A Few Years Ago, I Had an Experience Which Really Opened My Eyes About Quality What It

WNY 9 24 09

Thank you, Kate

It’s an honor to be here with you today in Western New York. I want to thank Shelley Hirshberg, the executive director of P2 for asking me to come up here. In case you did not know, Shelley is not just the director…she is also a force of nature!! She keeps me honest!!

I also want to thank Dr. Michael Cropp, the chair of P2’s Board of Directors—We’ve closely followed the progress you have been making and I know that under Michael and Shelley’s leadership great things are happening in western New York.

My name is Bruce Siegel and I direct the Center for Health Care Quality at the George Washington University. I also have the pleasure of directing the Aligning Forces for Quality program.

As you may know, Aligning Forces is the Robert Wood Johnson Foundation’s core initiative to transform the quality of health care in 15 regions across our country. Each community is uniquely positioned to make fundamental, cutting-edge change to rebuild their health care system. What we all want to see in Aligning Forces is a health care system that is more affordable and accountable, and one that allows patients to access the best quality care, no matter who they are.

A couple of months ago, I know that you all had a truly impressive meeting where almost three hundred of Western New York’s leaders, care givers, insurers and consumer advocates came together to learn about P2’s many achievements, especially around engaging consumers and doctors. But beyond all of the goals, accomplishments and plans that were discussed, what was remarkable was that people were able to have an honest, civil and constructive conversation about health reform – at a time when that sure wasn’t happening at other gatherings around the country. Clearly the rest of the nation can learn a lot from you.

All of us in this room know that across America – in every community – there are dangerous gaps between the health care that people should receive and the care they actually experience. In many places, for many conditions, a patient has a better chance of getting a ‘heads’ on a coin toss than he or she has of getting the right care … at the right time.

And most of us probably know – and have seen the data – that this care varies widely by where you live, in terms of both quality and quantity.

I could talk about all of this – and Shelley and I could point out all the ways that you are addressing these challenges through Aligning Forces.

But I am not going to do that.

Not today.

Instead I want to talk about the health care that a lot of people who are not in this room receive. You see, although the quality of care is poor for many Americans, some of our neighbors of certain racial and ethnic groups receive even worse care.

This is true regardless of their income, regardless of their educational level, whether or not they are insured – regardless even if their doctor or their nurse is the same race as the patient.

Eliminating these inequities in care is a big goal of Aligning Forces for Quality, and I know it’s also a pressing need here in Western New York.

Everyone has a story, or knows someone with a story, that motivates them to be involved and continues to keep them at the bedside, or in the office burning the midnight oil.

So, let me tell you mine.

[Slide #1]

I had an experience a few years ago that really opened my eyes about the quality of health care provided in this country—about how certain populations, for whatever reasons, are disproportionately affected by the equity gap in America.

My mother, who is now 93 years old, God bless her, was found one day confused and laying on the floor. She was immediately taken to a big teaching hospital nearby, where she was admitted.

My mother is an immigrant from Haiti, so she speaks Creole and French—she speaks English, too, but as part of her confusion, she was really disoriented, and speaking only her native tongue.

The doctors ran lots of tests and told us that they could not figure out what was going on physiologically. They eventually came to the conclusion that my mother must have a psychological problem. She must be hysterical.

So they gave up after a week and called in a psychiatrist to interview her. But the psychiatrist didn’t speak Creole or French.

So she did something that we all know you shouldn’t do—she asked a family member to interpret. And that family member was me. You don’t need me to tell you that a son shouldn’t be asked to do a psychiatric exam on his mother.

Eventually another physician came on service and re-examined my mother’s case, now almost two weeks into hospitalization, and he thought there could be something else going on. He did an echocardiogram, drew blood cultures and eventually found that my mother had something called subacute bacterial endocarditis - a bacterial infection of the blood stream that was eventually cured with several weeks of intravenous antibiotics. My mother eventually returned home to our family.

This was a frustrating experience. The way in which my Mother was treated is far from the picture of patient-centered, safe care that all of us work to promote everyday. But as unnecessary and unfortunate this experience was for her, her story had a good ending. I knew that things could have easily gone in a different direction.

My Mom’s story spoke to me in a lot of ways. It spoke to the biases and expectations that many of us bring to our encounters with patients. It told me that it doesn’t matter whether you are the mother of a physician, whether you have insurance and access to some of the most advanced hospitals in the world – even with all of these resources, today in America an individual can still receive poor quality care because of the language that she speaks or maybe the color of her skin.

