When you think about safety in health care, what comes to mind?
Some obvious things might be security, trust, or avoiding harm.
It seems pretty straightforward, but let’s unpack that last word a bit: harm. What constitutes harm? Physical injury, of course. Or not receiving needed care.
But what if you experienced racism and discrimination when you went to your doctor’s office or visited an emergency department? How might this impact the safety of your care?
To learn more about Indigenous clients’ experiences with racism and discrimination in health care, a provincial collaborative is exploring ways to identify cultural safety concerns via BC’s Patient Care Quality program.
First Nations Health Authority (FNHA) defines cultural safety in its cultural humility resource booklet called Creating a Climate for Change:
“Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the health care system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care.”
In 2015, BC’s regional health authorities, PHSA, FNHA, and the Ministry of Health signed a Declaration of Commitment to advance cultural humility and cultural safety for Indigenous people receiving health care.
More recently, in 2020, the In Plain Sight report described widespread systemic racism against Indigenous people in BC’s health care system.
So, how can health care providers and leaders dig deeper to learn more about these experiences?
Patient Care Quality Program
One way that clients can share their stories is through BC’s Patient Care Quality (PCQ) program. Introduced by the provincial government in 2008, the program aims to help people resolve concerns about their care.
The regional health authorities and PHSA each operate a Patient Care Quality Office (PCQO), with an independent review board for unresolved concerns. Governed by the Patient Care Quality Review Board Act, PCQOs receive and manage complaints related to health care quality, using PSLS to record and process the feedback provided according to legislated procedures and timelines.
The PCQ program has now partnered with Indigenous and other health care leaders to explore how it can contribute to system-wide learning and improvement related to cultural safety.
In 2018, FNHA was invited to present to the PCQ Working Group, whose members represent health authority PCQOs, PCQ review boards, Ministry of Health, and PSLS. The working group meets regularly to identify and lead improvements to the PCQ program.
From this first meeting, the PCQ Working Group members were eager to partner with FNHA to further shared priorities related to Indigenous patients accessing the PCQO. A project was developed—co-led by the Ministry of Health and FNHA—with a collaborative committee to support the project’s goals and co-design initiatives.
“FNHA was starting to develop its complaints, feedback, and compliments process, but it isn’t a legislated program like the PCQO,” says Meghann Brinoni, Director of Quality at FNHA and co-chair of the collaborative. “Through conversations with the PCQ Working Group, FNHA was invited to join, even though we use different methods. This speaks to the openness of the health authority PCQO leads.”
In addition to PCQ Working Group members, the collaborative includes the BC Association of Aboriginal Friendship Centres, Métis Nation BC, health authority Aboriginal/Indigenous Health leadership, the Office of Indigenous Health, and the BC Patient Safety & Quality Council.
“The creation of the collaborative was driven by people working in the space knowing they had improvements to make in their programs to better serve Indigenous people,” adds Meghann. “They were ready and willing to collaborate, engage, and share learnings to make those improvements.”
Guided by the Declaration of Commitment, the In Plain Sight report, and the 2012 Health Partnership Accord, the project’s objectives are to work with First Nations, Métis, and Inuit partners to identify and eliminate barriers to the PCQ program, explore culturally appropriate resolutions to complaints, and focus on learning that supports improvement to the PCQ program and health care system.
Cultural safety concerns
The collaborative is working toward their objective in a variety of ways. This particular initiative focuses on identifying care quality complaints made by Indigenous patients and families.
For context, imagine that someone submitted a complaint about inadequate pain management during an inpatient stay. A concern like this could be related to any number of factors. How can PCQO staff identify if the concern is potentially related to Indigenous cultural safety?
The collaborative’s answer was simple: ask!
The answer may have been simple, but the process is anything but. Inviting patients and families to disclose their ancestry requires a thoughtful and multi-faceted approach that considers the needs of clients as well as PCQO staff and leaders.
“Self-identification of Aboriginal ancestry became a standing item on our agenda,” says Mark Matthew, Manager of Quality Initiatives and Partner Relations at FNHA. “Collectively, we helped plan a pilot process, exploring how staff could be supported and how PSLS could support the change technically.”
Interior Health volunteered to pilot the process, as Aboriginal self-identification has been part of its patient registration process since 2011.
“In order to improve cultural safety, we first have to be able to identify what is going on and learn about the concerns that Aboriginal clients are bringing forward,” says Shari McKeown, Director of Patient Safety, Interior Health. “We can’t know if the client is Aboriginal unless we ask.”
In addition to the support provided by the collaborative, Shari engaged her PCQO team, Interior Health’s Aboriginal Health program, and other leaders and groups within First Nations and Métis communities in the Interior. Information gathering was the first step. Best practices and lessons learned from the registration process were used to inform the plan and process.
Aboriginal Health team, 2019 (photo credit: Interior Health)
Prior to launch, PCQO team members were supported with a variety of training, including PHSA’s San’yas Indigenous Cultural Safety Training, trauma-informed practices, and education provided by the Aboriginal Health team.
It’s been an iterative process of learning for the team since the pilot began in August 2020. Although dialogue about ancestry can sometimes be uncomfortable, responses about the process from both clients and staff have generally been positive.
In addition to self-identification, Interior Health has been working with public members and Aboriginal partners to revise its PCQO website and communication materials to ensure they are welcoming, inclusive, and trauma-informed.
“We are also looking at new ways to manage feedback,” adds Shari. “Face-to-face meetings between clients and Aboriginal leaders within Interior Health, talking circles, and face-to-face meetings with providers can facilitate healing and resolve concerns in a more respectful way.”
One of the collaborative’s goals is to support each regional health authority and PHSA in implementing Aboriginal self-identification in its PCQO. And they’re well on their way, as each health authority is currently in some stage of implementation, from planning to launch.
So, what’s next?
“The collaborative is looking at other areas in health care that could benefit from collecting ancestry information, and we’d be happy to share our learnings,” says Meghann. “We’re also having conversations about data governance generally, and what considerations need to be in place when health authorities collect data.”
The group is also exploring opportunities to expand the PCQO’s current taxonomy in order to classify complaints related to cultural safety at a more granular level.
Some health authorities have created new positions for Aboriginal/Indigenous Liaisons within their PCQOs or jointly between their PCQO and Aboriginal/Indigenous Health program.
New ways to categorize patient safety incidents are also being explored. In October 2021, a new contributing factor based on the BC Human Rights Code was added to PSLS. Incident handlers can now select “Discrimination and cultural factors” when personal bias or prejudice related to race, colour, ancestry, origin, religion, marital status, family status, disability, sex, sexual orientation, gender identity, or age contributed to a patient safety incident.
We’ll leave you with this final thought from Leah Smith, Director of Quality and Strategic Initiatives at the Ministry of Health and co-chair of the collaborative:
“The Declaration of Commitment was a clear call to action that launched our project, and the critical insights in the In Plain Sight report have helped deepen our response. We’re grateful to our partners in FNHA for their leadership, to the wise voices on the collaborative for guiding us on this journey, and to our health authority partners for their strong commitment to this work.
By coming together to support a safe, meaningful, and accessible process for First Nations, Métis, and Inuit clients to share their health care experiences, we’ve built and strengthened relationships, expanded our understanding, and co-designed provincial and regional initiatives for improving client experience and helping their voices drive positive change.”
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