Progress eliminating health inequities is extremely slow. I use health inequities as an overarching term referring to differences between demographics in healthcare treatment or health outcomes, as well as differences in healthcare employee treatment and representation in leadership and governance positions. While increased awareness of disparities has improved our understanding of differences in health outcomes related to race, ethnicity, language, and other demographic factors, there remains limited reduction in healthcare disparities. Twenty years ago, the landmark report, Unequal Treatment, provided a common ground to acknowledge health disparities and set an ambitious agenda that called for better research, measurement, and reduction of healthcare disparities. Since its publication, however, there has not been enough progress.
“Never events” in healthcare refer to events and outcomes that should never happen in any care setting or for any patient. Performing surgery on the wrong knee is a never event. Administering the wrong medication to a person is a never event. There are dozens more examples of never events, and preventing them is paramount to improving patient safety in medicine.
Using lessons from the patient safety movement over the past several decades, I believe it is time to begin labeling health inequities as “never events.”
To do this we must set a goal of zero never events related to healthcare inequity. It was a pivotal moment in patient safety when a zero patient harm goal was first proposed. Initially it was thought too difficult to achieve. However, this bold, aspirational goal forced leaders to completely redesign their action plans — this was a much more significant overhaul than if the goal were, for example, a 5% improvement. Marginal improvement goals (e.g., 5% or 10% improvement), are designed in a way that you may think a little “extra effort” will be all that is needed to achieve success. All or nothing goals, however, necessitate a redesign with innovative and dramatic improvements. In practice, for healthcare inequity, this means capturing disparity measures in an organization’s “top quality” dashboard with a goal of zero disparity. This applies the same philosophy used in patient safety (e.g., zero infections). Other examples of practical applications include using employee engagement and inclusion surveys to ensure that Hispanic/Latinx employees feel as included (e.g., zero difference) as white employees, or establishing a 100% diversity match between hospital leadership and the community.
Goal setting is one component of achieving zero never events, but goals provide only artificial floors and ceilings. For health systems to change their perspective from some improvement to full improvement, they must shift their culture and values.
As another step toward the zero goal, we must supersize transparency. In the case of patient safety, harm events or never events are closely tracked with data, and in many organizations, the metrics are easily accessible for all to see. Health inequity measures should be tracked monthly using formats that are readily available for everyone within an organization.
Finally, let’s make it personal. The advantage of labeling health inequities as a systemic problem is that it provides a lens for organizations to address multiple contributing factors. However, it simultaneously decreases the power of the individual stories that humanize a problem for healthcare leaders, providers, and employees. When someone suffers immense harm from a foreign object wrongly left in their body following surgery, we both sympathize and see the immediate damage. It is harder to translate discrimination into a palpable emotion for those who have never experienced it. If those in healthcare could be moved to understand the harm it causes, progress could be accelerated. Let’s share many more stories of inequity. While many people may find this uncomfortable, sharing anecdotes can lead to more dialogue and understanding of the connection between the story and outcomes, all of which drive impatience for the status quo. Patient safety became a central issue of concern when more people (both consumers and health professionals) began to realize that harm can happen to anyone — even them. Let’s provide a face for the problem of health inequity.
Healthcare systems around the country are working to eradicate health inequities. For example, many have launched robust programs to collect metrics on social determinants of health. But that is an input, not an outcome. We need to take meaningful action to prevent disparate outcomes with the same effort we put into making sure never events never happen.
Practically, a health inequity never event means:
- There is a 0% (or 100% reduction) mindset
- Leadership at every level is accountable for preventing never events
- Efforts are focused on prevention, not fixing the issue after a never event occurs
- A timely root cause analysis or debrief is conducted after every event
- Never events are reported on the organization’s overall quality report or dashboard
- Every “health inequity event” gets reported to the Board Quality Committee
Progress eliminating health inequities is slow. Referring to efforts to eliminate health inequities as a “journey” or a “marathon” is unacceptable given the lack of progress. It’s time to deem health inequity as a never event in order to drive real change.
Maulik S. Joshi, DrPH, serves as the president and CEO for Meritus Health and president of the proposed Meritus School of Osteopathic Medicine. He is also an adjunct faculty member at the University of Michigan School of Public Health in the department of health management and policy.
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