title: 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 dual-minority 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 ("LGBT") 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.
authors.affiliation: Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.|Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
authors.forename: Rachel H
authors.initials: RH
authors.lastname: DeMeester
authors.affiliation: Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
authors.forename: Fanny Y
authors.initials: FY
authors.lastname: Lopez
authors.affiliation: Institute for Medicaid Innovation, Washington, DC, USA.|Department of Obstetrics & Gynecology, Medical School, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Moore
authors.affiliation: Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.|Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Cook
authors.affiliation: Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA. mchin@medicine.bsd.uchicago.edu.|Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA. mchin@medicine.bsd.uchicago.edu.
authors.forename: Marshall H
authors.initials: MH
authors.lastname: Chin
mesh_terms: D001291:Attitude of Health Personnel; D003657:Decision Making; D005006:Ethnicity / Q000523:psychology; D006801:Humans; D008490:Medical Informatics / Q000458:organization & administration*; D008913:Minority Groups / Q000523:psychology*; D017146:Models, Organizational; D015279:Organizational Culture; D010348:Patient Care Team / Q000458:organization & administration; D010358:Patient Participation; D011287:Prejudice; D011369:Professional-Patient Relations; D000072339:Sexual and Gender Minorities / Q000523:psychology*; D057188:Workflow
keywords: bisexual; disparities; gay; lesbian; practice redesign; race and ethnicity; shared decision making; transgender