Joanna Burke-Bajaj discusses the health equity of quality improvement and reliability
Health with Humanity
By Joanna Burke-Bajaj
High Reliability in Healthcare: Creating Reliable Health Equity through Quality Improvement and Patient Safety
You may not have heard the term High Reliability Organization (HRO) before, but you have probably been interacting with HROs and trusting them with your safety for most of your life. HROs operate at the nexus of high risk, high volume, and high complexity operations, and yet maintain high safety standards with consistently safe results. Golden examples of HROs can be seen in the airline industry. One industry that should rank at the top of High Reliability, but yet holds few organisations that can truly be classified as HROs, is the global healthcare industry. The field of healthcare quality improvement (QI) is devoted to improving healthcare processes with the goal of fine-tuning the industry into one of consistently high quality performance and safety, with care provided by HROs around the world. However, the current reality is that there are still many gaps between the level of health safety offered to patients of different backgrounds, socio-economic status, race, gender, age, location, and many more communities who can face biases and barriers in healthcare accessibility. The reality for those who are marginalised by our social systems is that high quality healthcare is not equally reliable for every individual needing care.
The field of patient safety came to the forefront of healthcare improvement in 1999 when the Institute of Medicine first released To Err is Human, but since that time major gaps have remained in understanding how patient safety can be affected by individual patient’s backgrounds and marginalized identities, or even how social risk factors such as socioeconomic status affect the safety and care that a patient is offered. Patient safety events refer to errors in aspects of healthcare such as administration, medication, diagnostics, or transition of care which can result in harm, injury, or negative consequence, and the frequency of patient safety events vary widely by geographic locations and by certain groups of patients. There is emerging evidence in primary care illustrating that female patients and patients from the Black community are more likely to experience patient safety events, and one proposed reasoning for this disparity is a lack of clinical training for presentations of certain illnesses in patients whose physiology is under-studied and less widely documented in medical literature (Piccardi et al. 2018). In addition, it has been found that common voluntary incident reporting measures in secondary care at hospital sites may routinely under-detect patient safety events for vulnerable groups (Schulson et al. 2021).
Many questions arise from these identified quality and safety gaps, but the key reflection for those of us who work to improve care should be: For whom is healthcare reliable? When it is reliable, for whom is it accessible? The name of this blog series, ‘Health with Humanity’, comes from a popular quote by Dr. Paul Farmer who stated, “If access to health care is considered a human right, who is considered human enough to have that right?” Along this thought, our series will bring up the concerns of how our individual perceptions of humanity inform the way that each of us interacts with healthcare systems – as healthcare providers or as patients – and point to the fact that inequity can be built into healthcare operations from the implicit biases that healthcare providers, policymakers, and management leaders hold. When healthcare operations look to the field of quality improvement, this also means striving for systemic improvement and upstream solutions to health concerns. It means pushing beyond advocating for better care for those who are left behind in our social system, to also ensure that they are not left behind in the first place. As written recently by Dr. Tejal Gandhi, “while health care organizations alone do not have the power to improve all of the multiple determinants of health for all of society, they do have the power to address disparities directly at the point of care and to impact many of the determinants that create these disparities,” (Gandhi 2021). If we are to truly pursue the title of High Reliability for our healthcare organizations through the meticulous planning of quality improvement and safety enhancement, then surely the first step on this path must be to ask: How can we build a future of healthcare that can be reliable for all?
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Gandhi T. (2021). Achieving zero inequity: Lessons learned from patient safety. NEJM Catalyst: Innovations in Care Delivery. Accessed online, NEJM Catalyst.
Institute of Medicine. (2000). To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.
Piccardi C., Detollenaere J., Vanden Bussche P. et al. (2018). Social disparities in patient safety in primary care: a systematic review. Int J Equity Health 17, 114. https://doi.org/10.1186/s12939-018-0828-7
Schulson LB, Novack V, Folcarelli PH, et al. (2021). Inpatient patient safety events in vulnerable populations: a retrospective cohort study. BMJ Quality & Safety; 30:372-379.