A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients

Abstract

Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dualminority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender (BLGBT^) racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

Development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients and their Clinicians

“…This is particularly concerning given the array of clinical contextual factors that can be leveraged to support SDM. 84 Thus, much more research is needed to obtain a comprehensive understanding of shared decision making among African-Americans along the entire spectrum of gender and sexual orientation, and how patients' intersectionality can influence physician perceptions and behaviors, the patient/physician relationship, and shared decision making within the clinical encounter. This paper focused on the synergistic negativity that multiple minority statuses may engender.…”

Use of Decision Aids with Minority Patients: a Systematic Review

“…41 Another opportunity for promoting SDM for minority patients is to consider making changes in the clinical environment. 42 The reality is that DAs cannot be designed for every micro-decision that occurs in the life of a patient and it may be potentially more important to create a culture of SDM. DeMeester and colleagues explore the drivers and mechanisms required to impact care; the model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives.…”

Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap

“…65 Ways to improve SDM with AAPI SGM range from simple recognition and awareness of implicit and automatic biases to more complex institutionalized changes to clinic culture and procedures. [22][23][24][25][26]36,[38][39][40][42][43][44][45][46]66,67 These changes include eliciting sexual orientation and gender identity in a culturally competent manner, and training providers and AAPI SGM to empower patients to expect competent care and to take appropriate actions if they do not receive it (Table 2).…”