While both safety and health equity have been individually and extensively studied, the intersection between patient safety and health equity has not received the same attention. The small body of research on this intersection has revealed race differences in patient safety incidence and reporting. Studies have that Black patients consistently experience higher rates of hospital-acquired illnesses and injuries during surgical procedures than White patients. Other studies examined voluntary patient safety event reports, which are descriptions of safety issues directly from health care staff; These studies revealed differences in event reporting by patient race, with fewer reports for Black patients. Further, voluntary safety event reporting differences were found by race when compared to automated chart abstraction, an algorithm-based approach for identifying safety issues directly from the electronic health record; this suggests racial reporting bias.
Applying an equity lens to patient safety could address avoidable harm to certain race/ethnics that would otherwise remain hidden. Likewise, knowledge gained from patient safety can be useful in understanding and addressing inequities to improve care. While research on the intersection of patient safety and health equity is advancing, a major limitation is the lack of data sources that contain both patient safety and race/ethnicity information. Accordingly, studying how race/ethnicity affects patient safety is generally limited to small datasets sourced from a few health care facilities, hindering understanding of the full scope and scale of the problem. Without enriching current patient safety data sources with race/ethnicity information, our ability to uncover, understand, and address race/ethnicity inequities in patient safety will remain hampered and may disproportionately subject certain race/ethnic groups to avoidable harm.
We propose changes to existing policies for soliciting data on patient safety to ensure inclusion of race/ethnicity information. These policy changes are focused on improvements to patient satisfaction surveys, patient safety event reports collected by health care organizations, and Patient Safety Organization (PSO) data collection and analysis. These changes will enable the types of large-scale analyzes required to fully understand the extent of this problem, develop necessary interventions, and measure outcomes.
Three Policy Changes To Improve The Collection Of Race/Ethnicity Information Related To Patient Safety
Require Collection Of Patient Perceptions Of Racial/Ethnic Bias And Patient Safety Through Existing Surveys
Challenge: Patients who experience racial/ethnic bias as a contributing factor to patient safety events may not have a process for reporting these issues. In addition, health care organizations may not proactively ask patients about these experiences. Accordingly, racial/ethnic bias may not be addressed by organizational leaders, state and federal authorities, or other stakeholders.
Opportunity: The Hospital Consumer Assessment of Health care Providers and Systems (HCAHPS) is a survey that asks patients about their hospital stay to measure satisfaction and is required by the Centers for Medicare and Medicaid Services (CMS). This survey, developed and tested by the Agency for Health care Research and Quality (AHRQ), could be expanded with specific questions about whether patients perceived racial/ethnic bias during their hospital stay. AHRQ could lead the development and validation of new questions focused on racial/ethnic bias and patient safety. Once developed and validated, these questions could be adopted by CMS as part of the HCAHPS.
Potential Impact: Including questions about racial/ethnic bias and patient safety in the HCAHPS survey would shed light on which hospitals nationally are associated with greater perceptions of racial/ethnic bias contributing to patient safety. This information could inform efforts to understand why patients have these perceptions and how to address these issues.
Require Health Care Facilities To Collect Patient Race/Ethnicity Information As Part Of Their Safety Improvement Efforts
Challenge: Most health care facilities collect patient safety event reports or other data that describe patient safety issues. However, these reports generally do not include patient race/ethnicity, which makes it difficult to identify race/ethnic differences in the reporting and rate of safety issues.
Opportunity: The Joint Commission’s Process Improvement standard requires hospitals to collect patient safety information, such as patient safety event reports; the collection of patient race/ethnicity could be required as part of this process. Similarly, as part of the CMS Conditions of Participation, health care facilities are required to report adverse patient safety events to CMS; This requirement could be optimized to mandate collection of patient race/ethnicity as part of each safety report. There is also an opportunity for state governments or specific state agencies to require collection of patient race/ethnicity when reporting safety data. For example, as of January 1, 2022, Pennsylvania health care facilities to include race/ethnicity in all reports of incidents of harm or potential harm to the Patient Safety Authority, which is an independent state agency.
Potential Impact: The availability of race/ethnicity information with patient safety reports would reduce the burden of health equity research on the relationship between and patient safety. This could enable larger scale, multi-site studies that would provide richer information on this relationship. It could also provide a way to measure the impact of different interventions to address race/ethnicity and patient safety challenges.
Encourage Patient Safety Organizations (PSOs) To Collect, Analyze, And Disseminate Information On Race/Ethnicity And Patient Safety
Challenge: PSOs, which are federally protected safe harbors for the collection and analysis of health care organization patient safety data through the Patient Safety and Quality Improvement Act (PSQIA) of 2005, are uniquely positioned to conduct large-scale analyses investigating the relationship between race/ethnicity and patient safety. However, PSOs may not be requesting that organizations include patient race/ethnicity with patient safety reports and may not be prioritizing analyzes that investigate race/ethnicity in the context of patient safety. For example, safety event reports from a PSO that received reports from 400 health care facilities across 10 states reported that less than 1% included race/ethnicity information.
Opportunity: AHRQ, with oversight of the PSO program, can encourage PSOs to collect patient race/ethnicity from submitting organizations and analyzes that investigate encourage race/ethnicity as a contributing factor. AHRQ can also incentivize PSOs to contribute data to the national patient safety database—a national repository of patient safety event reports, created by the PSQIA and hosted by AHRQ, that can be analyzed for patterns and trends in patient safety nationwide. Further, to be recognized as a PSO an organization must certify that it will perform certain patient safety activities; Legislation could be passed to require analysis of patient race/ethnicity as one of these activities.
Potential Impact: Focusing PSO efforts on race/ethnicity in the context of patient safety could provide greater insight, given the millions of patient safety event reports PSOs collect from a diverse set of hospitals and health care facilities. Legislation requiring PSOs to focus on race/ethnicity as part of their patient safety activities would move PSOs to request patient race/ethnicity information from individual health care organizations that are already contributing patient safety event report data. Such legislation would also motivate PSOs to conduct analyzes that investigate the role of patient race/ethnicity in patient safety.
The first step to addressing race/ethnicity as a contributing factor to patient safety is to ensure the most appropriate data is collected, leading to a better understanding of the problem. The changes we propose, leveraging already existing methods and policies for collecting patient safety information, could provide the much-needed data to begin to fully understand, address, and address racial/ethnic inequities in patient safety. All patients, regardless of race/ethnicity, deserve the safest care possible.