Social determinants of patient safety: A bridge to better quality of care

There is now broad appreciation that one of the fundamental drivers of the health of individuals and communities are social determinants of health (SDOH). SDOH are the conditions in the environments in which people are born, live, learn, work, play, worship, and age. These factors affect a wide range of health, functioning, and quality of life outcomes. These can be grouped into different domains, such as economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. SDOH influence the health of people in ways both positive and negative. They have become a high priority because they contribute to health disparities in populations, and reduce the potential for health and wellbeing for individuals. But there has been relatively little attention on how they might be related to problems with patient safety.3–5 It is time to bring patient safety into the SDOH conversation. SDOH also influence the quality of health care delivery, and significantly, affect patient safety.6–10 For example, low health literacy can reduce the ability of individuals to use medications safely. Health literacy has two important components, personal health literacy and organizational health literacy. An individual with diabetes with limited personal health literacy is more likely to misunderstand the correct way to use insulin to maintain their blood sugar within the required narrow therapeutic range. An organization with low health literacy fails to enable all individuals to find, understand, and use information and service to help them make medical decisions and care for themselves. In such an organization, it may be difficult for the person with diabetes to maintain the medications and equipment needed to prevent hypoglycemic episodes. For related reasons associated with comprehension, there is evidence that language barriers also undermine patient safety. Another example of adverse effects of SDOH is the impact of inconsistent transportation on access to healthcare. A patient on anticoagulant medication for atrial fibrillation who has unreliable transportation may be unable to consistently attend appointments for monitoring and wind up suffering from a bleeding episode or stroke. If we ignore the effects of SDOH, systems designed to improve safety and quality can increase disparities and impede quality improvement. For example, a study by Thomas et al. suggested that existing voluntary adverse event reporting systems may underestimate harmful patient safety events in members of racial minorities. We are likely to find economies of scale by joining forces devoted to improving safety and equity. Both are core aspects of healthcare quality, and leveraging existing resources could save time and effort. Chin, and Sivashankar and Gandhi suggest that an efficient strategy for health systems would be to integrate equity into existing quality and safety frameworks and infrastructure. The resulting marriage could help unpack the impact of SDOH on patient safety, and reduce health disparities. In an earlier paper, Chin et al. suggested a series of steps for reducing racial and ethnic disparities in care that include recognizing disparities, committing to reduce them, and making equity an integral component of quality improvement. The specific interventions could be applied at multiple levels of the healthcare system, including the patient, provider, microsystem, organization, community, and policy to improve safety. In the United States, the Centers for Medicare and Medicaid Services (CMS) has instituted an ambitious new policy to address SDOH and advance health equity. The initiative focuses on screening Medicare inpatients for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. CMS has mandated that hospitals paid under their inpatient quality reporting program send them the resulting information. Submission is on a voluntary basis in 2023, and is required in 2024. For patients who screen positive for one or more SDOH, hospitals will also need to report what steps they are taking to remedy the problem. If successful, the CMS program might have positive effects on both health equity and patient safety. However, healthcare organizations may feel challenged to address problems traditionally considered to be beyond their direct influence. Although they can address some disparities at the point of care, their reach into the community is more limited. What can hospitals, local teams, and healthcare providers do to reduce the impact of SDOH on quality of care, including patient safety? Hospitals can begin by acknowledging the impact of SDOH on quality and safety, and establish the goal of identifying and addressing SDOH. The next step is to create information technology and workflows to collect patient level Editorial