Quality is everyone’s issue, and make no mistake – disparities in the care that Americans receive are a real part of the quality problem. We simply cannot cross the quality chasm without crossing the equity chasm.

Let’s take a moment to look at the larger picture of disparities in America. The numbers really tell a story of their own and for years they’ve been telling us this: in America, the quality of care minorities receive is often dramatically worse than that of White patients.

Let’s take a look at this next slide:

[Slide #2]

The US Census Bureau projects that the number of minorities living in the United States will exceed the number of non-Hispanic whites sometime after 2040. Minorities in America will have become the majority.

[Slide #3]

Let’s take a look at this in another way – here you can see the Hispanic population will double by then, from 15 to 30 percent of the entire U.S. population.

America is in the midst of becoming a very different country. And the kind of health care we provide to Latinos, Blacks Asians and many others will largely define the care we provide in general. If most of our nation is not getting the full benefits of high quality care, then we will have lost the battle.

We know from literally thousands of studies that minority Americans suffer disparities in health care. The evidence may be strongest for African Americans and Hispanics. We know from countless studies that the quality of diabetes care for black patients is significantly lower than for white patients as they are less likely to receive routine services like eye exams or cholesterol tests. Black patients also tend to receive lower quality cardiac and joint care, and are less likely to be vaccinated for pneumonia and influenza. Hispanics are less likely to also get the right diabetes care and also essential treatment for heart attacks and heart failures. But the evidence also goes beyond this and shows grave inequities for American Indians, Asian-Americans and others.

These disparities are often there regardless of the patient’s health insurance status. For instance, many minority patients on Medicare get lower quality care than whites by many measures. Without ensuring quality, better financial access to the health care system is less of a fulfillment and more like half of a promise. And if America is on its way to becoming mostly minority, we can’t get to be the best in quality with half of our patient population lagging behind.

Let me ask you a couple of questions.

How many of you out there work in a hospital? (React)

Does your hospital provide the same high quality care to all its patients? (React)

How do you know?

I ask these questions a lot, because so often folks tell me “we provide great care to everyone……it’s in our MISSION STATEMENT”. And that is a good thing. But when I ask them, do you really KNOW this…have you actually measured quality by the race and ethnicity of your patients, well…it’s a short discussion!

Now, there are some institutions that just do not see the need to address disparities. Not because they don’t view it as an important issue, but because they may not believe it applies to them or the population they serve.

But you can’t know what you don’t measure and you can’t improve what you don’t know. In other words, unless you accurately know who your patients are, you won’t know the population you are truly serving and you have no way of determining how well you are serving them.

Take the University of Mississippi Medical Center in Jackson, Mississippi—it’s a 722-bed medical center that participated in Expecting Success, a Robert Wood Johnson Foundation funded hospital collaborative I directed.

Expecting Success aimed to improve cardiac care for racial and ethnic minority populations. For the first time, ten participating hospitals came together to systematically collect patients’ race, ethnicity and language data by (surprise surprise) actually ASKING the patient. This is critical, because in America today this data is either not collected, or collected haphazardly. So hospitals do not have a real sense of their patients’ race or ethnicity or language, and cannot figure out if the quality of care for many groups varies. Having such accurate data gave our hospitals the ability then to meet their patients’ needs and also to measure the quality of cardiac care they provided for different groups in their community.

Before the program started, U Miss told us that their community contained negligible numbers of Spanish-speaking patients. As they said to me then, “everyone here is pretty much black or white”. At the time, registration staff was determining a patient’s ethnicity by eye-balling them. (You, you look white, so let’s mark that down…or let’s just leave the field empty because it’s not important anyway).

It could be worse, another one of our hospitals was determining race by accent over the phone for patients pre-registering before elective admissions.

But under Expecting Success, U Miss implemented a framework to collect patient race, ethnicity and language data systematically and to look at their data and take action.

And what they found in Mississippi was surprising. A hospital that thought they had no Spanish speaking patients actually found that they were registering 600 of these patients a month! Which ain’t small potatoes.

