Tools for Measuring and Monitoring Webex Slide deck …€¦ · · 2015-12-30Tools for Measuring and Monitoring Equity in ... • Interpretation ... W d thi th h d t ll ti d l iWe

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Tools for Measuring and MonitoringTools for Measuring and Monitoring Equity in Quality: The Hospital

Perspective

Thursday, January 27, 20113:00-4:30pm EST2:00-3:30pm CST

This web seminar will begin momentarily.This web seminar will begin momentarily.

2:00-3:30pm CST1:00-2:30pm MST 12:00-1:30pm PST

Tools for Measuring and Monitoring Equity in Quality: The Hospital PerspectiveQuality: The Hospital Perspective

Susana Rinderle, MAManager, Diversity, Equity & Inclusion

(DEI) at University of New Mexico Hospitals,

Albuquerque, NM

James Walton, DO, MBAVice President and Chief

Health Equity Officer, Baylor Health Care System, Dallas, TX

Sarah Rafton, MSWDirector, Center for Diversity and Health

Equity, Seattle Children’s Hospital,

Seattle, WA

Joseph R. Betancourt, MD, MPH

Director, The Disparities Solutions Center at MGH

Moderator

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Diversity, Equity & Inclusion (DEI)Diversity, Equity & Inclusion (DEI)at UNM Hospitals: at UNM Hospitals:

Tools for Measuring & Monitoring EquityTools for Measuring & Monitoring EquityTools for Measuring & Monitoring EquityTools for Measuring & Monitoring Equity

Susana Rinderle, M.A.Manager ~ Diversity, Equity & Inclusion

University of New Mexico Hospitals

January 27, 2011

UNM Hospitals

• Only public and only teaching hospital of note in N.M.– One of only 30 hospitals nationwide who are both public safety net

and teaching/academicand teaching/academic

• Only Level I Trauma Center in the region

• Only emergency adult psychiatric services

• 619 beds: 5 hospitals, 48 clinics (22 offsite)

• Payer mix: 47% Medicare/Medicaid; 17.3% uncompensated

• Employees: 5900p y

• Providers: 579 faculty, 116 midlevels

• Outpatient visits: 492,000

• Inpatient days: 180,000

• Budget: $705 million

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New Mexico• Population: nearly 2 million• State with fourth highest percentage of “frontierState with fourth highest percentage of frontier

lands”• One of only two states in the U.S. that have always

been “majority-minority”• The only majority Hispanic state in the U.S. at 45.6%

(California and Texas follow behind at 37%)• State with second highest percentage of Native

Americans (fifth highest total number)• The state with the second highest percentage of

residents that speak a language other than English at home, at 36.5%

Source: Census Bureau

Diversity, Equity & Inclusion • Interpretation – since 2003

• 16% of patients are LEP18 f ll ti i t t (14 S i h 3 Vi t• 18 full time interpreters (14 Spanish, 3 Vietnamese, 1 Navajo), 1 educator, 2 admin support staff• Only in-house interpreter dept. in state

• 130 dual role interpreters in 9 languages• Video interpreting• Pacific Interpreters 24-hour phone line

• Participation in the Disparities Solutions CenterParticipation in the Disparities Solutions Center Disparities Leadership Program, third cohort 2009-2010

• Office of DEI created October 2010

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What is DEI?

The UNMH Office of Diversity, Equity & Inclusion l d th ff t t k th t UNMHleads the effort to make sure that every UNMH patient receives the safest, most effective, most

sensitive medical care possible, regardless of the patient’s race, ethnicity, or any other group identity.

W d thi th h d t ll ti d l iWe do this through data collection and analysis; community collaboration; cultural “competence”

training, education and consulting; and process improvement.

How does DEI do these things?

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Diversity is a driver of Diversity is a driver of qualityquality

QU

ALIT

Y DIS

PA

RIT

IESCOMPLIANCE

COMMUNITY

COMPETENCE

CARE

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2010: “REALS” data

RaceRace

Ethnicity

Age

Language (primary oral)

SSex

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Collection and use of REALS

• 100% electronic medical record (EMR)• Outpatient

• Self-reported on a form at registration and data entered into EMR by staff

• Inpatient• Same self-reporting process at all points of p g p p

entry (ED, admitting)

• Included in unit/department “Operational Plans” effective July 2010

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2011: “SOREAL” data

SeSex

Orientation (sexual orientation/transgender)?

