Over the last 20 years, children's hospitals have put significant time, energy and resources into establishing reliable institutional practices to prevent harm. With these practices as a backbone, children's hospitals are working to identify connections between social determinants of health (SDOH) and serious safety events (SSE) and examining how to deliver more equitable care.
Typically, when a safety event occurs—such as a central line-associated bloodstream infection—a group of internal stakeholders review the event to learn how to prevent it in the future. A standard case review looks at a patient's entire journey in the hospital and identifies deviations in care that may have resulted in harm.
This concept applies to the way Children's Minnesota in Minneapolis is examining health equity. For case reviews, the same format with a patient journey and timeline are presented but deviations are identified based on SDOH.
"Our goal is to use the established strength and discipline around preventing harm and apply those principles to harm events influenced by characteristics such as race, gender identification or disability," says Emily Chapman, M.D., chief medical officer and senior vice president of medical affairs.
The team at Children's Minnesota conducted an SSE review and identified events that met the definition of an SSE, not by medical error standards but by inequity of care based on race, English as a second language, and other patient and family characteristics.
For example, in an SSE review of a post-surgery complication for a patient from a non-English speaking family, the team identified points in the patient journey where language barriers and an inability to access post-op care potentially resulted in poorer outcomes.
"We learned the system we had built for post-op care assumed certain access and privilege that this family and community did not have," says Chapman. "As a result, we had a post-op complication and admission that would otherwise not have been needed. This is a serious safety event."
At Children's Mercy Kansas City in Missouri, teams are also leveraging SSE reviews to identify how SDOH plays a role in patient harm. "During every review, we ask everyone involved whether they think any of the following SDOH might have played a role in the event in some way: language, culture, race or ethnicity, age, gender, sexual orientation, religion, or any other characteristic of anyone involved," says Lisa Schroeder, chief medical quality and safety officer at Children's Mercy Kansas City.
Schroeder says the most common SDOH that influenced patient safety were age, socioeconomic status, language, and cultural or religious beliefs. From the start of fiscal year 2022 through early March, Children’s Mercy asked the SDOH question in 100% of safety reviews with 50% citing SDOH as being somewhat likely or very likely to have contributed to the event.
Chapman says these conversations are difficult to have, but seeing the real effects of inequity on the patients keeps the staff motivated.
"Every safety event is about a child," Chapman says. "Let's talk about the children involved. Applying these conversations to disparities and outcomes moves people to act and demonstrate more improvements than if we simply talk about rates in disparities."