Date of Award

2024

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)

Department

Nursing

Faculty Chair

Katie Butte

Faculty Reader

Katie Butte

Executive Summary

Executive Summary

Quality Improvement: Compliance of a Gender Identity Toolkit After an Education

Tammy Davis

Background/Significance

In the United States, one in two hundred and fifty, or about one million people, self-identify as transgender or gender nonconforming (Caughey et al., 2021). This population of people face healthy disparities such as increased rates of suicide, mental health concerns, they are more likely to be victims of hate crimes, and often do not receive preventative health services (Cahill et al., 2014). The transgender community reports barriers to care due to negative experiences with their healthcare providers that leads to avoidance of the healthcare system (Caughey et al., 2021).

Transgender persons are among the most health disparate in the country (Safer et al., 2016). Within this population, 44% suffer from clinical depression, 33% suffer from anxiety, and 28% from somatization (Safer et al., 2016). While recent statistics from 2020 show that 82% of transgender persons have considered suicide, more alarming is that 40% have attempted suicide (Austin et al., 2020). Suicide attempts in this population are twenty-six times greater than the general population (Safer et al., 2016). Further, transgendered women have a worldwide human immunodeficiency virus (HIV) prevalence of 20% and transgendered people are more likely to smoke cigarettes at a rate that is one and a half times that of the general population (Safer et al., 2016). The population is also more likely to use drug and alcohol with 26% of people reporting current or former use (Safer et al., 2016).

Transgender people have significantly lower rates of preventative health care visits compared to cisgendered populations (Hoy-Ellis et al., 2022). They are less likely to have physical exams, colonoscopies, mammograms, pap smears, prostate specific antigen testing, and osteoporosis screenings (Hoy-Ellis et al., 2022). Lack of screening combined with social economic barriers results in lower life expectancy and decreased quality of life (Hoy-Ellis et al., 2022). While more research needs to be done to determine prevalence of cancer related to lack of screening in this population, data shows they are more likely to have chronic disease such as asthma, arthritis, diabetes, coronary artery disease, myocardial infarction, and depression when compared to the cisgender population (Downing & Przedworski, 2018).

Problem and Purpose Statement

Transgender people experience barriers to healthcare leading to poor health outcomes that are both physical and mental (Downing & Przedworski, 2018). Healthcare providers lack both the experience and education on how to properly communicate with this population leading to poor healthcare experiences and avoidance of care (Safer et al., 2016). To address these concerns, numerous agencies including but not limited to the Institute of Medicine, Centers for Medicare and Medicaid (CMS), The Joint Commission, and Healthy People 2030 have recommended standardized inquiry about gender identity and sexual orientation at healthcare visits (Cahill et al., 2014). They recommend utilizing the electronic medical record system to gather information that could be used to direct clinicians to proper preventative health care screenings (Cahill et al., 2014). The United States Preventive Services Task Force (USPSTF), which is responsible for providing evidence-based recommendations for preventative care, has also made this recommendation (Caughey et al., 2021).

To fulfill this recommendation, a gender identity toolkit for healthcare providers to use to update the electronic medical system has been developed. However, there remains a gap for healthcare providers to have the appropriate training to utilize this toolkit in transgender patients. Thus, there is an urgent need to train, educate, and equip healthcare providers to implement a gender identity toolkit. Proper use of this toolkit will lead to more trusting relationships with care providers, documentation of organs (uterus, prostate, etc.) that will require screening such as pap smears and prostate exams, and ultimately lead to better health outcomes.

Methods

In alignment with current recommendations by Institute of Medicine, Centers for Medicare and Medicaid (CMS), The Joint Commission, and Healthy People 2030 (Grassco et al., 2021; Hoy-Ellis et al., 2022) an electronic medical record system tool was created within the study organization in 2018. This tool is called the gender identity tool kit. It was created and validated by the Epic team. This tool is not widely used within the organization. This intervention will focus on increasing the use of the gender identity toolkit by clinicians by implementation of an education program.

The purpose of this study is to examine the effects of implementing a clinician education program and measures the intention to use, and the actual use, of the gender identity toolkit within the electronic medical record system. This education program will be held in an Oncology outpatient setting in Snohomish County, Washington. It will include ten clinicians. A survey will be completed pre and post implementation of the education. The survey will be utilized to measure their level of confidence and intent to use the gender identity tool kit.

Results

The education intervention took place in an out-patient office setting in Washington State. There were eleven participants (N=11). The results of the study indicated significant improvements in various aspects related to the participants' confidence, intention, motivation, support, and positive attitude towards using the toolkit. According to the survey results prior to this education only 36% (n=4) of the participants had ever heard of the toolkit and 0% of them had ever used the toolkit. This underscores the need for raising awareness and providing education about the existence and purpose of the toolkit. The education intervention led to a substantial increase in participants' confidence in using the toolkit, their intention to use it, their motivation to engage with it, and the level of support they felt in utilizing it. These changes were statistically significant (p < 0.05), indicating the positive impact of the educational program.