Race

Ethnicity

AAge

Language (primary oral and written)

Initial data indicatorsClinical:

• Mortality• Length of stay (LOS)

R d i i t• Readmission rates• HgA1C levels • Outpatient pneumovax vaccines• Inpatient core measures for pneumonia• Childhood immunizations or asthma• Colorectal cancer screening

Non-clinical:• Employee race ethnicity age sex and (a) job position and (b)• Employee race, ethnicity, age, sex and (a) job position and (b)

organizational level• Employee satisfaction • Patient satisfaction• Patient no-show rates• Patient/family complaints• Self-reported employee/provider awareness, attitudes, beliefs

(pending)

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Primary Spanish-speaking patient satisfaction

88

90

92

78

80

82

84

86

Outpatient

Inpatient

72

74

76

CY

06

Q1

CY

06

Q2

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Q3

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88

90

92

78

80

82

84

86

Outpatient

Inpatient

?

72

74

76

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Q1

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88

90

92

78

80

82

84

86

Outpatient

Inpatient

• Implementation of VIP• 2-TALK with stickers• ILS Educator

72

74

76

CY

06

Q1

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ILS Educator• Vehicle• Phone splitters in clinics• First ILS campaign• ISPEAK cards• Patient initiator cards

Spanish-speaking patient satisfaction survey returns

140

160

180

40

60

80

100

120

140

Outpatient

Inpatient

0

20

40

CY06 Q

1

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2

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Spanish-speaking patient satisfaction survey returns

140

160

180

40

60

80

100

120

140

Outpatient

Inpatient

1.Increase in budget and # sent

2.Clinic campaign

0

20

40

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First equity dashboard

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First equity dashboard

Next steps• Modifications to data fields and collection form

• Separation of race & ethnicityCh t t ib l d li i t i• Changes to tribal and religion categories

• Exploring options for multiracial category• Addition of written language• Adding LGBT information

• Analysis of initial equity dashboard findings• Strategic plan and recommendations toStrategic plan and recommendations to

Competence and Care task forces• Rollout of unit-specific and organization-wide

training, system and process changes, and other interventions

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What questions do you have?

Susana Rinderle, M.A.Susana Rinderle, M.A.Manager, Diversity, Equity & Inclusion (DEI) Chair, Health Literacy Task ForceUNM Hospitals933 Bradbury Drive SE, Suite 3057Albuquerque, NM 87106

tel (505) 272-1698pager (505) 951-3927fax (505) 272-5477http://hospitals.unm.edu/dei/index.shtml

Seattle Children’s

About Us

• Specialty medical center serving Washington, Alaska,

Montana, and Idaho

• 250-bed facility

• 227,901 ambulatory visits in FY 2009

• Medicaid and state-funded health insurance 49% of patients

• Provided over $90 million in uncompensated care in FY 2009

• Culture of Continuous Performance Improvement

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Who do we serve? FY10 Patient Race

Who do we serve? FY10 Patient Ethnicity

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Who do we serve? FY10 Familieswith Limited English Proficiency (LEP)

16% of all families at Seattle Children’s FY10 were LEP

O 1%Other, 1%Telugu, 0%French, 0%Farsi;

Persian, 0%Laotian, 0%Portuguese,

0%Urdu, 0%Tamil, 0%Nepali, 0%Burmese, 0%German, 0%Thai, 0%Mongolian, 0%

Sign-Signing Exact English

SEE, 0%Swahili;

Kiswahili, 0%Hmong, 0%Hebrew, 0%Indonesian,

0%Unknown, 0%Mein, 0%Turkish, 0%Bengali, 0%Bulgarian, 0%Marshallese,

0%

Sign-Signed English/PSE,

0%Samoan, 0%Polish, 0%Bosnian, 0%Panjabi, 0%Ethiopian, 0%Malayalam, 0%Albanian, 0%Soninke, 0%Gujurati, 0%Kannada, 0%Ilocano, 0%

