From the Director

Expecting Success: Developing Solutions to Eliminate Disparities

Five years ago, the Institute of Medicine issued a sobering report on the quality of American health care. The report called the difference between the quality of care patients could receive and the quality of care they actually receive "not just a gap, but a chasm." While progress has been made since then, when it comes to tackling the issue of equity in care, hard work awaits us.

Within a relatively short period of time, about half of America's population will be non-white. Despite this reality, our health care system still provides poorer quality care to patients who are Hispanic, black or don't speak English. We might like to think otherwise, but the evidence overwhelmingly proves it.

Pointing fingers at reasons why disparities exist doesn't help solve the problem. We've inherited the legacy of a system none of us designed, and we certainly don't need to defend. But we do need to fix it. It is past the time for theoretical discussions about racial and ethnic disparities, and high time for practical solutions to close the gaps. If we want quality health care in America, assessing and ensuring equity must now be front and center.

That's why the timing is right for Expecting Success: Excellence in Cardiac Care, a national program to reduce racial and ethnic disparities in American health care. Through this initiative, a Learning Network of 10 hospitals will identify and test quality improvement strategies across the continuum of cardiac care. The participating hospitals all have large minority patient populations, treat many cardiac patients and share a proven track record of effectively improving the care of their patients. These hospitals have come forward as leaders. This periodic newsletter will bring you real, tested tools and strategies being piloted at the Expecting Success hospitals.

Why Cardiac Care?

Expecting Success chose to focus on cardiac care for four reasons:

• There is overwhelming evidence of disparities in the quality of cardiac care that African Americans and Hispanics receive.
• Treatment of cardiovascular diseases dominates U.S. health care, and the toll that heart disease takes on African Americans and Hispanics is particularly high.
• The recommended standard of care for cardiac patients is well established.
• Measures to determine whether patients are receiving the right treatment are clear and in use every day in America's hospitals.

Starting With Quality Data

In my discussions with physicians and hospital leaders across America, I am impressed by their heartfelt commitment to doing the right thing for their patients. At the same time, I see a troubling reluctance to consider their patients' race, ethnicity or language in relation to the quality of care their institution provides. We all want to think that all patients are treated the same. But if we aren't brave enough to gather data and look at the evidence in our own hospitals, we will never know if that is really the case . . . and if we need to take action.

Of the 122 hospitals that applied to participate in Expecting Success, we think only a handful were already asking patients their race and ethnicity. Even fewer used that information to look at the quality of care their patients received. Either they haven't thought of it, or maybe they are afraid of what the results might show. But this issue requires leadership, not fear.

Expecting Success is helping hospitals collect uniform data in order to identify gaps in care and make changes that will result in reduced disparities and higher quality of care for everyone. But the first and most-critical step is gathering data based on patient race, ethnicity and primary language in order to assess the situation with honesty and facts.

Building Quality into In-Patient and Out-Patient Systems

As data is gathered and assessed, the Expecting Success hospitals are working to make sure every cardiac patient consistently gets the recommended evidence-based care for heart attacks or heart failure.

Our hospitals are working with their nurses and doctors to implement standard order sets, create documentation systems to ensure that discharge instructions are given, design approaches for transitional care to outpatient settings and do many other things so that patients consistently receive the right care. And if they do not, they are analyzing precisely what failed. It requires a team approach – and a solid commitment from the top – to identify where proven quality interventions are being missed, and to redesign systems to ensure that the standard of care is followed.

The same attention is being given to the outpatient arena. While some disparities exist in inpatient care, the quality of care after hospital discharge for patients of different races and ethnicities can be dramatically different, and is clearly outside of a hospital's complete control. Expecting Success is working with providers and clinics in the 10 hospital communities to better manage cardiac patients after they leave the hospital, giving them tools and resources to help their patients prevent unnecessary readmissions and emergency department visits.

A Call to All of Us

While much of the learning from Expecting Success will be generated at the 10 hospitals, we all play a role in reducing racial and ethnic disparities in cardiac care.

Every hospital in America needs to start a discussion of these issues that will lead to action in their institutions. I am more convinced than ever that the most important component for success is the strong commitment of top management. I mean real commitment, with action – walking around the hospital and talking with patients, nurses and doctors about how care can be improved.

Success requires an exploration into whether disparities exist in a given hospital and the courage to address the findings. It requires knowing exactly who the hospital's patients are and identifying whether these patients receive the same care regardless of color or language. It requires a thorough examination of hospital processes to determine where proven, effective care is being rendered, and to whom.

I invite you to follow our progress. Working together, we can help bring forth a new health care system that works for all Americans.

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Bruce Siegel, M.D., M.P.H. is director of the Expecting Success program. He is also a research professor in the department of Health Policy at The George Washington University School of Public Health and Health Services. Siegel has served as New Jersey commissioner of health, president of the New York City Health and Hospitals Corporation and president of Tampa General Healthcare.

 

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