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Policy Innovation Profile

Medical Center Improves Collection and Analysis of Demographic Information, Leading to Better Interpretation Services and Higher Quality Cardiac Care


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Snapshot

Summary

Realizing the importance of accurate demographic information, the University of Mississippi Medical Center requires staff to use a standard protocol for collecting information on race, ethnicity, age, and gender from all patients at registration. Staff follow written scripts and use electronic medical records with fields for all required information. To promote adherence to the protocol, staff also receive training on the importance of collecting this information and how to do so effectively. Medical center staff, including a health care disparities council, use the information to identify and address disparities. The program has improved the accuracy and completeness of demographic data collected, increased awareness of health disparities among staff, enhanced interpretation services for patients with limited English proficiency, and increased the consistency and quality of care for cardiac patients.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on the percentage of patients for which demographic information is collected and staff awareness of the importance of collecting this information, along with examples of specific actions taken to address disparities identified through the data.
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Developing Organizations

University of Mississippi Medical Center
University of Mississippi Medical Centerend do

Use By Other Organizations

Nine other hospitals serving diverse communities also participated in Expecting Success. Many others have used the Health Research and Educational Trust Disparities Toolkit and/or the Expecting Success Toolkit to improve collection of REAL data at their hospitals.

Date First Implemented

2006
Registration staff were trained on the protocol of collecting race, language, and ethnicity data in February 2006.begin pp

Patient Population

Vulnerable Populations > Non-english speaking/limited english proficiency; Racial minoritiesend pp

Problem Addressed

Racial and ethnic minorities have higher rates of disease and death than nonminorities. Hospitals cannot ensure that they provide the same quality of care to all patients without accurate, comprehensive demographic information (e.g., race, ethnicity, preferred language), something that many hospitals fail to collect consistently. 
  • Persistent health disparities across racial and ethnic groups: Racial and ethnic minorities tend to have poorer health outcomes than nonminorities, even after adjusting for insurance status, income levels, and health risk factors.1 For example, African Americans between the ages of 20 and 64 are more than twice as likely to die from heart disease than whites, while other minorities also experience increased risk of death from this disease.2
  • Unrealized potential of comprehensive information: By collecting accurate, comprehensive information about race, ethnicity, and language (commonly known as "REAL" data), health care organizations can identify and address racial and ethnic disparities in the care they provide.1 Yet many hospitals do not have a standard procedure for collecting this information, and consequently may not collect all the information needed. In some cases, hospital staff may be uncomfortable asking for demographic information and may therefore skip these questions or fill in the information based on appearance or assumptions, leading to incomplete or erroneous information.3 For example, before implementation of this protocol, the University of Mississippi Medical Center collected racial data during the registration process, but the information was often incomplete or inaccurate. Nurses sometimes collected information on preferred language later in a patient's stay, but that information appeared only in the paper chart, rather than in electronically stored registration data.

What They Did

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Description of the Innovative Activity

Realizing the importance of accurate demographic information, the University of Mississippi Medical Center requires staff to use a standard protocol for collecting REAL information from all patients at registration. Staff follow written scripts and use standard forms with fields for all required information. To promote adherence to the protocol, staff also receive training on the importance of collecting this information and how to do so effectively. Medical center staff, including a health care disparities council, use the information to identify and address disparities. More details on implementation of this policy are outlined below:
  • Standard protocol: Staff in the patient access (i.e., registration) department follow a standard procedure for gathering demographic information from all patients, using a process developed in collaboration with the American Hospital Association’s Health Research and Educational Trust. This process involves written scripts, standard forms, and patient education, as outlined below:
    • Scripts: To ease staff discomfort related to asking about race and other potentially sensitive information, registration staff use a modified version of a standard script recommended by the Health Research and Educational Trust.
    • Standard registration forms: Registration staff use electronic medical records that have been modified to include fields for preferred language as well as race and ethnicity. This information is categorized under the Demographics section of the records.
    • Patient education: Signs provided by the Robert Wood Johnson Foundation (see Context section for more information on the foundation's role in the program) explain to patients why staff ask them for REAL information, using the slogan "we ask because we care.” Staff also answer any questions patient may have about the program, and patients remain free to not provide any or all of the information requested.
  • Mandatory training: All registration staff attend a 1-hour training session on the protocol. The session covers health disparities, the importance of tracking quality of care, and the need to collect REAL data to identify and address disparities. It also provides an opportunity to review the scripts and use of the standard forms. When the policy was first implemented, 265 existing employees attended a special session led by registration department managers; new department staff receive this training as part of the mandatory orientation process.
  • Identifying and addressing disparities: The medical center regularly tracks quality of care using standard performance metrics, with breakdowns by race, ethnicity, and primary language. A multidisciplinary health care disparities council uses this information to identify and address problems.
    • Tracking, analysis, and reporting of disparities: The medical center routinely tracks performance on key cardiac care metrics by race and ethnicity. For example, the hospital tracks performance measures for patients who have had a heart attack (acute myocardial infarction or AMI) or who experience heart failure. The data corresponds to the recommendations of the National Cardiovascular Data Registry for AMI and the American Heart Association's Get With the Guidelines for Heart Failure Program. By using these recognized standards, the medical center tracks overall quality of care for all patients (with comparisons to other organizations) and identifies disparities in care across race, ethnicity, age, and gender. Information provided in July 2013 indicates that the University of Mississippi Medical Center also collects data on stroke patients for the American Heart Association’s Stroke Get With the Guidelines Program. Data from the Stroke and AMI databases have been incorporated into the University of Mississippi Medical Center Health Disparities Quality Report Card.
    • Disparities council: This multidisciplinary council meets monthly to discuss equity issues related to care. The council focuses on health literacy, access to care, patient experiences with care, education and awareness, and quality of care for diverse populations. REAL data collected on language is used to monitor need for interpreter services. The council regularly reports its findings to hospital leaders. All departments can nominate an individual for the council, with the vice chancellor of the medical center making the official appointment. The council currently has about 40 members, including physicians, nurses, interpreters, registration staff, social workers, and others with an interest in health disparities.

