Achieving Health Equity and
Providing Quality Care
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
Outline

Disparities, Equity and Quality

Building the Foundation: Data Collection & Monitoring

Moving to Action: Improving Quality & Achieving Equity

Achieving Spread: The Disparities Leadership Program
Disparities, Equity and Quality
Diabetes-Related Death Rate, 2010
Deaths per 100,000 population
50.3
50.1
50
40
30
33.6
22.8
18.4
20
10
0
WHITE
BLACK
HISP/LTN
AI/AN
ASIAN/PI
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
•
System factors
•
Provider factors
•
Patient factors
IOM’s Unequal Treatment
www.nap.edu
Recommendations

Increase awareness of existence of disparities

Address systems of care
– Support race/ethnicity data collection, quality improvement, use of
EGB’s, 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
Quality Health Care

Health care should be
– Safe
– Effective
– Patient-centered
– Timely
– Efficient
– Equitable
Linking Disparities to Cost, 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
8
Cost of Disparities
Between
2003 and
2006, the combined
direct and indirect cost
of health disparities in
the United States was
$1.24 trillion (in 2008
inflation-adjusted
dollars).
Building the Foundation:
Data Collection and Monitoring
Achieving Equity

Key Process
Collect Data
Identify and Report by R/E
Implement Solutions
Evaluate
Strategic Planning
MGH Disparities Committee 2003
Underlying Principle

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
Data Collection
Perceived Challenges

Collection of information is illegal

Patients won’t want to provide information

Registrars won’t want to collect information
(have history of just deciding patient info)

Process will take too long, impede registration

Adapting IT systems to collect info costly

Uncertain how information will be used
Data Collection: Timeline
Prior to 2003

Collected R/E data in 5 basic categories and
preferred language

Registrars asked basic questions

Little training or quality assurance

No preamble to collection of data

No campaign to inform patients of purpose

Information not linked to quality data
Data Collection: Timeline
2003
 Boston Mayor convenes Hosp CEO’s & Community Leaders
– Agree to effort to address disparities in health and health care
– Boston hospitals to be required to collect race/ethnicity
2004
 Piloted new method of collection
– 3 models among 7000 patients (R/E, subgroup, language, education)
– Metrics: Collects key info in timely fashion in way patients could
understand

Registrars receive intense training and QA Process
– Includes preamble, methods to respond to questions


City releases PR Poster Campaign
MGH passes policy that all Quality Data will be stratified by
race/ethnicity and language
Data Collection: Timeline
2006
 MA Health Care Reform requires race/ethnicity, language,
and highest level of education to be collected
 MGH begins preparation of Disparities Dashboard
–
–
–
–
–
Poster campaign series and website unveiled
Disparities questions incorporated in Quality Rounds
Patient Experience Survey Conducted
Multicultural Advisory Board Convened
Patient Satisfaction stratified by race/ethnicity, and language
2007
 MGH develops first Disparities Dashboard
 Disparities found, interventions developed
2008
 MGH begins public reporting via web
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
Initial Disparities Dashboard

Measures
– 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
Disparities Dashboard Evolution

H-CAHPS Inpatient satisfaction by race/ethnicity

All-cause and ACS Admission by race/ethnicity

CHF Readmissions by race/ethnicity

Sentinel Measures
– Mental Health
– Pain Mgmt in the ED
– Wait time for Renal Transplantation

New Minority Patient Experience Survey

Interpreter Pilot Project

Cross-Cultural Communication Training Report
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)
Moving to Action:
Improving Quality and
Achieving Equity
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
Diabetes Control Improving for All:
% of Patients with Poorly Controlled Diabetes (HbA1c
> 8)
Gap between Whites and Latinos Closing
50%
40%
37%
34%
29%
30%
24%
24%
Whites
20%
20%
Latinos
10%
0%
*
2007
2008
2009
Year
* Chelsea Diabetes Management Program began in first quarter of 2007; in
2008 received Diabetes Coalition of MA Programs of Excellence Award
Chelsea CRC Navigator Program

