TJC: Quality Improvement Should Include Data Analysis on Equitable Care
The CDC reports people from racial and ethnic minority groups are at higher risk of contracting COVID-19 and experiencing worse outcomes.1 The Joint Commission (TJC) calls on hospitals to use data analysis to ensure all patients receive equitable care.
TJC recently issued “Quick Safety 57: Supporting safe, equitable care during the COVID-19 pandemic,” which suggests methods for identifying healthcare disparities and addressing them.2
Over the past year, the COVID-19 pandemic has put a spotlight on the substantial disparities in healthcare that have existed in the United States for many years, says Elizabeth Even, MSN, RN, CEN, an emergency department nurse at Northwestern Memorial Hospital in Chicago and associate director of standards interpretation with TJC.
“We as a country have gone through this pandemic together, and data collection is at an all-time high in many ways and is frequently scrutinized publicly. It is impossible to read a newspaper article or tune into the local news without some kind of COVID-related story,” she says. “Unfortunately, particularly with reported COVID infection rates and deaths and then again with the vaccines, the data are pointing to definite patterns and trends in terms of which ethnic groups and minorities have higher COVID infection rates and death as well as lower vaccination rates when compared to other groups across the country.”
According to the CDC, American Indian and Hispanic/Latino populations are almost three times more likely to contract COVID-19 and close to five times as likely to be hospitalized.1 Race and ethnicity are risk factors for multiple reasons, including underlying medical conditions that are more prevalent in certain ethnicities, as well as other issues, such as socioeconomic status and access to healthcare.
These groups also may be subject to more virus exposure because of their occupation, as many of these vulnerable populations are frontline, essential workers.
History of Addressing Inequities
TJC has been supporting health equity issues for many years with standards and educational resources. For example, in April 2016, TJC issued a Quick Safety focused on implicit bias in healthcare.3 In October 2016, the agency addressed cognitive bias in healthcare.4 Those are in addition to longstanding requirements in standards to address health equity across all of TJC’s healthcare manuals, according to Even.
Even points to a definition of health inequalities from the World Health Organization as health differences that “are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.”5
“The Joint Commission’s vision is that all people always experience the safest, highest-quality, best-value healthcare across all settings. Not only is this the right thing to do, but it is also required by the Civil Rights Act of 1964, which prohibits discrimination on the ground of race, color, or national origin in hospitals and other healthcare organizations that receive federal financial assistance,” Even says. “At the root of healthcare disparities, there are significant systemic barriers, such as poverty, access to affordable healthcare, and mistrust in the medical community, to name a few. Healthcare disparities break down communities and lead to unnecessary pain, suffering, [and] loss.”
Even suggests a resource from the Department of Health and Human Services to address the disparate effect of COVID-19 on African Americans and other racial and ethnic minorities.6
QI Leaders Critical to Process
Quality improvement professionals can play a key role in this effort. “There is a saying that what gets measured gets managed. Quality improvement professionals set the stage for what data are collected, how data collection is prioritized and analyzed, as well as next steps taken based on the analysis,” Even says. “In other words, it’s important to understand who your patients are so you can develop or tailor initiatives to meet the needs of a diverse patient population. Regarding next steps, it is important that leadership is aware of the information collected as they play a key role in quality improvement decisions.”
Regarding data collection, Even offers an example of the TJC African American Heritage Committee hosting an event for Black History Month in which a speaker discussed how the “other” category is difficult when collecting data about race and ethnicity. The category does not give an organization much to go on.
“Now we know that this is a very common category, as it is impossible to have every single option listed on a form. For example, what about biracial and blended individuals? Which box do they check? Both? Several?” Even says. “The point is that organizations should take a detailed look at the population they serve and make their own decisions about race and ethnicity data while keeping in mind the national data used that can serve as the benchmark, one category of which is ‘other.’”
TJC encourages organizations to collect granular ethnicity information if they want to learn more information about their population. For example, if a hospital serves a large Asian population, leaders may want to find more details about how many patients are Japanese, Filipino, and “other” options. “What we are looking to avoid is random data collection without a real plan as to what the issues are or how they will be addressed along with the analysis,” Even says.
There are resources that can aid with improving data collection and training staff on how to do it, from admission to discharge, as well as resources to ensure compliance with law and regulation.7,8
Use Data to Identify Needs
Patient race and ethnicity data can be used to stratify quality measures, to identify potential healthcare disparities, and to develop or tailor initiatives to address those where needed.
For example, if an organization serves a large African American population and hypertension is a common medical condition among patients, leaders may devote more resources toward education and prevention of high blood pressure than an organization that treats a large Asian population and does not see a high prevalence of high blood pressure.
“Perhaps your organization invests in a registered dietician as a resource to your patients, and nutrition counseling is offered to at-risk individuals to hopefully prevent the need for medications or other interventions,” Even says. “In addition, a health system may partner with community and other organizations to support a food co-op to address access to affordable fresh items.”
Access might be an issue for a system’s primarily geriatric population, and administrators are trying to bundle as much care as possible into the same visit and to limit the frequency of off-site referrals. The organization might partner with community programs for drop-off and pick-up programs. Telehealth also has exploded during the COVID-19 pandemic, and communities have partnered with local libraries and other public resources to assist those in need who perhaps do not have a home computer or internet access.
If an organization is not collecting collecting data that allows analysis of diversity issues, it may not fully understand the scope, severity, or the opportunity. On the other hand, a hospital cannot collect data on everything. This is where quality professionals come in.
“Understanding the community you serve as well as the care offered will inform the data to be collected. Distilling down to the race and ethnicity data within a data set may offer additional insights,” Even says. “If an organization knows that 30% of its patients have been diagnosed with hypertension, that is one data point. If they also see that of that 30%, 70% of them are African Americans and 60% of that group are males over 40, now the organization has a much more meaningful place to target when deciding how very precious resources are used moving forward.”
Outcome data can be analyzed to see if goals are met with current initiatives as well as patient satisfaction surveys to further understand the overall feeling of impact.
“Useless data has the real potential to waste time and money, something that obviously no organization is interested in doing,” Even says. “Look for trends in your data. Set meaningful and specific goals as they will set the stage for resource allocation. Organizations can use comprehensive data and the analysis of that data to understand where their biggest opportunities lie, how effective their strategies have been, and ideas for ways to move forward in the coming years.”
- Centers for Disease Control and Prevention. COVID-19 cases, hospitalization, and death by race/ethnicity.
- The Joint Commission. Quick Safety 57: Supporting safe, equitable care during the COVID-19 pandemic. Feb. 8, 2021. http://bit.ly/3q6Z5xW
- The Joint Commission. Quick Safety 23: Implicit bias in health care. April 2016.
- The Joint Commission. Quick Safety 28: Cognitive biases in health care. Oct. 20, 2016.
- Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992;22:429-445.
- U.S. Department of Health and Human Services. HHS initiatives to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities.
- The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Feb. 9, 2011.
- Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated Feb. 12, 2021.
- Elizabeth Even, MSN, RN, CEN, Associate Director, Standards Interpretation, The Joint Commission, Oakbrook Terrace, IL. Email: [email protected].
The COVID-19 pandemic has put a spotlight on the substantial disparities in healthcare that have existed in the United States for many years. The Joint Commission recently issued tips for identifying healthcare disparities and addressing them.
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