Ensuring REL Data Collection with the Use of a Post-Discharge Survey Tool

Mercy Campus, Muskegon, Michigan

Verify that race, ethnicity and preferred language information collected at registration is patient-identified.

Including a question in an existing post-discharge patient satisfaction survey that asked if patients recalled being asked about their race, ethnicity and preferred language (REL).

The post-discharge question allows the hospital to directly address the issue of REL data collection with registration staff so that they can improve from initial survey results in which only about 25 percent of patients surveyed recalled that they were asked about their race, ethnicity and preferred language.

Mercy Campus
1500 East Sherman Boulevard
Muskegon, MI 49444
Ph: (231) 672-2000

From the C-Suite:
"Quality improvement is a process that involves constant modification and refinement. As we are committed to reducing disparities and improving the quality of care, it’s critical that we receive feedback on our improvement efforts to adequately affect patient care."

Jon Hinderer, D.O.
Chief Medical Informatics Officer, Mercy Health Partners

Mercy Health Partners is a teaching hospital and the second largest health system in West Michigan.

Clinical areas affected:

  • Admissions Areas

Staff involved:

  • Registration Staff
  • Community Relations Staff

From the initial idea to implementation, it took less than one week for community relations staff to add the questions about patient-reported race, ethnicity and preferred language collection during registration to the post-discharge survey.

Jon B. Hinderer, D.O.
Chief Medical Informatics Officer
Ph: (231) 728-4052

Innovation implementation:
Quality assurance is an essential process in delivering or creating services and products. In the clinical setting, quality assurance involves activities that assess, monitor or define health care services.

At a meeting for the Equity Steering Group at Mercy Health Partners, a member broached the issue of how to ensure patients are being asked about their race, ethnicity and preferred language. Since the hospital had already implemented REL data collection into the admission process only recently, there was concern that procedures in place may or may not have been followed.

The group decided the easiest and quickest way to obtain an initial gauge was to use the existing patient satisfaction survey. Within a week of discharge, the hospital’s community relations staff calls all patients to survey satisfaction with their hospital experience. Questions are continuously added and revised to the survey to refine results, and new questions were easy to add.

The group worked with the community relations staff to begin implementation of the REL question as part of their standard follow-up calls. Since implementation, the hospital team has had a better tool to ensure that the race, ethnicity and preferred language information is not merely observational on the registrar’s part—meaning patients are being “eyeballed” rather than asked—but that it is patient-reported.

Advice and lessons learned:

  1. Use existing resources. Many hospitals have a method to survey patients; consider incorporating your REL data collection quality assurance initiative into ongoing efforts.
  2. Think about how to evaluate results. Should the questions about REL be asked only at the initial registration, or at every registration after initiation of patient-reported REL data collection? How are you going to evaluate and act on the results?

Cost/benefit estimate:
There were no new costs involved in adding the question to the discharge satisfaction survey and the resulting data has allowed the hospital team to better monitor registrar compliance with the effort.