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New hospital guide pushes plan to address disparities

Eduardo A. de Oliveira

A new guide created by the Disparities Solutions Center at Massachusetts General Hospital (MGH) in Boston discusses the issue of health disparities head on and from the top down.

Launched on Dec. 18, 2008, at a Web seminar for 250 hospital presidents and CEOs, “Improving Quality and Achieving Equity: A Guide for Hospital Leaders” is aimed at changing habits at the top of the medical ladder.

“A lot of leaders don’t even believe that there’s [a] difference in the quality of care in their hospitals,” said Dr. Joseph Betancourt, director of the Disparities Solutions Center.

Funded by a grant from the Robert Wood Johnson Foundation, the guide already has been downloaded by more than 500 medical professionals across the U.S. and Canada.

For more than a year, a committee of six medical professionals at MGH held extensive conversations with top leaders of 10 U.S. hospitals. The committee later broadened the discussion with four case studies from the Seattle Children’s Hospital in Washington, the Duke University Hospital in North Carolina, and the Baylor Health Care System in Dallas, Texas.

The guide offers an in-depth look at the barriers faced by immigrant patients who “might not trust the hospital or its providers” or “may be afraid to seek care due to language barriers and embarrassment or cultural differences.”

For many CEOs, the guide can represent a comprehensive path to achieving cultural competency because it makes the case that detecting health disparities within their hospital ranks is also a way of “protecting the bottom line.”

In a “5 Stages of Getting Involved in Equity” PowerPoint presentation that Betancourt has used in seminars across the country, he makes it clear that confronting disparities can be a lengthy process.

Similar to the process of dealing with grief, the presentation says that addressing disparities requires experiencing denial, anger, bargaining, depression and acceptance. Hospital officials are encouraged to have a plan to get through these stages; the presentation suggests they “talk about it, think broadly, measure it (WELL), then share, do something about it [and] (repeat).” caught up with Betancourt by phone while he was in San Francisco. He talked about the role of ethnic representation in hospital staff and the guide’s recommendations for hospitals about President-elect Barack Obama’s prospective policies for health care.

How can the guide address issues like racism in hospitals?

Our guide is really meant to convince people of the importance of addressing equity. A lot of leaders don’t even believe that there’s [a] difference in the quality of care in their hospitals.

The first step you take is you show the evidence that proves there is difference in quality and then, for a leader who cares about the budget, the legal environment and medical [environment], you try to make a connection between equity and all the important things that are on the leaders’ radar screen.

We don’t necessary say, “OK, here’s a training guide on how to address racism,” but we try to tell them that equality has an impact on the bottom line, on potential lawsuits, on quality care.

We let the leaders decide what to do, but amongst those efforts might be some training in cultural competency. Our goal with the guide is getting leaders to care about the issue while offering them some tools to address it.

How does the guide address the importance of having ethnic diversity reflected in the medical field?

In the guide, we do talk about the importance of diversity. There are problems that relate to nurses, doctors [and] psychologists, because we have a limited amount of Latinos in the health professions.

Diversity is certainly a big component to solving the major problems. Although we don’t give a plan, we offer a menu of approaches and at the recommendations, we do refer [the leaders] to a lot of links, reports and much more extensive studies.

The Obama transition team is gathering information, some related to disparities, from several communities across the country. Does the guide weigh in about the need for health reform?

The guide does talk about the things that hospital leaders need to be concerned about. For example, the Joint Commission (the body that accredits hospitals) will have accreditation standards on issues related to disparities and cultural competency.

We also let them know that there are certain policies coming down the pipe, like reimbursement policy, and [these policies] are going to be asking more of hospitals.

The Center for Medicare and Medicaid Services reimburses hospitals for Medicare patients. If you have a patient with heart failure who’s discharged and readmitted within 30 days, your reimbursement will be limited. The assumption from the federal government is that you didn’t do a good enough job of making sure they had a smooth transition back into their homes and communities.

And those issues are the ones that disproportionally impact minority patients, and those with limited English proficiency. So what we try to do in the guide is to point CEOs in the direction of oncoming regulations that will certainly be part of Obama’s health care policies.

There are several excellent hospitals in Massachusetts. Do you see them partnering with MGH and adopting the guide?

Sure, local hospitals are already downloading the guide. We’re trying to get the interest of several hospitals across the country.

But collaboration among local hospitals is not unprecedented. We’ve seen that type of partnership with Boston teaching hospitals when the mayor brought them all together. I do see hospital collaboration in the future.

What are the expected results from this guide for patients in the future?

Hopefully patients can expect that when they go to a hospital, no matter what is their background, the hospital will be monitoring to make sure that they can get the same quality care everyone gets.

But more importantly, we hope this guide can generate efforts from hospitals across the country that can help the day-to-day visits with doctors, like helping [patients] to navigate the system, with communication skills, or offering materials they can understand.

The guide can be a concrete plan in setting a whole effort to bridging the gap in hospitals.