Improving Quality and Achieving Equity
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1 Improving Quality and Achieving Equity Measuring Performance and Taking Action A Case Study of Massachusetts General Hospital Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School
2 Disparities in Health Care 2002 Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for. Many sources contribute to disparities no one suspect, no one solution
3 Linking Disparities to Quality and Safety Safe Minorities have more medical errors with greater clinical consequences Effective Minorities received less evidence-based care (diabetes) Patient-centered Minorities less likely to provide truly informed consent; some have lower satisfaction Timely Minorities more likely to wait for same procedure (transplant) Efficient Minorities experience more test ordering in ED due to poor communication Equitable No variation in outcomes Also Minorities have more CHF readmissions, ACS admissions, and longer LOS 3
4 IOM s Unequal Treatment Recommendations Increase awareness of existence of disparities Address systems of care Support race/ethnicity data collection, quality improvement, evidencebased guidelines, multidisciplinary teams, community outreach Improve workforce diversity Facilitate interpretation services Provider education Health Disparities, Cultural Competence, Clinical Decisionmaking Patient education (navigation, activation) Research Promising strategies, Barriers to eliminating disparities
5 Underlying Principle A Case Study of MGH Disparities Committee 2003 While data specific to disparities at MGH important, not necessary to begin to take action given IOM Report documented issue nationally Charge Identify and address disparities in health and health care wherever they may exist at MGH Subcommittees: Quality, Pt Experience, Education/Awareness Present plan and results to Board, Executive Council and other hospital leadership regularly
6 Progress to Date at Mass General Hospital Quality and Disparities -R/E Data Collection, Registries, Dashboards, QI System Equity Provider -CC Education -Facilitate adherence to guidelines Patient -Screen for non-adherence -Provide focused education, activation, navigation
7 Initial Disparities Dashboard Welcome and Purpose Definition of Disparities Focus on disparities in care Purpose of Dashboard Annual Report Embedded into Q and S Reporting Data and Measurement How race/ethnicity data collected Process, categories Data Sources IDX, PATCOM, TSI, H-CAHPS survey data, medical record review (Core/NHQM) Snapshot of diversity of MGH patients Who they are and where they are seen
8 Measures Initial Disparities Dashboard Clinical quality indicators Inpatient: National Hospital Core Measures AMI, CHF, CAP, SCIP Outpatient: HEDIS Measures Mammogram, Pap, CRC Screening Diabetes, Coronary Artery Disease Physician, Practice Linkage Patient Experiences with Care Press-Ganey Inpatient satisfaction by r/e Results of Quality Rounds Results of Minority Survey Communication with LEP patients
9 Disparities Dashboard Evolution H-CAHPS stratified by race/ethnicity All-cause and ACS Admission by race/ethnicity CHF Readmissions by race/ethnicity Sentinel Measures Pain Management in the ED New Measures Pediatric Asthma Treatment OB Measures (GrB Strep) Greater focus on disparities by LEP Outline of new initiatives including interpreter rounds, quality and safety rounds, and patient safety training (interpreters, providers) Now: Annual Report on Equity and Healthcare Quality
10 Disparities Dashboard Executive Summary Green Light: Areas where care is equitable National Hospital Quality Measures HEDIS Outpatient Measures (Main Campus) Pain Mgmt in the ED Yellow Light: National disparities, areas to be explored Mental Health, Renal Transplantation All cause and ACS Admissions (so far no disparities) CHF Readmissions (so far no disparities) Patient Experience (H-CAHPS shows subgroup variation) Red Light: Disparities found, action being taken Diabetes at community health centers Chelsea (Latino), Revere (Cambodian) Diabetes Project Colonoscopy screening rates Chelsea CRC Navigator Program (Latinos)
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12 Culturally Competent Disease Management: The MGH Chelsea Diabetes Program Collaboration of the Disparities Solutions Center, Chelsea Healthcare Center, and the MGPO A quality improvement / disparities reduction program with 3 primary components: Telephone outreach to increase rate of HbA1c testing Individual coaching to address patients needs and concerns regarding diabetes self-management to improve HbA1c Group education meeting ADA requirements *Also focus on link between mental health, chronic disease management, and prevention
13 Diabetes Control Improving for All: Gap between Whites and Latinos Closing % of Patients with Poorly Controlled Diabetes (HbA1c > 8) 50% 40% 30% 20% 10% 0% 37% 34% 24% 24% 29% 20% Year Whites Latinos * Chelsea Diabetes Management Program began in first quarter of 2007; in 2008 received Diabetes Coalition of MA Programs of Excellence Award *
14 Colorectal Cancer Screening CRC Navigator Program Initiated 2005 Navigator Program Use of registry to identify individuals, by race/ethnicity, who haven t been screened for colon cancer Navigator contacts patient (phone or live) Determine key issues, assist in process Education Exploration of cultural perspectives Logistical issues (transportation, chaperone) GI Suite facilitates time/spaces issues
15 CRC Screening Completion (%) CRC Screening Over Time 75% Chelsea Patients Latino White 65% 55% 45% 35% 25% Year
16 Summary There is a significant body of evidence that has identified racial/ethnic disparities in health care Hospitals can play a major role in their elimination through performance measurement and quality improvement IOM recommendations will improve the care not only of minorities, but of all Americans This is more important now than ever before, given major healthcare transformation
17 Thank You Joseph R. Betancourt, MD, MPH
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