Subcommittees

Quality

Members

Charge: To develop methods for ongoing quality measurement of outcomes stratified by race and ethnicity. Design QI initiatives to address when issues are identified.

Projects and accomplishments:

Monitoring

• Medical Policy:
  On May 3, 2006, The Medical Policy Committee, upon the recommendation of the MGH Committee on Racial and Ethnic Disparities and staff of The Disparities Solutions Center, amended the Quality Policy on Data Management to include the following statement:
  Racial and ethnic disparities:  In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant PI data should be collected and stratified by race and ethnicity.
  This change will enable additional measures of disparities in quality of care within the MGH to be evaluated.

Medical Policy Statement

The Institute of Medicine Report "Crossing the Quality Chasm" delineated that the principle of "equity" is central to the delivery of quality health care. As such, there should be no variations in quality based on personal characteristics such as race and ethnicity. A subsequent Institute of Medicine Report, "Unequal Treatment," found that racial/ethnic disparities in health care exist in the United States, and that minorities tend to receive a lower quality of care than do whites, even when controlling for socioeconomic status, education, and insurance. As a method of ensuring equity and fulfilling the call to action of addressing disparities, "Unequal Treatment" recommended:

1. Collection and reporting data on health care access and utilization by patient's race, ethnicity, and primary language
2. Including measures of racial/ethnic disparities in performance measurement
3. Monitoring progress toward the elimination of health care disparities

As such, we recommend a policy which states that all data collected for quality improvement activities be collected and stratified by race and ethnicity...(fill in criteria here as you see appropriate)...

• Quality Rounds:
  Quality and Safety Rounds were started at the MGH in 2002 with the goal of identifying from hospital staff what might be key issues that could jeopardize patient safety or lead to medical errors. To achieve this goal, a doctor-nurse team routinely visits an inpatient floor (in rotating fashion) and meets with a group of multi-disciplinary members of the care team who are available over lunch (which is provided as an incentive for attendance).  Issues that have been identified in general include prevention of falls, for example. In 2003, a specific question focused on disparities was incorporated into the Quality and Safety Rounds. First, a preamble was read, in varying formats, and then questions were asked. The introduction to this issue may vary with the group, but always contains the same ideas. Frequently, the introduction also makes it clear that this question, and the answers to it, are of specific interest to Senior Leadership and the Disparities program, and the comments are forwarded to these groups. We have added this to the introduction as a way of showing the commitment and emphasis of Leadership on this topic – it is often a step in a different direction than what they expected to talk about, surprises them sometimes, but is well received.

To date, the issue of language barriers has been highlighted with greatest frequency, but other issues raised in response to this question also include issues of understanding and acceptance of varying cultural traditions (particularly around gender issues, religion, and visiting policies and issues of access, particularly in the ambulatory settings). Staff felt that MGH Interpreter Services were excellent at admission and discharge, when the encounter can be specifically scheduled in advance, but during the course of the hospital admission, when nurse or staff is trying to check-in with a patient or assess or respond to an acute situation, language barriers pose a significant challenge to patient safety.

The most gratifying response is almost always the strong affirmation that nursing services, in particular, feel there is no bias or discrimination in their care, though they do recognize barriers and limitations, particularly in the day to day language issues. Our sense is that this process of increasing emphasis on this issue has led to significant improvements in a number of aspects of care, but has also by its very asking, raised awareness and sensitivity on the part of the staff.

MGH Quality Rounds Disparities Questions

Preamble

Research across the country, as well as several national reports, has shown that minority patients—even with the same type of insurance—may receive lower quality of care than whites, including while they are in the hospital. This is concerning to the MGH, so we want to ask a few questions about what happens here.

Questions 

• We know that at times there are difficulties in delivering same quality of care to people of all racial, ethnic and cultural groups.  Has this been a concern on this unit? Why might this happen?