Sign-ASL and Qualified

Deaf Interp, 0%Finnish, 0%Danish, 0%Aramaic, 0%Italian, 0%

Does Not Read, 0%Serbo-

Croatian, 0%Hungarian, 0%Pashto, 0%Mandalesh, 0%Tonga; Nyasa,

0%Dutch, 0%Norwegian, 0%Swedish, 0%Mixteco, 0%Wolof, 0%Kirundi; Rundi, 0%Tibetan, 0%

Chinese, Minnan (inc Taiwanese),

0%Armenian, 0%Czech, 0%Georgian, 0%Oriya, 0%Creole, 0%Greek, 0%

Sign-ASL for Deaf Blind,

0%Afrikaans, 0%Abkhazian; Abkhaz, 0%Quechua, 0%Twi, 0%Lithuanian,

0%Norwegian

Bokm?/td>, 0%Khmer, 0%Latin, 0%

Native American Indian, 0%

Sogdian, 0%

Russian, 4%

Cantonese, 3%

Amharic, 2%

Korean, 2%

Mandarin, 2%Hindi, 1%Oromo, 1%Other, 1%g Sogdian, 0%

Spanish, 61%

Somali, 7%

Vietnamese, 7%

Seattle Children’s Center for Diversity & Health Equity

• Formed in 2007

• Reports to President and Chief Operating OfficerReports to President and Chief Operating Officer

• 8FTE (6.5 internally funded)

• Internal and external oversight

• Three part function:

– safe and effective care for all patients

– community outreach and engagement

– workforce diversity and professional development

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Measuring Equity

Keys to success

• Self-identified race ethnicity and language collectionSelf identified race, ethnicity and language collection is essential foundation

• Partner with your registration staff – Educate: how and why– Empower– Treat them like gold!– Ongoing QA processes

100%

Would have liked more involvement in decision making (Inpatient)

Measuring Equity: Family Experience Survey

40%

50%

60%

70%

80%

90%

%

2008

2009

2010

0%

10%

20%

30%

White Non-White Spanish Speaking

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100%

Had important questions about child’s treatment wanted to discuss but did not (Ambulatory)


40%

50%

60%

70%

80%

90%

2008

2009

2010

0%

10%

20%

30%

White Non-White Spanish Speaking

2010


What have we accomplished?

• Equity included in hospital quality dashboard• Equity included in hospital quality dashboard

• Hospital awareness of disparities

• Hospital support and significant resources dedicated to equity

St ff d f lt i t t i i i i t ti• Staff and faculty interest in improving interactions across culture

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What are limitations?

• Mailed home 60+ question survey• Mailed home 60+ question survey

• Not a QI tool

• Our hospital focuses on individual survey questions, but the instrument was designed and validated for “dimensions of care” – multiple questions reflecting a patient’s experience within a domain of care – such as access, partnership, continuity, etc.

• What are effective interventions to impact this satisfaction?

Patient Navigator Program: Improving Satisfaction

Patient navigation is an intervention to improve satisfaction

• Culturally congruent patient navigators who are also• Culturally congruent patient navigators who are also certified medical interpreters

• Teach immigrant parents to effectively use health care system for chronic and complex pediatric disease

• Coach and empower parents to participate in care

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Patient Navigator Program: Improving Satisfaction

25%

30%

10%

15%

20%

English Proficient

Spanish: No Navigator

Spanish: With Navigator

0%

5%

0%

Access to Care Partnership Between Family and Clinician

Continuity of Care

Measuring Equity: Expanding the Scope

Evaluating hospital clinical and safety metrics for equity

• Blood Stream Infections• Blood Stream Infections

• Time to Emergency Department Physician

• Pain Management

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Measuring Equity: “Peeling an onion”

Blood Stream Infections (BSI’s)

I. BSI demographic evaluation initially indicates disproportionateI. BSI demographic evaluation initially indicates disproportionate rates for Latino

II. Further evaluation by clinical areas at high risk for BSI (Hem/Onc diagnoses, N=808; dialysis N=208) and by families’ residential zip codes.