CRC Navigator Program
– Initiated 2005
– 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
CRC Screening Over Time
Chelsea Patients
Latino
White
CRC Screening Completion (%)
75%
65%
55%
45%
35%
25%
2005
2006
2007
2008
Year
2009
2010
Health Care Provider and Staff Training



Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI
Incentive in Q3 2009; case-based, evidence-based, interactive e-learning program
which allows learners to develop a skill set to provide quality to patients of diverse
cultural backgrounds
987 doctors completed; more than 88% said program increased awareness of
issues, would improve care they provide to patients, and would recommend to
colleagues; average pretest score 51%, posttest score 83%
Training 3000 frontline staff with Healthcare Professional Version
1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.
New Initiative: Patient Experience Survey

Goal:
– Gain additional insight into the experiences of diverse
patients and harder-to-reach vulnerable populations

Methods:
– 800 interviews, stratified by R/E, ambulatory, ED, and
inpatient (will include Peds, and possibly mult languages)
– Self-administered paper survey and telephone follow-up

Instrument:
– MGH 2004 Disparities Survey with modifications
– Standard patient experience domains and disparitiesrelated issues, including experiences of perceived
discrimination or unfair treatment

Preliminary results expected Fall 2012
*Funded by the MGH Center for Quality and Safety
New Initiative: Improving Safety in Patients
with Limited-English Proficiency



Funded by Agency for
Health Care Research
and Quality (AHRQ)
Disparities Solutions
Center in collaboration
with Abt Associates, Inc.,
Cambridge
Project Years: 2009-2012
Project Goals
• A hospital guide on
preventing, identifying, and
reporting medical errors due
to language barriers and
cross-cultural communication
problems.
• A new TeamSTEPPS®
training module, focused on
team behaviors to improve
safety in LEP and culturally
diverse patient populations
MGH New LEP Safety Initiatives

Interpreter Rounds
– Medical interpreters will conduct rounds to assess quality of
care and patient experience of LEP patients

Executive Quality and Safety Rounds
– Executive rounds will include manager of interpreter services
to incorporate focus on role of language and cultural factors

Training
– Interpreter Training: Patient Safety 101, Reporting,
Communication Tools via TeamSTEPPS® LEP Module
– Provider Training: E-Learning Program on partnering with
interpreter services and tools for working with interpreters
New Initiative:
MGH Patient Activation Poster Campaign

Launched: June 2011

Languages: English and
Spanish

Long Term Plans:
Expand to other
languages, ideally
evaluate impact of poster
campaign on patientprovider communication
and error reduction
Achieving Spread:
The Disparities
Leadership Program
The Disparities Leadership Program

One year, Exec Q/S, Distance Learning Program

Develop cadre of leaders in health care equipped with
– Knowledge of disparities, root causes, research-to-date
– Cutting-edge QI strat’s for identifying/addressing disparities
– Leadership skills to implement and transform organizations