Prompts:

• Differences in trust or mistrust
• Differences due to language
  

 

• What are the barriers to delivering same standard of care to all people regardless of their racial, ethnic or cultural background?  What systems are not in place? What systems should be in place

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Reporting

• Disparities Dashboard:
  The goal of the Disparities Dashboard is to monitor several key components of quality by race and ethnicity. It was developed in response to The IOM Report Crossing the Quality Chasm, among which equity – the principle that quality of care should not vary by race, ethnicity, or gender, among other characteristics - is one of six pillars of quality. Although race/ethnicity data had been collected routinely at the MGH for several years and was in the process of being upgraded as a result of a large city-wide and Partners-wide initiative (described above), this data had not been routinely analyzed or reported in any way. As a result, the first key step to insuring that a Disparities Dashboard could be developed was to pass a medical policy stating that all quality improvement data collection and initiatives need to be stratified by race and ethnicity. Once this was done, several ideas were generated by the MGH Disparities Committee, as well as the Quality Subcommittee, regarding what should be included on the dashboard. After significant deliberation, the following components were selected:
  • Welcome and Purpose: This section provides introductory material that highlights the IOM Report Unequal Treatment and Crossing the Quality Chasm, and makes the case for why a Disparities Dashboard is necessary. It goes on to describe what a disparity is, as well as how we collect race and ethnicity data at MGH. Finally, it presents the purpose of the dashboard, with strengths, limitations, methods for interpretation and process for distribution and dissemination
  • Snapshot of Patient Diversity at the MGH: This section provides graphs (from data for the past year) detailing the race/ethnicity breakdown of our inpatients and outpatients (compared to the city of Boston and the state of Massachusetts); the race/ethnicity breakdown of patients in our health centers versus the main hospital; and the race/ethnicity breakdown of patients by clinical service (for example, the majority of minority patients are seen in Obstetrics and Pediatrics)
  • Quality Measures: This section provides data stratified by race/ethnicity for:
    • National Hospital Core Measures (inpatient measures for acute myocardial infarction, community acquired pneumonia, and congestive heart failure)
    • HEDIS Preventive Services and Diabetes Measures (outpatient measures that include mammography, pap smears, diabetes, etc.)
    • Patient Satisfaction, both inpatient (using Press-Ganey with two additional questions added to get at issues of disparities from their question bank; MGH moving to HCAHPS) and outpatient
    • Quality and Safety Rounds (described in more detail in next section)
    • Wait times for appointments
    • Number of interpreter visits
  • Summary: This section summarizes areas where we are doing well and areas where disparities were found and where there is need for improvement.
  • Action: To address the latter issue, this section also includes a summary of what we are doing to address disparities that have been found. In our first report, we describe our two disparities interventions in diabetes and colorectal cancer screening (described in more detail below).

To download the MGH Disparities Dashboard Outline, please click here.

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Interventions

• Chelsea Diabetes:
  • The Chelsea Diabetes Disparities Program is a quality improvement and disparities reduction intervention targeting poorly controlled diabetic patients at MGH’s Chelsea Health Care Center.  The Disparities Solutions Center is actively involved in the design of this program based on a culturally competent disease management model involving both individual coaching and group visits. The Center will conduct the evaluation study to assess improvements in glucose control, patients’ potential barriers to achieving control of their diabetes and reductions in disparities between Latino and non-Latino white patients. Initial funding provided by the MGH.
• Chelsea Colorectal Cancer Screening:
  • The DSC has begun to work with the MGH Gastroenterology Unit, the Community Benefits Office, and MGH Chelsea HealthCare Center to develop a quality improvement/disparities reduction project to address the marked disparity found in colonoscopy screening rates, particularly striking among Latinos. Similar to the Diabetes Program, this program will focus on identifying barriers to CRC screening and overcoming these barriers with the help of a bilingual, culturally competent patient navigator. The program will also focus on patient education, provider education and overcoming logistical and financial barriers to colonoscopy screening.
• Mental Health:
  • The Disparities Solutions Center is working with MGH Psychiatry to investigate where disparities in mental health service utilization exist throughout MGH, both through research and collaboration with participating clinics.  The DSC will propose measures to increase mental health services to minority populations and seek to encourage clinicians and support staff to participate in improving care for minorities with depression.

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