III. Hem/Onc and zip code evaluation finds ethnic disparity does not exist

• More Latino patients come from Central and Eastern Washington where there is no competing children’s hospital.

IV. Dialysis evaluation underway for chronic dialysis patients

Measuring Equity: “Peeling an Onion”

Time to Emergency Department MDMedian time to MD,patients admitted to

Median time to MD, patients discharged topatients admitted to

hospitalpatients discharged to home

English Proficient 23 40

Limited English Proficient 24 44

Non‐Hispanic 23 40

Hispanic 23 45

White 23 40

Observe concerning differences in time to MD for specific languages:• Somali patients admitted• Russian patients discharged to home

Currently underway: stratification by acuity

Non‐White 23 43

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Measuring Equity: “Peeling an onion”

Pain Management study

• Center supports faculty evaluation of association between E li h P fi i d d f i t dEnglish Proficiency and adequacy of pain assessment and treatment (Jimenez et al, J. Pain, accepted 2011.)

• Found LEP families received average of 1.5 medical interpretations per day.

• No significant differences found in median number of pain assessments per day or median pain scores.

• Further investigation and larger sample needed to evaluate• Further investigation and larger sample needed to evaluate possible differences in opioid analgesic prescribing (p=0.07).

• Additional next steps: focus groups homogeneous by language, race, ethnicity to determine cultural differences in the expectations of pain management.

Health Equity Improvement: The Baylor Health Care SystemThe Baylor Health Care System Vision and Experience

Jim Walton, DO, MBA Vice President & Chief Health Equity Officer

Baylor Health Care SystemDallas, Texas

“Tools for Measuring and Monitoring Equity in Quality: The Hospital Perspective”

January 27, 2-3:30 pm CST

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Baylor Health Care System

• North Texas integrated health care system:

– 24 owned, leased, affiliated and short-stay hospitals , , y p

– 120+ primary care, specialty care, and senior health centers

– 17 ambulatory surgery centers

– 450+ employed physicians in the BHCS affiliated physician network, HealthTexas

• 20,000+ employees

• ~127 000 inpatient admissions annually

©2009 Baylor Health Care System

3/4/05 This is a test footer. 4343

• ~127,000 inpatient admissions annually

• >$3.8B net operating revenue (FY09)

Community vs. BHSC HospitalInpatient Race Distribution

Black inpatient use higher than Black population



White inpatient use higher than White population

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Community vs. BHSC Hospital Inpatient Ethnicity Distribution

Hispanic inpatient use lower than Hispanic population



Office of Health Equity

• Office of Health Equity (OHE) developed in 2006

T d i ti i h lth• To reduce variation in health care access, care delivery and health outcomes due to:

• Race and ethnicity

• Income and education (i.e., socioeconomic status)

• Age

G d



• Gender

• Other personal characteristics (e.g., primary language skills)

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• Design and implement an annual “BHCS Health Equity Performance Analysis” (HEPA) & Report:

Office of Health Equity: Goals

Performance Analysis (HEPA) & Report:

Quality of Care measures (Core Measures)

Experience of Care measures (Satisfaction)

Outcome measures (Mortality & Readmission)

• Utilize Health Equity Performance Report as a tool to focus



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resources and efforts to reduce inequalities and improve quality

BHCS Analysis Methodology

For each equity measure: Patient population broken down into dichotomous Patient population broken down into dichotomous

variables • Race: White vs. Non-White

• Ethnicity: Hispanic vs. Non-Hispanic

• SES Proxy: Commercially Insured vs. Self-Pay/ Medicaid

Percentages of eligible patients calculated, and the differences between each dichotomous variable are


3/4/05 This is a test footer.

differences between each dichotomous variable are calculated

• Identify dichotomous variable differences that are statistically significant (p<=.05)

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BHCS Health Equity PerformanceAnalysis - Dashboard

