Safety, High Reliability, and Equity Are Intertwined

Added on Jun 25, 2020

equity graphicTo achieve optimal quality, according to the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, care must be safe, timely, efficient, effective, patient-centered, and equitable. The fact that “equitable” was listed last reflects how, even at that early stage, equity was somewhat of a “forgotten” domain. In fact, over the past two decades, equity has been the subject of far less work and attention than the other domains.

Suddenly that has changed. Equity is receiving tremendous attention, having been brought to the forefront by the terrible confluence of the COVID-19 pandemic, which has disproportionately affected the health and financial stability of certain groups, and the video footage of tragedies that highlight the inequities Black and other diverse communities face every day.

The reality we are all recognizing now is that inequity is a type of harm, both for patients and the workforce. Why has it taken us so long to realize this? For many years I worked as a safety officer in a large academic medical center, focusing on improving culture and processes with high reliability concepts. In all that time, the work being done to close gaps in equity of care and health outcomes and to address social determinants of health was separate from the rest of health care quality improvement. The safety team did safety work and the equity team did equity work. We fell in different places in the organizational chart and had different performance goals, so it is not surprising that we never joined forces.

For the past few years, Press Ganey has advanced the understanding that safety, quality, patient-centeredness, and workforce engagement are interconnected. We have been working to break down silos across these domains, and now we have another wall to remove: the one keeping the concept of equity separate from other dimensions of what we consider excellence. We need to bring the equity lens to all the work we are doing to advance quality, safety, engagement, and experience.

To this end, we—as individuals, organizations, and groups of organizations working together—have a lot of learning ahead of us. At Press Ganey, we are evaluating what we can do to help organizations close the equity gap and have drawn the following early conclusions about what is needed.

  • Organizations have to work toward high reliability with a holistic perspective on excellence.This holistic perspective must be one that integrates safety, coordination, technical excellence, empathy, and equity. Excellence cannot be achieved in the absence of any of these.
  • Organizations can only improve what they measure. To capture the data needed to detect and improve inequity, providers must routinely ask patients and the workforce for race and ethnicity data on all data sources. This includes patient experience surveys (quantitative and comment data), engagement surveys, patient safety and quality data (particularly outcomes data and safety reporting data), and patient complaints. Press Ganey can help organizations use these data to perform the stratified analyses necessary to help identify and prioritize inequities.
  • Racism and other forms of inequity must be viewed as important deviations from quality. Inequity can lead to physical harm, or emotional harm, and often both. It can lead to a poor patient experience, diminished staff engagement and resilience, and an increased risk of burnout. To achieve zero harm for patients and our workforces, our equity strategies must focus on both groups and leaders must clearly communicate this aspiration and prioritization across the organization. Once inequities are identified, improvement must occur.
  • Those leading improvement efforts must have a core understanding of the principles of equity. They must know which questions to ask and how to understand and analyze the data. They must also be prepared to execute improvement strategies using high reliability principles, to ensure that the strategies are effective and are truly embedded in the fabric of the organization and do not result in unintended consequences to certain populations. In addition, all staff must have a common language and understanding of equity, systemic racism, and unconscious bias to make progress. Finally, operational processes and human resources practices must include an equity lens in key areas of hiring, retention, policies, procedures, and ongoing support. 

Press Ganey has products and consulting offerings that can help in all four of these areas, including strategy and road map development, training and education for staff and leaders, measurement and analytics, and support for implementing a high reliability operating system and best practices for human resources departments.

High reliability is the foundation for building sustained improvement across numerous domains of quality, including equity. Therefore, leadership commitment to equity as a safety and quality imperative is essential, as is the reliable collection of demographic and other key data to help us understand the inequities that exist in our quality data and work to eliminate them. At Press Ganey, we are committed to achieving zero harm and to ensuring that we incorporate equity as a key domain and use the same reliability methodologies to help achieve it.

Visit our dedicated COVID-19 webpage for additional resources.