With national conversations about racial inequality snowballing in recent years, healthcare leaders have been forced to re-examine and address care inequity.
The emergence of COVID-19 further showcased the need for healing divides, with the danger of not understanding or prioritizing the needs of underserved populations becoming more apparent. Some communities have been hesitant to get vaccinated, reflecting mistrust driven by historical mistreatment or misinformation campaigns targeted at vulnerable populations. Furthermore, even as intention to seek vaccination rose across groups, gaps in perceived ability to access vaccines between individuals who identify as White and those who identify as Black or African American expanded 4.5% between December 2020 and March 2021, showing a troubling trend for equal access to immunization.
Institutions themselves are prioritizing the creation of more equitable and inclusive work settings. The latest data on diversity and equity shows that institutions with robust diversity, equity, and inclusion (DEI) focuses are less likely to lose talented team members during these stressful times. Addressing equity gaps in the workplace is not only the right thing to do, but it also reinforces hospital teams and reduces turnover.
Committing to and implementing strategies for DEI are also vital for reducing bias in the delivery of patient care. Understanding the varying health and systemic challenges of different demographics improves efforts to serve populations in an equitable way and develop treatment plans conducive to individual identity.
A recent Press Ganey study reflecting 2020’s patterns in patient perceptions of care within the inpatient (1.6 million responses), emergency department (1.2 million responses), and medical practice (6.2 million responses) settings assessed health disparities by race and ethnicity. These findings, representing more than 2,000 hospitals, compel leaders to delve into specific metrics describing how patients interact with healthcare systems to truly understand how different communities experience care. This, in turn, can shed light on how to best treat all patients.
THINK BEYOND GLOBAL MEASURES
High-level patient experience indicators help executives and leaders understand sentiment in broad categories, like overall rating of care and likelihood to recommend the hospital (Figure 1). Reviewing disparities between different patient communities with global measures can be a useful starting point for discerning equity gaps. However, to adequately assess performance in DEI, hospitals must dive deeper and incorporate more specific metrics about how patients experience care and how well their needs are being met.
For instance, when reviewing only global summary measures, such as overall rating or likelihood to recommend, we found little difference between experiences of patients who identify as Black or African American and those who identify as Native American or Alaska Native. Both groups were slightly less likely to rate the hospital as a 9 or 10 (out of 10) and less likely to recommend their hospital. However, looking at more specific questions related to healthcare competencies—like caregiver behaviors and team dynamics—identified important nuances. Black or African American patients reported lower scores for fewer measures than Native American or Alaska Native populations (Figure 2), but the disparity in scores was larger (i.e., more negative) for the Black or African American community.
Next step: Go beyond segmenting global outcomes or single metrics to understand the differences in experiences across multiple patient needs. Ensure you ask patients about the critical elements of care that drive their overall view of your organization.
Figure 1: Differences in HCAHPS top-box scores—the optimal response to each question—by race and ethnicity. (Each group is compared to the scores for the All-Patient total.)
Figure 2: Comparison of full inpatient experience (top-box scores) across communities. (Each group is compared to the scores for the All-Patient total.)
CONSIDER MEASUREMENT STYLE WHEN ASSESSING DEMOGRAPHIC RESULTS
Surveys use varying measurement styles to elicit responses and generate different results. For instance, CAHPS tools ask patients to report how often something occurred (Never, Sometimes, Usually, Always) whereas Press Ganey surveys ask patients to evaluate how well care met their needs (Very Poor, Poor, Fair, Good, Very Good). Our analysis revealed that evaluative measures identify greater disparities than frequency-based measures.
For example, HCAHPS inpatient surveys generally identified fewer opportunities to address disparities for racial and ethnic communities. Across the 19 individual HCAHPS measures, only the group of Native American or Alaska Native patients reported worse experiences for more than half of the 19 HCAHPS measures. However, with the addition of Press Ganey’s 17 evaluative measures we find that Black or African American and Asian patients also report lower top-box scores for more than half of the total question set.
Next step: Use measures that go beyond the minimum scope of regulatory requirements to generate more evaluative responses reflecting patients’ full experiences.
FACTOR IN CLINICAL CARE TYPE TO IDENTIFY DISPARITIES
Another important element to incorporate when reviewing results for equity gaps is clinical care type. Further segmenting patient experience by different clinical needs can reveal unique disparities among demographics.
For instance, when looking across all inpatient responses we find that Black or African American patients report worse experiences for 67% of the survey measures. When we further segment by clinical service line (medical, surgical, maternity) we find that the patterns for medical and surgical patients look similar whereas patterns for maternity show greater need for improvement. Maternity patients who identify as Black or African American report worse experiences across 97% of the measures asked across HCAHPS and Press Ganey inpatient survey questions.
Next step: Analyze disparities within clinical care type to help accurately assess opportunities for improvement in specific departments or for specific communities.
ANALYZE CARE SETTINGS TO REVEAL EQUITY GAPS
When reviewing inpatient feedback, experience varies within racial and ethnic groups. All demographics have some measures that score more favorably and some that score less favorably than the All-Patient group. When assessing disparity gaps in patient perceptions for ambulatory settings, a drastically different pattern emerges.
For example, when looking at the emergency department and the medical practice setting, patients who identify as White tend to report more positive experiences across all measures while patients in non-White racial or ethnic groups report more negative experiences.
Next step: Go beyond the inpatient setting and assess disparities in scores within each care setting.
REMEMBER THAT NUMBERS ARE JUST THE BEGINNING
Though reviewing the data is an important place to start when organization leaders tackle the complex challenge of promoting health equity, information alone won’t fix these gaps. It’s vital that leaders understand how unconscious bias, structural racism, social determinants, and historic policies have contributed to inequitable health, access, care delivery, and experiences. Institutions need to share data transparently while also creating greater cultural humility and awareness regarding the lived experiences of their patients.
Beyond quantitative results, organizations committed to equity can leverage comments to hear the voice of their patient communities. Qualitative feedback from patients can provide valuable insights that may be left out of standard survey scopes and illuminate areas for improvement in healthcare equity that would have otherwise been missed.
Next step: Use segmented patient experience data to understand how different communities experience care within your organization and partner with your DEI leaders to identify next steps in cultural change to address identified needs.
All healthcare institutions benefit from prioritizing diversity, equity, and inclusion. Having truthful conversations about care inequities can be uncomfortable at first. However, laying the initial groundwork to identify the right metrics and factors to analyze and consider will pay dividends in the long run and position organizations as strong partners in the healthcare journeys of all patients.
Speak with one of our experts to find out more about how your organization can use continuous listening to improve its diversity, equity, and inclusion efforts. Join Press Ganey’s Equity Partnership for access to exclusive DEI resources.