1. Disparities Registration Questions
Effective Date 07/09/2007
Background
This presentation was prepared as a tool to use with BIDMC registration staff to inform them about upcoming changes to CCC registration questions regarding data collection of health disparities information.
How to use
Each slide has notes to the trainer with directions and suggested discussion points. Directions to trainer are displayed in this style and font. Suggest scripting for trainer are displayed in this style and font. Suggested timing and page number of corresponding handout are displayed in this font at the top of each note. The recommended length for training is between 1 and 1.5 hrs depending on the use of role plays.
Materials for training
Health Disparities Registration Questions Powerpoint with notes
Health Disparities Handout
Health Disparities Job Aid
Training Role Plays From Boston Disparities Group
Electronic copies of the documents can be found at BIDMC General portal (green tab)>BIDMC>Clinical Side (left)>Patient Access Services>Disparities (tab).

2. Agenda Background to Health Disparities CCC Questions and Responses
Scripting
3 minutes, P 2 2 Minutes Total
The purpose of today’s training is to talk about some minor changes made to the CCC registration system so that BIDMC can better collect health disparities information (if you don’t know what that is – you will by the end of the session!).
Review agenda for the training: Will discuss why we are here talking about health disparities, we’ll look at the actual changes made to CCC. Lastly, we’ll talk about how to ask the questions, and how to respond to patient concerns.
Review length of training and expectations.
Review handouts.

3. Training Objectives Staff should be able to:
Explain to patients the importance of collecting health disparities data
Phrase disparities interview questions according to designated scripts for language, race/ethnicity, education (also for religion and next of kin)
Appropriately respond to patient questions or objections to health disparities questions
Select choices in CCC that best represent the patient’s answer to health disparities questions
1 minutes, P 3 3 Minutes Total
Review objectives listed on screen that participants will learn during the training.
You may want to acknowledge up front that these changes mean additional questions for the patient which means more work for registration staff. Acknowledge that it is already hard enough to get the information we need from the patient. Reinforce that these changes are small, the typical registration interview only lasts 2 to 3 minutes, this is only going to add a few extra seconds to the interview. Reinforce this is something that we are required to do – it is not an option. Reinforce that we need staff to be positive about these questions so that the patients will feel positive about answering them – because the information is being collected for a positive reason – to improve health services!
So let’s get started by making sure everybody understands what health disparities are…. (next slide)

4. Health Disparities Causes Examples Data Collection Data Use
Race/Ethnicity
Language
Highest Level and Country of Education
Data Use
7 minutes, P 4 11 Minutes Total
Ask group: Does anyone know what health disparities are?
Health Disparities are differences between populations in presence of disease, access to health care, use of health care services and delivery of health services. Like one group of patients receives more pain medication than another, or one group of patients gets discharged faster than another. There is a disparity because all groups didn’t receive the same care.
Disparities are caused by social, economic and environmental factors, barriers to getting health care and differences in quality of health care. Maybe the group that got less pain medication didn’t speak English and they couldn’t communicate that they needed medication. Or maybe the group that got discharged faster didn’t have health insurance and a way to pay for non-emergent services at the hospital.
Commonwealth of Massachusetts and City of Boston now mandate some of the registration data that hospitals collect so that studies can be performed in the future to get a better understanding of the different public health issues. The information will then be used to develop health programs that address disparities in healthcare.
The questions affected by this mandate are race, language and educational level. We already ask race and language, so only the education questions are new for us.
In order to help collect good data, registration staff at all hospitals needs to consistently ask the same questions in the same way. The more data that we get from patients, the better information that BIDMC and the Public Health Department will have to develop effective programs to help patients. Once you know that non-English speaking patients typically receive less pain medication, you can put in place programs – having all interpreters explain up front to patients that they need to communicate about pain, and how to do this even if interpreter isn’t present, etc.
Let’s look at how we are addressing these mandates in CCC.

5. CCC Changes Re-ordered questions Added introductory statement
Added highest education and location
Re-phrased language question
Removed translator field in the registration form
Added second next of kin question for all
5 Minutes, P 5 16 Minutes Total
Customize this slide and comments so that only the CCC changes relevant to your CCC system are displayed. The points on the slide cover all of the potential changes in CCC.
The changes were made to CCC registration systems within the registration form.
A few other changes were made along with adding the education questions to make things flow smoother in the question flow.
2 questions were actually added … education level, and where education took place.
Those questions were grouped together with race and religion and are preceded by an introductory statement explaining that you are about to ask sensitive questions.
The language question was re-phrased.
In some systems, there was a translator field that appeared if a language other than English was displayed. This translator field was removed as the interpreter is actually collected and scheduled at the visit level. This translator question actually replaced the second next of kin question for non-English speaking questions. Now for all patients, regardless of language selected , the second next of kin question will display.
The changes are different depending on which CCC system you use – the system you use may not have originally displayed all of these fields, in which case you won’t see the changes to these questions.