Sustainability

The sustainability plan focuses on continued education and support for clinicians, aligning with the organization's commitment to health equity and quality improvement. The study's results underscore the urgent need for healthcare providers to be educated about transgender care and the effective use of tools like the gender identity toolkit. By addressing these gaps, healthcare organizations can improve trust, communication, and the quality of care provided to transgender individuals, ultimately leading to better health outcomes for this marginalized community. All education materials will be provided to the quality improvement team for use in future training. Health equity measures have become a focus within the quality improvement department of the organization and the team has reported the desire to continue these training sessions in the future.

Implications

The use of the gender identity toolkit benefits the organization by helping increase quality measures such as health maintenance scores. It does this by ensuring that transgender patients are receiving primary prevention health maintenance such as mammography, cervical screening, and sexually transmitted infection screening. Sustaining this project will benefit the patients in this community and the health care organization. The Center for Medicare Services has provided a framework for 2022-2023 that provides guidance for organizations to attain the highest level of health equity for all people (Center for Medicare Services, 2020). The top priority is to expand the collection, reporting and analysis of standardized data (CMS, 2022). This quality improvement project directly correlates with this goal.

References:

Austin, A., Craig, S. L., D'Souza, S., & McInroy, L. B. (2022). Suicidality Among Transgender Youth: Elucidating the Role of Interpersonal Risk Factors. Journal of interpersonal violence, 37(5-6), NP2696–NP2718. https://doi.org/10.1177/0886260520915554

Cahill, S., Singal, R., Grasso, C., King, D., Mayer, K., Baker, K., & Makadon, H. (2014). Do ask, do tell: High levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers. PLoS ONE, 9(9). https://doi.org/10.1371/journal.pone.0107104

Caughey, A. B., Krist, A. H., Wolff, T. A., Barry, M. J., Henderson, J. T., Owens, D. K., Davidson, K. W., Simon, M. A., & Mangione, C. M. (2021). USPSTF approach to addressing sex and gender when making recommendations for Clinical Preventive Services. JAMA, 326(19), 1953. https://doi.org/10.1001/jama.2021.15731

Downing, J. M., & Przedworski, J. M. (2018). Health of transgender adults in the U.S., 2014–2016. American Journal of Preventive Medicine, 55(3), 336–344. https://doi.org/10.1016/j.amepre.2018.04.045

Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H.-J., Lehavot, K., Walters, K. L., Yang, J., Hoy-Ellis, C. P., & Muraco, A. (2014). The Health Equity Promotion Model: Reconceptualization of Lesbian, gay, bisexual, and transgender (LGBT) health disparities. American Journal of Orthopsychiatry, 84(6), 653–663. https://doi.org/10.1037/ort0000030

García-Acosta, J. M., Castro-Peraza, M. E., Arias Rodriguez, Á., Perez-Cánovas, M. L., Sosa-Alvarez, M. I., Llabrés-Solé, R., Perdomo-Hernández, A. M., & Lorenzo-Rocha, N. D. (2019). Impact of a formative program on Transgender Healthcare for nursing students and health professionals. quasi-experimental intervention study. International Journal of Environmental Research and Public Health, 16(17), 3205. https://doi.org/10.3390/ijerph16173205

Grasso, C., Goldhammer, H., Thompson, J., & Keuroghlian, A. S. (2021). Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and Population Health Management in Electronic Health Record Systems. Journal of the American Medical Informatics Association, 28(11), 2531–2535. https://doi.org/10.1093/jamia/ocab080

Hoy-Ellis, C. P., Fredriksen-Goldsen, K. I., & Kim, H.-J. (2022). Utilization of recommended preventive health screenings between transgender and cisgender older adults in sexual and gender minority communities. Journal of Aging and Health, 34(6-8), 844–857. https://doi.org/10.1177/08982643211068557

Institute of Medicine (2024). Health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press

Mclver, L. S. (2022). CMS Framework for Health Equity. CMS. Retrieved October 13, 2022, from https://www.cms.gov/go.cms.gov/framework

Patel, K., Lyon, M. E., & Luu, H. S. (2020). Providing inclusive care for transgender patients: Capturing sex and gender in the Electronic Medical Record. The Journal of Applied Laboratory Medicine, 6(1), 210–218. https://doi.org/10.1093/jalm/jfaa214

Rycroft-Malone, J., & Bucknall, T. (2010). Models and frameworks for implementing evidence-based practice linking evidence to action. Wiley-Blackwell.

Safer, J. D., Coleman, E., Feldman, J., Garofalo, R., Hembree, W., Radix, A., & Sevelius, J. (2016). Barriers to healthcare for transgender individuals. Current opinion in endocrinology, diabetes, and obesity, 23(2), 168–171. https://doi.org/10.1097/MED.0000000000000227

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Tammy Davis digital poster .pdf (262 kB)
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