The Next Frontier in Quality Improvement

Decreasing delays in discharging hospitalized children require multifactorial approaches that address provider workflow, institutional culture, and the social needs impacting patients and families.1–3 In volume 15 of Hospital Pediatrics, Oumarbaeva-Malone et al assess the effectiveness of multiple interventions to decrease discharge delays for hospitalized pediatric patients.4 In their quality improvement (QI) study, the authors implemented multiple interventions to increase the number of discharges before noon for a single, low-acuity hospital medicine service. The study interventions included creating the role of a dedicated discharge provider called the patient flow provider (PFP). Oumarbaeva-Malone et al measured the percentage of patients discharged before noon before and after the implementation of the PFP.4 They were successful in surpassing their initial goal and saw increases in discharges before noon from 19% to 34% following PFP implementation.The authors conducted a multivariate logistic regression analysis and an equity analysis to evaluate the effects of their interventions by race, ethnicity, language, and gender. Despite similar improvement in discharges before noon for all study subgroups, disparities across race, ethnicity, and language remained unchanged.4 They saw increased percentages of discharges before noon for Black and Hispanic patients as well as patients who used languages other than English (LOE) for medical care. However, both before and after the intervention, Black and LOE patients had fewer discharges before noon as compared to white and English-speaking patients. The authors should be commended for assessing their intervention’s impact on baseline disparities. It is only by evaluating inequities that we can understand them and then successfully address them. These results also pose some interesting and important questions when considering what to do once we have identified potential disparities and suggest new frontiers to consider at the intersection of QI and equity.When undertaking QI, there are important nuances to consider related to the difference between equality (doing the same thing for everyone) and equity (giving each patient or family what they need to achieve the same outcome). In health care, equality is built upon the notion that everyone should have the same access and opportunities regardless of their background or past experiences.5 Equity, however, considers that patient populations have differential access to resources, opportunities, and privileges.5–7A recent scoping review by Schechter et al looking at pediatric hospital–based QI interventions and racial, ethnic, language, and socioeconomic disparities in care found that implementing intentionally equity-focused QI interventions can meaningfully reduce preexisting disparities.8 These interventions typically account for those baseline differences in resources, opportunities, and privileges and aim to address them. On the contrary, initiatives that target broad and heterogenous patient populations equally (ie, more general QI interventions) are more likely to maintain or even worsen existing disparities.5–9Oumarbaeva-Malone et al’s study interventions successfully improved early discharges across all patient subgroups but did not mitigate baseline disparities for Black and LOE patients. The authors acknowledged that patients and families from diverse demographic and socioeconomic backgrounds may require different resources to achieve the same desired patient outcome.4 If we go a step further and consider the desired outcome for this study—discharges before noon—perhaps we should also question whether this metric is even appropriate for all patient subgroups? This is particularly relevant for LOE patients, who commonly face communication barriers stemming from inconsistent language access.10,11 A later discharge time might reflect more equitable care if it allows for the additional time necessary to ensure discharge teaching and care coordination have occurred effectively in their language. A later discharge could also, of course, be due to unnecessary delays that do not improve care and thus do not represent equity. Additional investigation into why these discharges occur later is necessary to understand the difference and determine whether there is a disparity. It may be worth reconsidering our QI outcome measures from an equity perspective, carefully considering the extent to which each outcome measure reflects high-quality care for a given population.Historically, in QI work, interventions are developed to target drivers of inequities in care. For example, Oumarbaeva-Malone et al mention that although their study did not specifically aim to reduce inequities, they did consider key drivers that might improve equity, such as having the PFP round with an interpreter for Spanish-speaking patients first.4 The intervention the authors implemented primarily addressed a crucial clinical resource constraint, which was clinician time. While their initial work is important, the next phase of work might be to focus on equity-driven outcome metrics, which should be tailored to address the specific needs and barriers to equitable care for specific subgroups of patients. Rather than focusing on a hospital system metric that may not be a relevant priority across different subgroups, such as discharges before noon, adopting an equity-focused approach might seek to answer a different question: How do we progress as a field to accurately measure whether patients and families received the care that they actually needed?Equity-focused QI is QI in which the primary goal is to eliminate a disparity or improve care for a group known to receive inequitable care.5–9 A critical step of this intentional work is to proactively identify preexisting drivers of inequities. Collecting and measuring data stratified by race, ethnicity, language, and socioeconomic status, among others, should be an initial step taken to identify subgroups who are receiving inequitable medical care and are at a higher risk of worsening disparities.5–7 In evaluating these analyses, it is important to recognize that race and ethnicity serve as proxies for racism and its effects because race and ethnicity—which are social constructs—do not cause disparities; instead, it is how people are treated due to their race and ethnicity that causes disparities.12 Remembering this principle will be critical for Oumarbaeva-Malone et al and other QI teams with similar findings when they seek to address a persistent disparity based on race and ethnicity, as was found with this intervention for Black children.A deeper dive into how interpersonal racism and/or socioeconomic disparities (many of which are the sequelae of past racism) may be factoring into discharge delays for Black patients may allow for more nuanced approaches to developing successful interventions or more sensitive outcome metrics. Hirschhorn et al suggest that early and continuous engagement with key collaborators, including patients, families, and community partners, can assist with the in-depth exploration of root causes of disparities and inform successful project design and thoughtful tests of change.7 Researchers may also need to look beyond traditional QI metrics and leverage qualitative methods to identify barriers unique to subgroups and thus allow for better customization and cultural tailoring of QI initiatives. For example, Jones et al’s qualitative exploration of patient discharge experiences highlights the value of in-person interpretation to review discharge instructions for LOE patients.13 The discharge process involves complex coordination of numerous care processes at the individual and system level. This inherent complexity increases the risk of medical errors and fragmented care that can be addressed with equity-focused improvement measures.Oumarbaeva-Malone et al’s study offers an important view into the critical work we should all be doing around QI and equity. As their study suggests, QI teams should track disparities via subgroup analyses even when equity is not the team’s main priority. As was the case in this study, doing so makes possible the additional questions that will advance both patient care and the science of QI. By identifying that disparities for Black and LOE patients were unchanged by their intervention, they invite crucial investigation into what is driving the underlying disparity—because that is what a successful intervention will need to target—and bigger questions about how we need to rethink outcome measures to be sure that they reflect important patient-centered priorities and adequately account for differences in those priorities that may exist across groups. Changing how we measure equitable outcomes will likely need commitment from hospital leadership, insurers, and policymakers who help define hospital quality metrics (like morning discharges) for workflow and financial purposes. This next frontier in QI research requires prioritizing patient-centered, equitable interventions and outcome measures to better tackle the key drivers of disparities in care for hospitalized children and their families.