2/4/20

For this post, the Department of Quality and Safety asked one of our team members, Karthik Sivashanker, MD, MPH, CPPS, medical director for Quality, Safety, and Equity, to discuss Brigham Health’s focus on equity, how it can be misunderstood, and why it is a critical patient quality and safety issue.

The New Year is a common time for people to pause and consider what’s important to them and where they’d like to be in the future. At Brigham Health, we’re excited to renew our commitment to providing equitable high-quality care to all of our patients for 2020 and beyond. To understand why this is so important, we first need to understand what we mean by equity, and how that ties into the quality and safety of our patients’ care.

We can begin by asking what matters to you as our patient? For most of us, being treated with respect and dignity is high on that list. We might even say that we want to be treated “equally,” no matter our race, religion, language, gender, etc. But is equality really the goal or is it something else?

Here’s an example to help us think through this. Consider this picture of people waiting in line for the bathroom:

Have you seen long lines for the bathroom before? If so, is it usually for the men’s or the women’s bathroom? In general, most of us would say that women’s bathrooms tend to have the longer lines. Have you ever paused to wonder why that might be? Why would we design bathrooms that lead women to wait longer than men? The answer, of course, is that we didn’t. Or at least, we didn’t intentionally design bathrooms in this way. More likely than not, these bathrooms were designed with the assumption that what works for one group will also work for others, resulting in bathrooms that are designed similarly for both.

Are these bathroom designs working well for women? Clearly not. But what about for men?

Before answering, consider men who may be with women waiting in line. Don’t many of them end up waiting as well for their wife, sister, daughter, friend, etc. to finish? What about fathers with babies using bathroom that don’t have changing stations? Or fathers with young daughters who may have to bring their daughters into a bathroom full of men?

Clearly, many bathrooms don’t always work well for men either.

This is a simple example to illustrate a complex point. If we design bathrooms to be “equal,” they may not serve the needs of the diverse people using them. In fact, they may not serve the needs of anyone in the best possible way. We considered men and women, but we can ask the same questions for other groups like transgender people or the disabled. At the end of the day, equal doesn’t mean fair.

Instead, we should be aiming for equity. The goal with equity is to design a system that works well for everybody. This is easier said than done and gets even more complicated when you think about how these ideas apply to health care.

Consider the example of access to routine preventative cancer screenings, like mammograms for breast cancer. Many people don’t have the money, social support, or the other things that are needed to access such care. Although care is equally available to all groups, inequities exist that prevent certain groups from receiving the care they need.

Here at Brigham and Women’s Hospital, we feel strongly that every single patient should get the very best and safest care (i.e., equitable care). This does not mean treating every patient the same, because who we are matters. What works for one patient may not work for another. With this in mind, we are taking a new approach that considers equity at every step of the way, starting with patient safety and quality.

When a patient suffers an avoidable harm, we try to understand what happened. This means getting at the “root” of the problem using different tools. Instead of re-inventing the wheel when it comes to equity, the idea is to take the same “root cause” approach, and to add an equity lens. Sometimes, this is as simple as asking the question: “Was there an inequity that played a role in this patient not receiving safe and excellent care?”

An article (and Podcast) in the New England Journal of Medicine this month by Dr. Karthik Sivashanker highlights this approach and explains a new way of thinking about patient safety, quality, and equity that should improve the care for all our patients and families. You can learn more by reading the article here.