Baylor Health Care System - FY-10 Health Equity Performance Dashboard

Metric WHITE NON-WHITEEQUITY OF

CARE NON-HISPANIC HISPANIC

EQUITY OF CARE

AMI perfect care bundle (%) 97.9 97.4 = 97.8 98.1 =

HF perfect care bundle (%) 96 94.1 Favors White 95.5 93.9 =

PNE perfect care bundle (%) 92.1 91.8 = 91.9 92 =

SCIP perfect care bundle (%) 94.5 94.5 = 94.6 94 =



Inpatient overall satisfaction mean score

88.1 87.4 Favors White 87.9 88.9 Favors Hispanic

Emergency Department overall satisfaction mean score

87.5 84.2 Favors White 87.1 84.3Favors Non-

Hispanic

AMI=Acute Myocardial Infarction; HF=Heart Failure; PNE=Pneumonia; SCIP=Surgical Complication Infection Prevention

Health Equity Performance:ED Patient Satisfaction-Race



Persisting Racial

Inequity Observed

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Health Equity Performance:ED Patient Satisfaction-Race

Baylor Hospitals

f iperforming worse than average



BHCS Health Equity Improvement Strategy

Establish Pilot intervention within 2 facilities Identify specific satisfaction survey questions

where race/ethnicity differences are magnified Develop local intervention team Review available literature to support evidence-based

intervention*

Establish new process sensitive metrics



Establish new process-sensitive metrics Collection of Health care language preference Use of Language lines &/or translators

*Hispanic satisfaction rating of health care quality compared to outcomes???????

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Health Equity PerformanceDiabetes Care Management-Ethnicity


3/4/05 This is a test footer. 5310 % or more difference between Historically Advantaged and Disadvantaged patient populations observed in achievement of HgA1c=<7. (p=<0.05). 11 Private Clinics‐HealthTexas Provider Network

BHCS Health Equity Improvement Strategy

Establish Pilot intervention within 4 Clinics– Export tactics identified in local best practice –

Diabetes Equity Project• 4 private practice clinics within close proximity to culturally-

sensitive Diabetes Health Promoters • Available to 246 of 475 (52%) Hispanic patients from 11

clinics

Develop local intervention team



Develop local intervention team Review available literature to support evidence-based

intervention*

*Review of Literature for CHW-led Diabetes Care improvement project??????

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Health Equity PerformanceDiabetes Care Management



Minnesota Community Measurement and Minnesota Department of Health. 55.0% (A1c < 7) 2009 data - Includes patients from 1/1/2008 through 12/31/2009 with two or more visits coded with a diabetes ICD-9 code, and has been seen within 7/1/2008 through 12/31/2009 once regardless of any diagnosis code . Measured annually. http://www.health.state.mn.us/diabetes/pdf/FactSheet2010.pdf.

HealthTexas Provider Network Decision Support EHR Audit Report Dashboard. Percentage of Patients with A1c Control. Includes patients with two or more patient visits at least 7 days apart. Measured every six months through June 2010, then quarterly.

Health Equity improvement is a shared Baylor

Quality performance strategy

Conclusions

Module 3:Health Equity Performance Improvement Exercise

Quality performance strategy

Hospital & Ambulatory Care health disparities

exist as do inequities in health care access

Improving Health Equity is consistent with the

Baylor mission



Baylor mission

Best practices exists and should be piloted

before broad dissemination

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Question and Answer PeriodQuestion and Answer Period

Tools for Measuring and Monitoring Equity in Quality: The Hospital PerspectiveQuality: The Hospital Perspective

Susana Rinderle, MAManager, Diversity, Equity & Inclusion

(DEI) at University of New Mexico Hospitals,

Albuquerque, NM

James Walton, DO, MBAVice President and Chief

Health Equity Officer, Baylor Health Care System, Dallas, TX

Sarah Rafton, MSWDirector, Center for Diversity and Health

Equity, Seattle Children’s Hospital,

Seattle, WA

Joseph R. Betancourt, MD, MPH

Director, The Disparities Solutions Center at MGH

Moderator

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For more information about

the Disparities Leadership Program

and current application deadlines

www.mghdisparitiessolutions.org

or

http://www2.massgeneral.org/disparitiessolutions/dlprogram.html

Thank you for your participation.

Documents

Tools for Measuring and Monitoring Webex Slide deck …€¦ · · 2015-12-30Tools for Measuring and Monitoring Equity in ... • Interpretation ... W d thi th h d t ll ti d l iWe