6. CCC Systems Affected OPD Registration Admit Fiscal Inpatient Admitting
Emergency Department
Fetal Monitoring
OR Scheduling
Satellite OB
Appointment Scheduling
2 minutes, P 5 18 Minutes Total
The purpose of this slide is to explain how the different systems were affected with the changes for a mixed group using different systems. You may want to customize this slide if your group does not use different systems.
Since all of our registration systems look a little different, and can be programmed separately, here’s how the changes break down….
OPD Registration, Inpatient Admitting, Emergency Department systems are affected by all the changes.
Appointment Scheduling is only affected by the language changes.
Admit Fiscal is only affected by the introductory statement, race and religion

7. CCC Changes Added Introductory Statement Race/ Ethnicity
Moved Religion
Added Education ?’s
Re-phrased Language Question
2 minutes, P 6 20 Minutes Total
Customize this slide and insert the print screen of the changed/added questions for your relevant CCC system. The screen displayed is from OPD Registration.
If possible, go into CCC and display the changed/added questions, otherwise review this print screen.
Remind staff that ?? refreshes the screen at the Edit prompt. These questions all have long options and tend to scroll off the screen.
Let’s look at how the changes actually look in CCC…
Added 2nd Next of Kin

8. When to Ask Questions Every full registration for a new patient
Full re-registration if the question was not previously answered
2 minute, P 5 22 Minutes Total
Customize the comments for this slide to be relevant for your group. If your group does not interview patients for a full registration, then they won’t necessarily be asking all of these questions. They may need this information because they will see the questions displayed for reasons other than interviewing the patient.
So when are you going to ask these questions?
The registration questions discussed today must be asked during every full registration for a new patient, and if not previously recorded during the full re-registration process.
Since the education questions are new – this means they will need to be asked during every re-registration until we get this information collected.

9. Introductory Statement
Script: The next few questions are voluntary and confidential and are meant to ensure everyone gets the best care regardless of background.
5 minutes, P 7 27 Minutes Total
Customize scripting to coordinate with only the questions displayed in your CCC system. Each upcoming slide shows how the question displays in CCC, and lists the script for how the questions should be asked. Also, may want to have participants view Job Aid at this time, so that they can see the questions and possible answers.
Next we are going to go through each of the question additions or changes in CCC that affect you and discuss how to ask the patient the questions. After we go through each questions we will discuss how to respond to patient concerns.
The first change - There is an introductory statement placed before the religion, race and education questions.
This statement should be read to the patient.
Using this statement will decrease your patient’s concerns/objections about these questions.
The statement acknowledges that you understand you are asking sensitive questions, and lets patient feel at ease that they won’t have to answer if it is too uncomfortable.

10. Race/Ethnic
Script: Which of the following best describes your race or ethnicity: American Indian, Asian, Black, Hispanic, Middle Eastern, White or Multiple Race/Ethnicity? If patient selects a race, read the CCC options available for that race.
7 minutes, P 7 34 Minutes Total
BIDMC has long asked patients about race and ethnicity, the goal is to now collect more specific race and ethnicity information.
The changing American population has required that we update how we collect information about race.
Display the options (if you can’t display use the next screen to see example of the options) and demonstrate how we are trying to capture two levels of information: race and ethnicity. Tell staff right off, that you are aware the list is not all inclusive. That’s why we have “other” options. Demonstrate the question with one or two training participants. After demonstrating the interview technique, confirm information below.
Read the question listed on slide to patient with the options.
When they select a category, read the sub-categories available for that race.
Select 10 Multiple Race/Ethnicity to add free text available to describe the background of someone multi-racial.
If the patient doesn’t know what general race to choose – ask “Would you like me to repeat the options or is there another way to describe your race?”
If the patient doesn’t know what specific race/ethnicity to choose - tell them what you can record and give options: “I can list Other, Multiple Race/ethnicity or I can just list your race as Black, etc.”

11. Race/Ethnic Options This is only a sample of options. There are more.
Use this screen with previous screen/notes.
This is only a sample of options. There are more.