Context of the Innovation

A 598-bed teaching hospital in Jackson, MS, the University of Mississippi Medical Center serves as the state’s principal diagnostic and referral center. The hospital provides care to a large number of racial and ethnic minorities (two-thirds of patients are African American), many of whom do not speak English as their primary language. Recognizing the importance of ensuring that all patients receive the same high quality care, medical center leaders decided to apply to participate in the Robert Wood Johnson Foundation Expecting Success initiative, a pilot program to analyze and address health disparities in cardiac care. More than 120 hospitals applied, with the University of Mississippi being one of 10 acute care facilities chosen. Eligible hospitals had to: demonstrate their willingness to uncover health disparities and their commitment to improving care; have a strong track record in quality improvement; and serve a large base of African-American or Hispanic patients.

Did It Work?

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Results

The program has improved the accuracy and completeness of demographic data collected, increased awareness of health disparities among staff, enhanced interpretation services for patients with limited English proficiency, and increased the consistency and quality of care for cardiac patients.
  • Accurate, complete data: The medical center now collects complete data on race, ethnicity, and preferred language for more than 98 percent of patients (99.3 percent for race, 99.4 percent for ethnicity, and 98.5 percent for preferred language).
  • Enhanced staff awareness, higher morale: Staff report that the training and protocol have increased their awareness of the critical role that collecting demographic data plays in preventing and detecting potential health disparities. Managers believe that seeing the reports generated from the data has helped to raise staff morale.
  • Better interpretation services: By collecting accurate data on the many non-English speaking patients served by the medical center, the program helped to build support for improvements in interpretation services for these patients. For example, the hospital used to have three interpreters, each operating out of a separate department. Now these staff work together in the Office of Patient Affairs, enabling them to better serve the entire facility. The hospital has also added telephone and video interpreting services, and regularly trains clinical staff on how to use interpreters effectively during patient encounters.
  • Better, more consistent cardiac care: Staff identified several opportunities to improve the quality and consistency of cardiac care after analyzing and interpreting data on performance on core cardiac measures. As a result, the proportion of patients receiving all core measures for heart attack and heart failure increased from 74 to 82 percent in the first 2 years of the program. In addition, after staff identified a need for more postdischarge disease management support for heart failure patients, the medical center established an outpatient clinic led by a nurse practitioner who works with patients previously hospitalized for heart failure. Roughly a year after the outpatient clinic opened its doors, the readmission rate for clinic patients fell to 0 percent.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on the percentage of patients for which demographic information is collected and staff awareness of the importance of collecting this information, along with examples of specific actions taken to address disparities identified through the data.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Training from national experts: Through the grant program, consultants from the Health Research and Educational Trust came to the medical center to train staff about disparities, the importance of collecting REAL data, and how to do so. They also worked with staff to adapt the standard script to the community served by the medical center.
  • Revising computer-based and other registration forms: Information technology (IT) staff modified the existing registration forms to add fields for preferred language and for required racial and ethnic information.

Resources Used and Skills Needed

  • Staff: The program requires no additional staff, as administrators, IT staff, and frontline staff developed and execute the policy as part of their regular jobs.
  • Costs: The costs for developing and implementing the protocol are not available, although costs were generally low since no additional staff were required.
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Funding Sources

Robert Wood Johnson Foundation
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Tools and Other Resources

Hasnain-Wynia R, Pierce D, Haque A, et al. Health Research and Educational Trust Disparities Toolkit. 2007. Available at: http://www.hretdisparities.org.

Robert Wood Johnson Foundation. Expecting Success Toolkit. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=28433.

