Improving the identification of equity-related adverse events in gynecology


      The practical tools to detect and understand systemic racism and pervasive bias have not been well-delineated. For gynecologic patients, bias and racism—systemic and individual—may affect the quality of care in several ways: delays in care, cognitive bias in a clinician’s decision making, care coordination, access, and other effects of social determinants of health (SDOH). Currently, there is no described equity-focused process or framework to evaluate the role of SDOH, bias and racism in adverse events. The aim of this project was to establish a sustainable and trackable process to delineate the role of SDOH, bias, and racism in adverse gynecologic events.

      Materials and Methods

      The existing process entails monthly reviews of adverse events based on standard criteria established by the Yale Gynecologic Quality and Safety Committee. Each case is assessed for preventability, harm, and care standards.
      The equity-focused process consisted of:
      1. Creation of a standardized checklist of SDOH based on the World Health Organization framework.
      2. Application of the standardized checklist to each gynecologic adverse event beginning September 1, 2020 [Figure 1].
      3. Collection of event review data in a secure central digital repository at the time of review.
      4. Review of the cases to understand apparent causes of the event by the committee.
      5. Exploration of areas for improvement utilizing process improvement and SDOH checklists.
      6. Identification of specific change ideas.


      Within 12 months, 33 cases were identified by standard criteria. Twelve of the cases were deemed preventable. Of those twelve, there were 5 cases in which SDOH and/or bias were identified to play a role. From this sample, important themes emerged including: the role of patient trauma and previous microaggressions affecting trust in the medical system; mismatched understanding between patient and provider in the shared decision-making paradigm; cognitive bias affecting provider’s understanding of pain in certain populations; a need for consistent access to language services; and gaps in care coordination for certain populations.
      [Figure 2]


      These initial findings have been leveraged to encourage inclusion of the discussion of bias and racism in gynecology and, by doing so, normalizing this conversation. We have included these cases in departmental Morbidity and Mortality Conferences. This work represents an initial exploration and serves as a needs assessment. Within our department this information has identified units that may need directed bias training. There are now plans to utilize this checklist in perioperative services and other surgical services. As we continue to gather data and share stories, we hope to further normalize conversations about bias and racism, integrate equity into quality and safety efforts, and identify opportunities for improvement.
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