Dr. Komal Bajaj, NYC Health + Hospitals: ‘You can't consider healthcare to be high-quality unless it is equitable’

Providing safe, high-quality, equitable care is a top priority for many healthcare leaders working to reduce disparities. In 2023, the Centers for Medicare and Medicaid Services will ask hospitals to include data on social drivers of health as part of their reported quality measures. How exactly does equity tie into safety and quality work, and how does it relate to your position on the Agency for Healthcare Research and Quality’s National Advisory Council?

While equity has been a stated goal for a very long time, it’s clear that some of our structures, processes and biases impact healthcare, so certain groups experience differences in access, prevention and outcomes. We can, and must, do better. The Institute for Healthcare Improvement surveyed healthcare leaders in July 2021, and overwhelmingly, the sentiment was that there cannot be any progress in healthcare quality unless there’s progress in health equity. When I think about healthcare equity, I think about this notion that everyone can live their healthiest life—no matter who they are, where they are, how much they make, what language they speak or the color of their skin. You can’t consider healthcare to be high-quality, unless it is equitable.

The AHRQ’s mission is to produce evidence related to high-quality care—and going one step further, to make sure that evidence is understood and translated. As a healthcare leader, there’s been a lot of products that have come from the AHRQ that have been transformative for my practice. Things like the TeamSTEPPS playbook, the National Healthcare Quality and Disparities Report, resources that equip patients to get the most out of their interaction, and new resources related to diagnostic safety. I think the AHRQ is poised to make an impact on healthcare quality, as defined as inclusive of equitable care.

You are uniquely positioned with experience working in the Chicagoland area and New York neighborhoods like the Bronx, and a background in obstetrics, gynecology and genetics. What are some of the main safety and quality issues you’ve witnessed in your work with communities of color and populations that are medically disadvantaged?

So much of health is impacted by what happens outside of our physical or virtual “four walls.” While quality and safety leaders, rightfully so, are focused on things that happen in the care environment—catheter-associated urinary tract infections, cancer screenings, falls, et cetera—what keeps me motivated is thinking about how we can impact health across that continuum, recognizing that so much of health happens upstream. How can we impact things like community safety, housing instability and access to healthy food? Because at the end of the day, these are some of the really important components to health. I was talking to some international healthcare leaders recently, and while their practice settings are very different, and the needs of their communities are very different, this sentiment and thinking about the totality of health shone through.

“It’s a moral imperative for health entities, for payers, for policymakers to work toward delivering equitable care.”

What resources and strategies are necessary to address safety and quality problems?

There’s no single resource or strategy that’s going to result in equitable healthcare. It’s going to be this tapestry filled with a variety of solutions that place patients and communities at the center, from design, to implementation, to assessment. It’s a moral imperative for health entities, for payers, for policymakers to work toward delivering equitable care. I’m heartened to see the movement around accreditation and remuneration that is going to accelerate this change.

At NYC Health + Hospitals, one core strategy is to think about how our current structures support or hinder the integration of equity into quality and safety processes. Another strategy to ingrain equity into quality and safety processes is to include the patient voice in hiring, so no key quality and safety role is filled without a patient being part of that interview team. It has resulted in some important, fascinating conversations, and I think it signals to our patients and community, as well as to those who are joining our organization, that the patient voice and perspective is front and center to what we do. Another crucial strategy is to apply a proactive equity lens to performance efforts. This means prioritizing efforts based on identified disparities, or ensuring that there aren’t any intervention-generated disparities. We’ve also worked hard to ingrain equity into event analysis, including patient grievances. Our event reporting system includes the opportunity for staff to share with us their perspectives on bias and injustice, building agency within our teams around equity-related work.

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Diagnostic errors are a huge quality and safety issue that disproportionately affect patients of color who are often improperly diagnosed or treated because of medical bias. Apart from waiting on innovations in technology and artificial intelligence to solve this problem, what are some ways clinicians can reduce diagnostic errors and ensure more equitable care?

The diagnostic process can often be complex, and it usually requires a lot of collaboration, sometimes multiple visits, with multiple different types of healthcare teams or situations. The National Academies of Sciences, Engineering and Medicine defines diagnostic error as a failure to establish an accurate and timely diagnosis, or a failure to communicate that diagnosis or explanation to the patient. It’s clear that diagnostic safety contributes significantly to quality and can exacerbate healthcare disparities. As I reflect on my journey as a healthcare leader and my practice as an OB-GYN geneticist, I think that individuals can work to identify and mitigate their own bias. I certainly have had some major “aha” moments over the course of the last decade.

In the diagnostic process, there is some uncertainty, and it’s challenging to communicate uncertainty sometimes. It’s important to partner with patients in their diagnostic journey, and to have equitable care requires patients and communities at the center of this work.

There are examples at organizational levels of how people have been thinking about improved diagnostic safety, including a recently published Safer Dx Checklist, which includes a whole host of actions that organizations can take, such as explicit board commitment to diagnostic safety work; strategies to measure diagnostic safety events; and purposeful efforts to build feedback loops and structured handoffs. Equally important in this conversation is the human side of change: fostering psychological safety and a safety culture so that we can have honest conversations around diagnostic safety events.