乌鸦传媒

Last year marked the 20th anniversary of the publication of two undeniably ground-breaking publications: (IOM, 2000) and (IOM, 2001). It was a perfect time for the National Academy of Medicine (NAM) to convene the leaders of various U.S. healthcare quality organizations for a discussion around important priorities for the healthcare quality movement.

Interestingly, in their recommendations for advancing healthcare quality in the coming 20 years, as "the area of most urgent and cross-cutting concern for the field."

What does health equity have to do with quality?

We've tended to consider health quality and safety strictly in terms of what happens within the healthcare environment – things like providing preventive care (e.g., diabetes and cancer screenings), reducing medical errors, and preventing potentially deadly hospital-acquired infections. But we now know that health quality and safety is influenced to a far greater degree by other factors - the safety of the community in which an individual lives, housing and employment stability, and access to healthy food and healthcare to name a few.

Health equity refers to every individual having a fair and just opportunity to be as healthy as possible. For health equity to exist, obstacles to health – stemming chiefly from poverty and discrimination – must be removed.

Healthcare equity entails providing care that doesn't vary in quality by the personal characteristics of an individual such as race, ethnicity, gender, geographic location, socioeconomic status or other identifiers.

Clearly, we can't expect the healthcare system to address all of these factors single-handedly. But, as noted by the NAM, there are ways in which it can help advance equity within the system (continual improvement in the quality and safety of care) and outside the system (engaging with other sectors to address social needs, establishing and holding itself accountable for a racial equity agenda).

This sounds like a very heavy lift, but a with Komal Bajaj, MD (Chief Quality Officer of NYC Health + Hospitals/Jacobi) on this topic in Modern Healthcare (subscription required) convinced me that health systems can indeed incorporate equity into their work on quality and diagnostic safety.

Bajaj believes that ensuring equitable care is a moral imperative for healthcare entities, payers, and policymakers, and she is heartened by current efforts (e.g., CMS's 2023 quality reporting request for hospitals to include data on social determinants of health). Acknowledging that no single resource or strategy will result in equitable healthcare, she foresees progress in the form of a "tapestry filled with a variety of solutions that place patients and communities at the center ... from design to implementation and assessment."

NYC Health + Hospitals takes a proactive approach to building equity into the system; i.e., prioritizing efforts based on identified disparities, eliminating intervention-generated disparities. Equity is ingrained into event analyses including patient grievances. Importantly, the event reporting system enables staff members to share their perspectives on bias and injustice, thus creating a team culture around equity-related work.

Diagnostic errors are known to disproportionately affect patients of color; misdiagnosis and inappropriate treatment can result from medical bias. Clearly, diagnostic safety contributes significantly to quality and can exacerbate healthcare disparities. When asked about ways in which this issue might be addressed, Bajaj pointed out the innate complexity of the diagnostic process which can require collaboration among multiple clinicians over multiple sites and situations. As a rule, the diagnostic process is also complicated by a level of uncertainty, "and it's challenging to communicate uncertainty sometimes," says Bajaj.

Reflecting on her experience as a healthcare leader and a practicing obstetrician/gynecologist and geneticist, she believes that clinicians can work effectively as individuals to identify and mitigate their own biases. "I have had some major 'aha!' moments over the last decade."

The holiday season seems an ideal time to consider what more we -- as individuals, as healthcare professionals, and as a society -- might be doing to reduce discrimination and foster health equity.

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