Collecting data on diverse communities: Challenges and successes from health plans, hospitals, and health departments

1.) Background
Seattle Children’s is a specialty medical center serving Washington, Alaska, Montana and Idaho. Children’s has 250 inpatient beds and provides about 170,000 ambulatory visits per year. Over the course of Children’s 100-year history, the hospital has provided specialty healthcare, regardless of race, sex, creed, ethnicity, disability, or ability to pay for care. In FY2007, Children’s provided $65 million in under and uncompensated care to children. Over 40% of patients cared for at Children’s are covered by Medicaid or state-funded health insurance. For at about fifteen years, the hospital initiated efforts to improve care for diverse families. For example, in the 1990’s the hospital partnered with a community clinic to establish a bilingual, bicultural social worker for Latino families at the hospital. Children’s diversity committee has been active for over ten years. Children’s has now built on this institutional commitment to establish organization-wide practice and expectations, with the adoption of a Strategic Plan for Diversity and the creation of the Center for Diversity and Health Equity. Children’s is using data to inform where improvements are needed to provide culturally appropriate care for diverse families. Children’s accurately documents self-identified race, ethnicity and language, and has consistent collection rates of 90% for patient race and ethnicity, and 97% for interpreter need. At least thirty-six percent of children served at the hospital are non-white, including 13% Latino or Hispanic, six percent African American, and six percent Asian. About 15% of patient-families served at Children’s are Limited English Proficient, and Children’s provided interpretation in forty-four languages in 2007.
Children’s Diversity Advisory Council, a multidisciplinary committee with senior executive leadership, conducted a strategic planning process that resulted in the Board of Trustees adopting the plan in 2004. The strategic plan emphasizes five goals:

• A diverse workforce that reflects communities served;
• An environment that reflects values of inclusion;
• Providing effective and respectful care compatible with health beliefs, practices and preferred languages of the patients;
• Connections with the community through outreach, community service and employee volunteerism; and
• Fostering work/life balance.

In December 2005, Children’s began to plan a new Center for Diversity and Health Equity. The Center was formally launched in March 2007 and is responsible for stewardship of the Strategic Plan for Diversity, including informing efforts to decrease disparities. Accurate collection of race and ethnicity data is essential to these efforts. The Center currently includes four staff and a faculty leader. The Center reports to the hospital President and Chief Operating Officer.

2.) Innovations and Successes
Race and Ethnicity Collection
In 2005 Children’s established a data collection system to accurately capture patient race and ethnicity based on the Office of Management and Budget standards.  All registration staff were trained to ask families their race and ethnicity.  This data is applied regularly to patient safety indicators and patient satisfaction measures. With accurate race and ethnicity of patients, the Board of Trustees’ Quality Improvement Committee has integrated race and ethnicity into its evaluation of care. Uncovering Satisfaction Disparities
Children’s employs the NRC+Picker family satisfaction survey and has found statistically significant differences in scores between white and non-white racial and ethnic groups. In ambulatory settings, non-white families are less likely than white families to ask important questions about their child’s care. For inpatient care, non-white families feel less involved in decision making than whites. Identifying these differences led to the adoption of goals to reduce disparities. Disparities in family satisfaction are monitored and reported in a transparent and ongoing fashion. Improving satisfaction in the areas of known disparity is a management goal for 2008, included management performance evaluations.

Improvements to Interpreter Services
We have made significant headway in identification of language need and provision of interpreter services. We have established on-line order entry for interpretation, and hospital policy has been changed to require interpretation twice daily for LEP families. We are working to apply provision of language services to our efficacy of care. We have established an accurate, automated report that captures interpreters scheduled and ordered and would like to build upon this system to inform our clinical quality metrics. For example, what is the relationship between interpretation ordered and our provision of quality care for asthma?

Integrating Equity Measurement Hospitalwide
Next, Children's will apply race, ethnicity and language data to hospital goals and metrics. We will apply race, ethnicity and language data to clinical quality metrics such as asthma standard of care, to safety indicators such as blood stream infection rates, and to delivery goals such as no show rates, to examine the equity of care for these variables.

Interventions to Improve Care Children’s Center for Diversity and Health Equity has recently begun a patient navigator program for families at the hospital, including bilingual navigators, and oversight of community-based clinics serving 77% of our target population. Children’s has also begun a cultural consultation committee, to provide providers resources and assistance in real-time. The Center for Diversity and Health Equity will measure if these interventions make improvements in family satisfaction, provider satisfaction, clinical outcomes, and delivery indicators.

3.) Lessons Learned / Challenges Overcome
Strategic visioning and planning can tailor diversity efforts for your organization and build necessary momentum. Children’s Strategic Plan for Diversity has become a guidepost, focusing the hospital’s efforts, to assure prioritization amongst multiple interests, needs, and demands. Successful diversity and equity efforts require buy-in and leadership from the highest levels of the organization. Children’s President and Chief Operating Officer, and Senior Vice President and Chief Nursing Officer sponsor diversity efforts at the hospital. These senior executives and Children’s Chief Medical Officer are committed to the Center for Diversity and Health Equity, and to integrating disparities measurement into all hospital goals.  Evaluating hospital metrics by race, ethnicity, and language is a priority for senior leadership. Accurate collection of self-identified race and ethnicity is essential. Before race and ethnicity data were available, people questioned the need to focus on disparities. A reliable, integrated process to collect patient race and ethnicity is necessary to implementing organizational improvements. Using meaningful data that stakeholders care about can help move equity center-stage at a large organization.

Moving from high-level goals to implementation can be challenging. Focusing on meaningful and measurable change, using quality improvement methods can make seemingly daunting work scalable and rewarding.  Involving multi-disciplinary teams in your efforts, including nurses, physicians, and front-line staff will help toward make meaningful and sustainable change.

It is challenging to move beyond evaluating data to implementing interventions. Once disparities are measured and communicated, establishing targeted interventions in a large medical center is a challenge. Piloting interventions, relying on the expertise of community partners, and building on passion of internal champions can help make efforts viable.