This shed light on a part of their community and hospital they simply did not know existed. They didn’t know what they weren’t measuring. And that’s what information in health care is all about – it’s about understanding your patients and their needs. Otherwise, too many are left behind. U Miss now employs three full-time Spanish interpreters. Before there were none. And they switched vendors to ensure that their interpreter phone system was more tailored to their community’s language needs.

Last month, the Institute of Medicine released a report that called race, ethnicity and language data collection a “fundamental step” toward identifying at-risk populations.

The report states it clearly... “Although the collection of race, ethnicity and language data does not necessarily result in actions that will reduce disparities and improve care, the absence of the data guarantees that none of that will occur”.

Once you put in the pretty simple systems to collect this information, you have a pretty powerful tool that you can use to analyze every service line, and then you can start to make real changes that will improve your hospital and improve the lives of your patients.

So here is an example. Unplanned rehospitalizations are on everyone’s mind these days. They are a symptom of a dysfunctional system and are now on the radar screen of government policy makers. Too many patients with chronic disease are repeatedly hospitalized, when good community management would have prevented such events. It is expensive and harmful. Hospitals are now scrambling to bring readmission rates down for reasons driven by mission and dollars.

[Slide #4]

Here is one large hospital in our collaborative. What we found was

a strong relationship between a heart failure patient’s race and the likelihood they are readmitted to a hospital 30 days after discharge. Actually, no matter how you sliced it, blacks with heart failure were 6 to 8 times more likely to be readmitted. Without the tools of collecting accurate patient race data, they never would have known this. And the good news is that they are now taking steps to try to be a part of the solution to this problem, with electronic information exchange with primary care offices, and stepped up patient education efforts.

In El Paso, Texas the Del Sol Medical Center developed a one-page paper form to consolidate and streamline discharge and prescription instructions for patients. This simple form has allowed them to consistently reach 100 percent discharge measure compliance, reducing documentation errors and providing patients with better discharge instructions. Sinai-Grace Hospital in Detroit did something very similar, and experienced a significant jump in compliance and continues to improve to this day.

[Slide #5]

You have to see it to believe it. This graph shows how one of our hospitals (in an area with large numbers of Hispanic patients) was able to close the gap in providing heart failure patients with discharge instructions. You can see that in the beginning, Hispanic patients were much less likely than non-Hispanic patients to receive this information. The hospital was shocked by this gap, which was statistically significant. But after changes to their processes, Hospital Y was able to close the gap

This slide also shows something else. Most of the things our Expecting Success hospitals did helped all their patients. They used evidence based guidelines, like those developed by the American College of Cardiology and American Heart Association to not just end disparities, but to try to get everyone to perfect care. You can see that here as performance for all patients surged: High quality equitable care means we strive for perfection for EVERYONE.

Now making change is not always easy. It takes patience, persistence and a strategy. One of the things we knew we had to do was explain to patients, caregivers and entire communities why we were asking people about their ethnicity or language. Given the history of race in this nation, people are understandably nervous about why these questions are being asked.

[Slide #6]

Here’s a poster from a campaign that our hospitals used to promote understanding about race, ethnicity and language data collection in their organizations. This poster can be customized with a hospital logo and posted at gathering places like the registration desk, waiting area and cafeteria. This is just a small token from a big effort in those organizations. But it’s a symbol of a major shift in approach from the ground level to the C-suite. And it sums it up:

We ask because we care…We ask because you matter.

Interventions like the ones I’ve mentioned can be found in detail in the Expecting Success toolkit on the Robert Wood Johnson Foundation website. Along with each is an example of a tool, a template a checklist, or another resource the pioneering hospital has shared.

Today, in Aligning Forces, we continue our work in supporting hospital quality and eliminating disparities. We just announced in late August that three hospitals in this area -- Erie County Medical Center, Buffalo General Hospital and Millard Fillmore Gates Hospital of the Kaleida Health System-- have been selected to participate in the Aligning Forces Equity Collaborative, which builds on this work. It aims to improve quality and transitions for patients with heart attack and heart failure while reducing racial and ethnic disparities. As in Expecting Success, hospitals in the collaborative will standardize the collection of patient race, ethnicity and language data across the board, and use this information to identify and address gaps wherever they may be found. But this also means that a critical mass of major hospitals is working on these issues in one community:……… here!! I am not sure this has ever happened before anywhere in America. Through its hospitals, Western New York is making a commitment to high quality, equitable care for all. In that, I know they will find partners in many other parts of this health system. So…..