Improving Quality and Achieving Equity 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

Please note that the views expressed by the conference speakers do not necessarily reflect the views of Health Forum and the American Hospital Association.

A Case Study of 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, Patient Experience, Education/Awareness – Present plan and results to Board, Executive Council and other hospital leadership regularly

Build on Strong Foundation 

Diversity/Recruitment/Retention/Promotion at all levels, including Governance, Leadership, Physicians, Nursing, HR, GME



Fortify efforts in racial/ethnic data collection, add new elements

Education and Awareness 

Create a Culture of Equity and Socialize Message – – – –

Poster Campaign Biannual Disparities Forum Routine PR (Internal/External) Targeted/Integrated Equity Education and Reporting (Board, GEC)

Education and Awareness Physicians and Staff 



Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI Incentive; case-based, evidence-based, interactive e-learning program focused on skill set to provide quality to patients of diverse cultural backgrounds  987 doctors completed at MGH; 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%  Trained 1500 frontline staff with Healthcare Professional Version Training Summit over two years standardized education for all MGH

1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

Education and Awareness Patient Activation and Engagement Patient Activation Poster Campaign MGH launched a poster campaign modeled after the national Speak Up campaign developed by the Joint Commission/CMS The Speak Up campaign urges patients to take a role in improving quality and preventing medical errors by becoming active, involved, and informed participants of the health care team.

5

Patient Experience 



Creation of a Multicultural Advisory Board – Met quarterly with President and VP of Patient Care Services Patient Experience Surveying focusing on Racial and Ethnic Minorities – Initial survey conducted in 2004; served as benchmark  Goal: To go above and beyond standard surveying to get a better understanding of minority patient experience at MGH  Validated questions added, focusing on trust, respect  Initial findings demonstrated differences in perceptions and experience based on race/ethnicity – 2004 to 2012: Initiated several interventions  Service Matters Initiative  Quality Interactions Cross-Cultural Education for MD’s, Staff – Follow-Up Survey 2012  820 patients (50% response rate) in six languages, including children (ages 0-12) and adults (ages 18+) with visits January, 2012 to MGH primary care practices and health centers; minorities 6 oversampled; paper and telephone follow-up

Perception of Quality of Care Do you think the following group of patients receive a lower quality of care, same quality of care or a higher quiality of care than most White, English-speaking patients?

2012

9.1 21.0

2004 6.6

2012

25.0

2004

2012

2.6

2004

8.0

2012

14.2

N/A

2004 0

10

20

30

40

50

60

70

80

90

% Lower quality of care Hispanic/Latino (N=151)

Black/African American (N=164)

Asian (N=193)

LEP patients (N=141)

100

Quality of Care Performance Measurement—The Disparities Dashboard 

Welcome and Purpose – Definition of Disparities, Policy, Purpose of Dashboard – Data and Measurement  How race/ethnicity data collected



Snapshot of diversity of MGH patients – Who they are and where they are seen

Report of Quality and Safety Rounds  Patient Satisfaction, Experience  Communication with LEP Patients  Clinical Quality Indicators 

– Core Measures – HEDIS Measures – New measures

– Green Light: Care is equitable  National Hospital Quality Measures  HEDIS Outpatient Measures (MGH)  Pain Mgmt in the ED – Yellow Light: Areas being 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)  Pediatrics (Asthma), Ob (GrB Strep) – Red Light: Disparities, Action Taken  Diabetes at CHC’s – Chelsea (Latino), Revere (Cambodian) Diabetes Project 

Colonoscopy screening rates – Chelsea CRC Navigator Program (Latinos)

Quality and Safety Diabetes Disease Management Program

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

Quality and Safety Colorectal Cancer Prevention Program 

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

Quality and Safety LEP and Patient Safety 

Train Interpreters on Q and S – Safety Culture – What is a safety event/near miss – How to report an event



Include Interpreters on Q and S Rounds – Assess risks from staff



Conduct Interpreter Rounds – Assess whether patient needs being met



Train Interprofessional Teams* – MD’s, Nurses



Deploy Interpreters for High-Risk* – Discharge – Informed Consent

Summary and Key Lessons 

Leadership and accountability are critical – Routine Reporting to Board, Leadership



Socializing concept early is essential; high quality for all – Aspirational and tied to mission



Integration within departments is key – For example, Quality and Safety should be responsible and accountable



Incremental progress is progress – Strategic, deliberate, tactical, practical



Transparency demonstrates commitment; commit to action

Thank You Joseph R. Betancourt, MD, MPH [email protected]

www.mghdisparitiessolutions.org www.mghdisparities.org