Assist individuals and organizations to:
– Create a strategic plan to address disparities, or
– Advance or improve an ongoing project, and
– Be prepared to meet new standards and regulations from
the JC, NCQA, and health care reform
Our Experience:
The Disparities Leadership Program
• From 2007 to 2012 (5 Cohorts), the Disparities
Leadership Program trained:
• 190 participants from 86 organizations
• 43 hospitals
• 16 health plans
• 17 community health centers
• 1 hospital trade organization
• 1 federal government agency; 1 city government agency
• 7 professional organizations
• Representation from 28 states, along with the
Commonwealth of Puerto Rico and Switzerland
DISPARITIES LEADERSHIP PROGRAM 2012
Project Description
AIM Statement
We aim to improve the accuracy and collection rate from 81% to 95% for Race, Language, Ethnicity,
Hispanic/Non-Hispanic, and Religious Preference (REAL Plus) data collection for UC Davis Health
System within the next fiscal year (July 1, 2012 – June 30, 2013) and pre-work to begin in May 2012.
Project Scope
The DLP Project Team assisted us in “scoping” our project in specifically on developing strategic
plans to achieve the below indicated milestones:
Development of system-wide curriculum and ongoing training program for all staff with
competencies in collection of REAL data
Design of efficient infrastructure to measure patient experience outcomes with REAL Data
Collection REAL Data using CG CAHPS Cultural Competence Survey Integration
Ability to VALIDATE “accuracy” of collection of REAL Data with Coaching and Improvement Plan
Implemented
Disparities
Leadership Program
2012-2013
Goal
The goal of our project is to research and develop a disparities
dashboard to identify and strategically address AnMed Health’s
most vulnerable, underserved and costly patient populations.
The disparities dashboard will be adjunct to our system-wide
quality management strategies.
Project Objectives
•
•
•
•
•
Establish dashboard implementation team
Establish dashboard framework
Establish priority populations
System engagement
Project Evaluation & Phase II Assessment
National Hospital Quality Measures
1-White
1-Hispanic
2-Black
3-American
Indian
4-Asian
7-UTD
Total
Heart Failure
Discharge instructions
Evaluation of LVS Function
ACEI or ARB for LVSD
Adult smoking cessation advice/counseling
HF Appropriate Care Score (ACS)
97.34%
100.00%
96.52%
0.00%
100.00%
100.00%
97.16%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
99.33%
0.00%
100.00%
0.00%
100.00%
0.00%
99.50%
100.00%
0.00%
100.00%
0.00%
0.00%
0.00%
100.00%
97.76%
0.00%
97.18%
100.00%
0.00%
0.00%
97.64%
AMI
Aspirin at arrival
99.56%
100.00%
100.00%
100.00%
99.64%
Aspirin Prescribed at discharge
100.00%
100.00%
100.00%
100.00%
100.00%
ACEI or ARB for LVSD
100.00%
0.00%
100.00%
0.00%
100.00%
Adult smoking cessation advice / Counseling
100.00%
0.00%
100.00%
100.00%
100.00%
Beta Blocker prescribed at Discharge
100.00%
100.00%
100.00%
100.00%
100.00%
2.63%
0.00%
3.57%
0.00%
2.80%
100.00%
0.00%
100.00%
100.00%
100.00%
99.58%
100.00%
98.21%
100.00%
99.32%
100.00%
0.00%
91.67%
0.00%
97.62%
93.33%
0.00%
100.00%
0.00%
95.24%
99.80%
100.00%
Inpatient Mortality *Not tracked in 2011
Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI Appropriate Care Score (ACS)
AMI-T1a LDL Cholesterol Assessment
AMI-T2 Lipid-Lowering Therapy at Discharge (Test)
Appropriate Care
Scores
Pneumonia
Pneumococcal vaccination
100.00%
0.00%
100.00%
100.00%
99.45%
100.00%
96.34%
100.00%
100.00%
100.00%
99.05%
Adult smoking cessation advice / counseling
100.00%
0.00%
100.00%
0.00%
100.00%
100.00%
100.00%
Influenza vaccination
100.00%
100.00%
100.00%
0.00%
100.00%
0.00%
100.00%
Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU
100.00%
0.00%
100.00%
100.00%
0.00%
0.00%
100.00%
