by Laura Hoffman, DNP, MSN, RN, CPHQ
Vizient Performance Improvement Program Director
You may have heard the expression “walk the talk,” meaning that a person supports what they say not just with words, but also through their actions. When it comes to advancing health equity, having comprehensive data about race, ethnicity and language (REaL) are essential to better identify disparities in quality of care and target quality improvement interventions. However, obtaining complete and reliable REaL data can be challenging depending on the health care setting and by whom the data are collected. Leveraging the process improvement technique of a Gemba Walk may help your hospital or health system gather the data it needs to advance health equity.
The challenge with data collection
Some health care organizations may not have mechanisms in place for patients to self-report REaL data while other organizations have inconsistent data collection processes across care settings. This can lead to demographic information for patients in the electronic medical record (EMR) that differs from the information collected by the health care team during patient encounters. It can be further complicated by patients who may respond differently depending upon their understanding of why they are being asked and their perception of privacy when answering the questions. A lack of complete patient data can lead to fields for race, ethnicity and language being left blank or a larger-than-expected number of patients being categorized in an “unknown” category.
When it comes to inconsistent or a lack of REaL patient data it can be difficult to discern if the problem is that patients do not know how to answer the questions, if race and ethnicity fields do not match what patients identify as, if staff is having difficulty asking the questions or if patients are not being asked to self-identify.
These types of data collection challenges prompted many Vizient member hospitals and ambulatory care centers to focus improvement efforts in this area during their participation in a recent Improving Health Equity Performance Improvement Collaborative. These collaborative participants sought to understand if the REaL data collected were reliable as well as why data may have been missing. The process for collecting self-reported data seemed straightforward, or so it appeared, until the continuous improvement strategy of Gemba Walks told a different story.
Leveraging a Gemba Walk
The term Gemba is derived from the Japanese term “Gembutsu” which means “real place” or “real thing.” Gemba Walks means going to where the work is being done, talking with those doing the work, asking questions and viewing the work in progress. Gemba Walks are utilized in many types of industries to go to where people are conducting business processes and gather feedback and identify improvements. A deeper level of understanding about a process can be uncovered when change leaders deliberately seek input from the change-doers.
When applied to health care, Gemba Walks can be a helpful process improvement tool to gain insight into patient data collection efforts and help address challenges that will support hospitals’ health equity efforts. Here are a few tips to make Gemba Walks successful.
- Alert the unit or team to be observed in advance and share the purpose of the observation. Emphasize that the goal is improvement, and your observation will focus on workflow processes, not the individuals conducting those processes.
- Prepare questions in advance to ensure you are able to obtain the answers needed. For example, if you are seeking clarity about a process, you might ask “how was the standard work established?” or “how did you learn to complete this task?”.
- Observe, but do not fix. Observe processes and gather information. Do not ask for changes. At this stage, you do not want to change the processes, but you may ask “why” or “how” to help clarify what you are observing.
- Record your observations. Write down the processes that are observed, as well as the answers to your questions. For example, if you notice that some patients are asked about race or ethnicity and others are not, record the observation but do not attempt to fix.
After the Gemba Walk, capture key takeaways and categorize findings into themes. Discuss the themes with the leadership team, determine next steps, assign responsibility for improvement and agree on a date for completion. Finally, communicate the findings and plan for improvement with key stakeholders.
Walking the talk
During Vizient’s Improving Health Equity Performance Improvement Collaborative, several collaborative participants walked the talk and successfully utilized Gemba Walks to uncover information that was pivotal to improving their REaL data collection.
One hospital sought to identify why the number of “unknown” data fields were high while other fields were blank. Since patient access staff collect REaL data during patient registrations, it made the most sense to learn from these staff first. After performing Gemba Walks, the observer realized some patient access staff were not asking patients about REaL. A survey was conducted to garner patient access staffs’ level of confidence in asking patients about their REaL demographical data. Over 30% of respondents indicated they felt uncomfortable asking patients to self-identify. With these new insights, the hospital developed a training program to provide staff with skills to confidently address the patient, while remaining sensitive to patients’ individual needs. The team has since included patient access staff as key stakeholders in health equity improvement work.
To address concerns about data reliability, another hospital observed the patient registration process first-hand and discovered that when REaL data fields in the EMR were already filled in, patient access staff were not verifying the accuracy of the prepopulated information and did not know it was part of their responsibility to do so. A task force was launched to address these issues including identification of data and process owners, formation of an EMR optimization team, creation of internal dashboards to incorporate REaL into organizational scorecards and development of staff education materials. As a result of these efforts, they were able to begin identifying disparities in care and quality outcomes from a REaL perspective.
Resources for REaL data collection
Through Gemba Walks and process observations conducted by hospitals and ambulatory care settings participating in Vizient’s Improving Health Equity Performance Improvement Collaborative, a common thread was uncovered regarding the need to educate staff and patients about the data that hospitals collect and why. Below are a few recent publications to assist in educating patients and staff and learning how organizations can take action on REaL data collection.
- Education programs such as Henry Ford Health System’s We Ask Because We Care campaign are being used to teach staff and patients about the REaL data being collected and how it will be used to improve care delivery
- The Centers for Medicare & Medicaid Services recently published its Inventory of Resources for Standardized Demographic and Language Data Collection
- The American Hospital Association and its Institute for Diversity and Health Equity assembled the Health Equity Snapshot: A Toolkit for Action which focuses in part on REaL data collection and use and cultural competency education
- The Institute for Healthcare Improvement’s Roadmap for Race, Ethnicity, and Language Data Collection and Use in Connecticut is designed to help key stakeholders advance standardized REaL data collection and use
Have you begun to walk the talk in your health equity journey? Steve Jobs once said, “If you define the problem correctly, you almost have the solution.” Go to where the work is being done. See and feel for yourself the problems that are preventing the collection of REaL data and the solutions that can be uncovered when change leaders and change doers collaborate. If you’d like to learn more about how one organization advanced health equity by improving processes for REaL data collection and social needs screening, you’re invited to join Vizient’s free webinar on November 30 at 11 a.m. CST.
About the author
With a background in nursing, Laura Hoffman develops curriculum and facilitates member engagement and learning as a program director with Vizient’s Performance Improvement Collaboratives program. Laura earned her doctor of nursing practice degree from Walden University in 2019 where she focused on patient safety, quality, health literacy and best practices in patient education.