each:
- Classic diagnostic error, such as a missed or delayed diagnosis in a patient with COVID-19 who has classic respiratory symptoms. “There is certainly a potential for inequity in these kinds of errors because there may be a lack of access to quality facilities, a bias in who gets tested and, potentially, who is actually listened to, that could all contribute to these kinds of classic mistakes, ”she said.
- Abnormal error, such as a missed or delayed diagnosis of COVID-19 in a patient with no– respiratory symptoms and not tested for COVID. Bias regarding who is tested or listened to could also play a role here, Gandhi said.
- Warranty error, which is a delayed diagnosis of a non-COVID condition due to a patient’s delay in seeking treatment due to concerns related to COVID. “Certainly, inequity could contribute to this collateral error arising because patients perceived that the health system was not trustworthy for them,” she added.
- Unintentional error, which is defined as a missed or delayed diagnosis due to less direct interactions, including the rapid increase in telemedicine. “We see a lot of articles about the lack of access to telemedicine, language barriers and differences in digital literacy that can contribute to telemedicine potentially being less accessible or less well used for some populations, and which could contribute to more of these unintentional mistakes, ”Gandhi said.
How can the situation be improved? “Reporting security events is a really important starting point,” she said. “Most organizations have thousands of them coming in, but it’s not routine to have segmentation where you look at security in terms of the racial or ethnicity patterns in those reports.” One study found that there were racial differences in reported security events; the demographics of the reported patients differed significantly from the overall hospital demographics. “Understanding what is being reported on types of patients will be really important, especially if you rely on safety reports as your primary source for obtaining information on safety-related issues. “
Root cause analysis (RCA) is another thing to consider, Gandhi added. “We have ways of training security personnel to really add a fairness inquiry into the root cause analysis process, by integrating the prism of fairness into the questions asked, by incorporating it into the types designed and implemented action items, and also monitoring unintentional ones. consequences … RCA is another kind of handy fruit in terms of where you can start looking for inequalities and thinking about design to try to narrow those gaps. “