NR 307A Week 4 Organizational Equity Assessment Example

Five Ordinary Arrangements at a 180-Bed Community Hospital and the Patient Each One Assumes

Student Name

College of Nursing, Chamberlain University

NR 307A: Advancing Equity, Inclusion, and Diversity in Healthcare

Instructor Name

Month Day, Year

Five Ordinary Arrangements at a 180-Bed Community Hospital and the Patient Each One Assumes

The Organization and the Method

The organization is a 180-bed nonprofit community hospital in a small Midwestern city, with medical-surgical, telemetry, intensive care, labor and delivery and emergency services. I have worked there as a staff nurse for six years. I chose five arrangements that patients meet on almost every admission, and for each one I recorded where it is written, when it was last revised if I could find out, who enforces it, and the picture of the patient it takes for granted. I did not assess the mission statement, which promises compassionate care for every person, because it describes values rather than anything a patient experiences at the bedside. The matrix the course supplied is summarized in Table 1.

Two frameworks guided the questions. The federal standards for Culturally and Linguistically Appropriate Services, known as CLAS, set out what health care organizations should do to provide effective, understandable and respectful care, including language assistance and governance that is accountable for it (U.S. Department of Health and Human Services, Office of Minority Health, 2013). Braveman (2014) describes health equity as removing obstacles to health that fall on socially disadvantaged groups, which gives each arrangement a simple test: does it add an obstacle for some patients that it does not add for others?

Table 1

Assessment Matrix for Five Arrangements

Note. Revision dates come from the footer of each written policy where one exists; "Unknown" means no date was printed or available to staff.

Visiting Hours

The visitor policy, last revised in 2021 and posted at every entrance, reads: "Two visitors at a time, age 12 and older, 9:00 a.m. to 8:00 p.m. One support person may stay overnight in private rooms at the discretion of the charge nurse." Security staff at the front desk enforce the hours; charge nurses enforce the number. The policy fits a family of two adults, both free during the day, with no children to bring along. It works less well for a patient whose partner works a second shift and can visit only after 9:00 p.m., for large families who gather together, and for a parent who has no one to watch a 10-year-old. The overnight exception depends on the discretion of the charge nurse, which means it varies by shift and by who is asking.

No one designed the policy to exclude anyone. It was revised in 2021 to ease pandemic restrictions and has not been looked at since. That is the pattern I found repeatedly: arrangements that made sense for a particular moment and stayed in place.

Patient Portal Enrollment

The discharge checklist, revised in 2023, includes a line: "Enroll patient in the portal (email required) and confirm activation code." The activation code is sent by text and expires after 15 minutes. Laboratory and imaging results are released to the portal before anyone calls the patient. The arrangement assumes an email address, a smartphone with signal in the building, and comfort using both. Sarkar et al. (2011) studied portal use among more than 14,000 adults with diabetes and found that, after adjustment for other factors, Black and Latino patients and patients without an educational degree had higher odds of never logging on. When results go to the portal first, the patients least likely to log on are the last to learn their results.

Name on the Wristband and Whiteboard

The registration system prints the legal name from the insurance record on the wristband and pushes it to the whiteboard and the electronic record header. There is no field for a name the patient uses. The arrangement assumes that the name on a patient's insurance card is the name they answer to. It does not fit a transgender patient whose legal name has not been changed, an immigrant who uses an anglicized name at work, or an older patient known by a middle name all her life. Nurses write the preferred name on the whiteboard by hand when they know it, but it disappears when the board is wiped at shift change. No one I asked knew when the default was set.

Discharge Prescriptions

The discharge form states: "Prescriptions may be filled at the outpatient pharmacy in the main lobby, weekdays 8:00 a.m. to 6:00 p.m., Saturday 9:00 a.m. to 1:00 p.m." The hours were last revised in 2019. Patients discharged after 6:00 p.m. on weekdays, after 1:00 p.m. on Saturday, or at any time on Sunday leave with a paper or electronic prescription and must find a retail pharmacy that night or the next day. The arrangement assumes a patient who leaves during business hours, has transportation to a second stop, and can wait a day for a medication. It fails the patient going home at 7:00 p.m. with a new antibiotic and no car.

Language Field

The registration screen's language field offers three choices: English, Spanish and Other. There is no free-text field. Interpreter services are booked by language, so a nurse caring for a patient recorded as Other has to find out the language before booking, often by asking family members. Under the CLAS standards, language help should be free to the patient, and patients should be told about it in the language they prefer (U.S. Department of Health and Human Services, Office of Minority Health, 2013). A field that cannot record the language makes the first step of that impossible to do from the record.

Nobody Meant It

None of these arrangements was written to exclude anyone. Each fits the patient the author had in mind, often a patient who resembles the staff who wrote it: someone with daytime hours, a smartphone, one name and English. This matters for the recommendations, because blaming the security guard, the registration clerk or the discharging nurse would miss the point. They are enforcing rules as written. The changes need to come from whoever owns each rule.

Recommendations, Addressed by Owner

To the patient experience committee (owner of the visitor policy): replace "at the discretion of the charge nurse" with "One support person chosen by the patient may stay overnight in any room" and review the policy every two years.

To the director of nursing informatics (owner of the discharge checklist): change the portal line to "Offer portal enrollment; if declined or not possible, document preferred contact for results" and route results for non-enrolled patients to a phone call.

To the registration manager (owner of the registration system): add a "name used" field that prints on the wristband beneath the legal name and appears on the whiteboard and record header.

To the director of pharmacy (owner of outpatient pharmacy hours): for patients discharged after hours, provide a first dose or a short supply of any new antibiotic or anticoagulant at the bedside.

To the registration manager: replace the three-item language field with the full language list used by the interpreter service.

References

Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129(Suppl. 2), 5-8. https://doi.org/10.1177/00333549141291S203

Sarkar, U., Karter, A. J., Liu, J. Y., Adler, N. E., Nguyen, R., Lopez, A., & Schillinger, D. (2011). Social disparities in internet patient portal use in diabetes: Evidence that the digital divide extends beyond access. Journal of the American Medical Informatics Association, 18(3), 318-321. https://doi.org/10.1136/jamia.2010.006015

U.S. Department of Health and Human Services, Office of Minority Health. (2013). National standards for culturally and linguistically appropriate services in health and health care: A blueprint for advancing and sustaining CLAS policy and practice.