Adoption Considerations

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Getting Started with This Innovation

  • Keep administration in loop throughout process: The chief executive officer of University of Mississippi Medical Center and other administrators supported the original grant application. Once the medical center received the grant, the Robert Wood Johnson Foundation kept these executives informed of the program’s aims and progress through annual meetings.
  • Deal with resistance: Perhaps because race is a sensitive issue (especially in the south), staff initially resisted the idea of asking people to state their race. Program leaders addressed this issue by dealing with it directly, emphasizing the important benefits of collecting this information for patient care. Staff reacted positively to the idea that collecting the information helps to ensure that all people receive the same quality care. This dialogue also emboldened staff to ask questions, and enabled them to explain to patients why the information was being collected.
  • Adapt script to local community: Although the standard questionnaire has been designed for use in any community, adaptations can make it more effective in a particular setting. For example, after registration staff started asking patients about ethnicity, they found that local members of the Choctaw tribe would answer “no” when asked if they were Native American. To track care for this population more accurately, staff added "Choctaw" as one of the ethnicity choices on the registration form.
  • Incorporate patient education: As noted, the medical center posted signs explaining the program to patients and instructed staff to answer patient questions about the program and allow them to decline to provide requested information.

Sustaining This Innovation

  • Track reasons for not collecting information: Sometimes it may not be possible to collect all desired information. Staff should be allowed to explain missing data (e.g., patient is unavailable or unresponsive, patient refused to give information), thus making it clear that they are doing their job.
  • Share reports that demonstrate program impact: Administrators should share reports generated from the data, along with stories about how it has been used to improve care. This information lets staff see the tangible results of their efforts, thus motivating them to continue collecting the data.
  • Recognize that data differences may not signal disparities: Analysis might identify significant variations in care across racial or ethnic groups, but these differences might not necessarily stem from disparities in the care provided. For example, the medical center discovered a 10 percentage point difference in use of a recommended drug among white and black patients. Further analysis uncovered the fact that most of those not receiving the recommended drug were on a different, equally effective drug in the same category. In another case, the small number of patients in one racial category skewed results.
  • Celebrate accomplishments and contributions: Administrators regularly recognize staff for collecting data through positive feedback and celebrations. For example, they threw a party with cake and punch for all registration staff; the party included a presentation about the positive impact of the data collected. Because of staff turnover, such events should occur on a regular basis.
  • Apply lessons to other quality measures: Although this program started with cardiac care, it will likely be spread to all clinical areas. Demographic information will become increasingly important to the hospital's overall finances as pay-for-performance programs and accountable care organizations become more common.
  • Elicit community feedback: The University of Mississippi Medical Center plans to form a group of representatives from the community to give feedback on which aspects of the program work well and what needs to be improved. The medical center will share data and findings with this group to keep them informed of the institution’s progress in identifying and addressing disparities.

Use By Other Organizations

Nine other hospitals serving diverse communities also participated in Expecting Success. Many others have used the Health Research and Educational Trust Disparities Toolkit and/or the Expecting Success Toolkit to improve collection of REAL data at their hospitals.

More Information

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Contact the Innovator

Mary Mixon, RN
Assistant Administrator
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216
E-mail: mmixon@umc.edu

Innovator Disclosures

Ms. Mixon reported that the University of Mississippi Medical Center received funds from the Office of Minority Health (through the Mississippi Institute for the Improvement of Geographical Minority Health) to address of health disparities. The Robert Wood Johnson Foundation also provided funds to support the collection of REAL data and addressing health disparities.

References/Related Articles

Robert Wood Johnson Foundation. Expecting Success: Excellence in Cardiac Care, November 2008

American Hospital Association, Association of American Medical Colleges, American College of Healthcare Executives, Catholic Health Association of the United States, and National Association of Public Hospitals and Health Systems. National Call to Action to Eliminate Health Care Disparities. Eliminating Health Care Disparities: Implementing the National Call to Action Using Lessons Learned. Chicago: Authors, February 2012.

Footnotes

1 Smedley BD, Stith AY, Nelson AR, editors, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, National Academies Press, 2002. Available at: http://www.nap.edu/catalog/10260.html.
2 Savitz ST. Literature-Based Appraisal of Racial/Ethnic Cardiovascular Health Care Disparities. ISRN Public Health, vol. 2012. Available at: http://www.isrn.com/journals/ph/2012/235921/cta.
3 American Hospital Association, Association of American Medical Colleges, American College of Healthcare Executives, Catholic Health Association of the United States, and National Association of Public Hospitals and Health Systems. National Call to Action to Eliminate Health Care Disparities. Eliminating Health Care Disparities: Implementing the National Call to Action Using Lessons Learned. Chicago. February 2012. Available at: http://files.www.cmhnetwork.org/news/eoc-eliminating-health-disparities.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
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Original publication: August 29, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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