97.16%
100.00%
97.26%
100.00%
100.00%
100.00%
97.20%
Initial antibiotic selection for CAP in immunocompetent - ICU patient
95.45%
0.00%
100.00%
0.00%
0.00%
0.00%
95.92%
Initial antibiotic selection for CAP in immunocompetent - Non ICU patient
97.60%
100.00%
97.22%
0.00%
0.00%
100.00%
97.56%
Initial Antibiotic Received Within 6 Hours of Hospital Arrival
97.16%
100.00%
97.26%
100.00%
100.00%
100.00%
97.20%
PN Appropriate Care Score (ACS)
96.99%
100.00%
94.87%
100.00%
100.00%
100.00%
96.75%
97.34%
100.00%
96.52%
Prophylactic abx within 1 hr prior to surgical incision-Overall Rate
98.01%
100.00%
99.15%
0.00%
98.20%
100.00%
100.00%
100.00%
Prophylactic abx selection surgical patients-Overall Rate
98.48%
100.00%
99.16%
0.00%
98.60%
98.03%
100.00%
99.33%
0.00%
100.00%
99.19%
100.00%
93.75%
0.00%
98.58%
Adult smoking cessation advice/counseling
97.25%
100.00%
100.00%
100.00%
100.00%
100.00%
0.00%
100.00%
97.76%
0.00%
97.18%
99.56%
100.00%
100.00%
Aspirin Prescribed at discharge
100.00%
100.00%
100.00%
ACEI or ARB for LVSD
100.00%
0.00%
100.00%
Adult smoking cessation advice / Counseling
100.00%
0.00%
100.00%
Beta Blocker prescribed at Discharge
100.00%
100.00%
100.00%
2.63%
0.00%
3.57%
100.00%
0.00%
100.00%
99.58%
100.00%
98.21%
100.00%
0.00%
91.67%
93.33%
0.00%
100.00%
Pneumococcal vaccination
99.80%
100.00%
100.00%
Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital
99.45%
100.00%
96.34%
National Hospital Quality Measures
Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital
Initial antibiotic received within 8 hours of hospital arrival
Heart Failure
Surgical Care
Discharge instructions
Evaluation of LVS Function
ACEI or ARB for LVSD
Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate
Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose
Surgery Patients with Appropriate Hair Removal
99.11%
0.00%
99.82%
98.21%
100.00%
100.00%
95.24%
100.00%
96.97%
98.60%
HF Appropriate Care Score (ACS)
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg
97.66%
100.00%
98.89%
0.00%
98.66%
100.00%
96.67%
0.00%
97.51%
SCIP Appropriate Care Score (ACS)
91.93%
100.00%
91.25%
100.00%
91.89%
93.84%
100.00%
94.12%
0.00%
93.95%
100.00%
100.00%
100.00%
0.00%
100.00%
Surgery Pt on BB Therapy Received BB During Perioperative Period
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
AMI
Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero
Surgery Patients with Perioperative Temperature Management
Aspirin at arrival
Inpatient Mortality *Not tracked in 2011
Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI Appropriate Care Score (ACS)
AMI-T1a LDL Cholesterol Assessment
AMI-T2 Lipid-Lowering Therapy at Discharge (Test)
1-White
1-Hispanic
2-Black
Pneumonia
3-A
I
Measuring Equity:
Lessons Learned
Annette Johnson, MBA
Quality Analyst
Alameda County Medical
Center
“To measure is to know”…“If you cannot measure it, you cannot improve it”
Lord Kelvin, William Thompson, 1824-1907
Alameda County Medical Center
Anatomy of a Dashboard
Graph
Data for
Visual
Impact
Eliminate
Excessive
Nuance
Highlight
Asks and
Actions
Alameda County Medical Center
Balance
What is
Measured
Dashboard Strategies
Aim for
quick wins
Highlight
Bright
Spots
Alameda County Medical Center
Summary

There is a significant body of evidence that has identified
racial/ethnic disparities in health care, and impact on cost,
quality and safety

Hospitals can play a major role in their elimination through
quality improvement
– Essential elements include data collection, monitoring, quality
improvement, provider and patient interventions

Efforts to improve quality and achieve equity will improve the
care not only of minorities, but of all patients
Thank You
Joseph R. Betancourt, MD, MPH
jbetancourt@partners.org
www.mghdisparitiessolutions.org
www.qualityinteractions.org