12. Religion Script: Would you care to state your religious affiliation?
1 minute, P 8 35 Minutes Total
Nothing has changed with the religion question, other than to group it with the other sensitive questions.
This field is not collect for disparities purposes – it is collected so we can provide comprehensive services to the patient. Services affected by religion may include counseling, dietary restrictions, religious rites, etc.

13. Education Level
Script: What is the highest education you completed so far?
3 minutes, P 9 38 Minutes Total
The Education questions are the questions staff will be most resistant to. They may feel that this is intrusive or rude to ask patients. Reinforce that these questions have been piloted. Staff and patient opinions were evaluated before implementing these questions. Research showed that more experienced registration staff experienced little objection from patients regarding these questions. Additionally, patients will be asked these questions at other hospitals in the city, and will get used to hearing it.
This is one of the two new added questions.
Collecting education level helps to identify at-risk groups and create better community health programs.
For example, studies have shown in the past that the number of smokers decreases in people with higher education level. So if you wanted to start a Smoking Cessation program at the hospital, you might target people with high school level education or less.

14. Education Country
Script: Where did you reach your highest level of education so far?
2 minutes, P 9 40 Total Minutes
Point out responses to this question on job aid.
This is the second question asked about Education.
This information is important in recognizing the effects of public health education efforts in this country versus other countries that could impact patient’s care.

15. Language
Script: In what language do you wish to discuss health related concerns?
5 minutes, P 9 45 Minutes Total
Like race/ethnicity, language has long been collected here.
The difference is that we need to make sure that we are collecting accurate information about patient language.
We can do this by making sure that we ask each and every patient what language they wish to discuss health related concerns regardless of the language they are speaking to you in.
Every patient should be asked the question on screen.
Notice that the CCC question that needs to be answered actually needs a yes or no answer.
It is very important that staff uses the wording on screen, and do not supply English in the question. This could be interpreted by the patient as a cue that you want them to answer English.
Just a note – Language is not an optional question. We need patients to answer this question so that we can schedule intepreter services.

16. Next of Kin 1 Script: Who do you want to list as your next of kin?
1 minutes, P Minutes Total
Next of Kin is not related to the disparities questions but it does appear near the disparities questions.
Just wanted to use this time to remind you that we need this information for medical emergencies.

17. Next of Kin 2
Script: Who else would you like to list as your next of kin?
2 minutes, P Minutes Total
Previously, if a language other than English was selected a translator question replaced the second Next of Kin question which displayed for English speaking patients.
Now the translator question is removed from the Registration Form. The Interpreter question does still exist in the visit portion of the record.
The second next of kin now displays for all patients, regardless of language.

18. General Response Patient declined to answer
Patient unavailable to answer
1 minutes, P Minutes Total
With all of the registration questions mentioned, there are two CCC options listed for two different patient situations.
Patient declined to answer should be used when the patient does not want an answer recorded in the registration record. For example, I don’t want to list my race. I don’t want to list a religion.
Patient unavailable to answer should be used when the patient is either not present for the registration or unable to communicate.
Both of these options are worded differently for each one, be careful to choose the best one for the situation. Religious and Interpreter services have noted problems in the past that these responses have been used interchangeably.

19. General Objections The patient thinks the answers are obvious….
If the patient refuses to answer one of the questions…
If the patient still refuses….
5 minutes, P Minutes Total
If patients have questions or concerns, any of the information provided in the handout can be used to explain to the patients why we are asking these questions.
The goal is to remain positive with the patient, and to be positive about the hospital’s participation in collecting information that will improve health services.
You want to ask questions quickly but with a confident and personal tone– make them feel comfortable and this will help you to get information you need in any situation.
For example for the first objection on screen, the patient states can’t you tell by looking at me. “Well, I could guess, but I want to make sure that I record your response.”
For the second, “I know these questions are sensitive but your answer helps us to improve healthcare we provide to all. Why? Because collecting this information helps us to identify differences in healthcare and develop programs to make sure all people receive equal healthcare.”
For the third, “Okay. You have the right not to answer these questions.”

20. Conclusion
Collecting health disparities information is important to the care of our patients.
Using provided scripting ensures the collection of high quality data.
Changes are effective 07/09/2007.
1 minutes, P Minutes Total
Note that on the last page of the handout there are additional contact phone numbers and website for additional information or questions.
Collecting this information is important – it helps us to provide better care to whole communities.
We need you to be positive about these questions with the patient.
We need you to use the same techniques so that we can ensure the data we collect is good, and that is can be compared with data at other health organizations.