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A Health System Level Model for Improving Transgender/Gender Non-Conforming Health Care Quality


By James M. Ding, MD, candidate, Perelman School of Medicine, University of Pennsylvania, and Jesse M. Ehrenfeld, MD, MPH, founding director, Vanderbilt Program for LGBTQ Health, Vanderbilt University Medical Center, and senior associate dean, Medical College of Wisconsin

Health systems routinely fail to provide culturally competent care to transgender and gender non-conforming (TGNC) patients. 

According to the National Center for Transgender Equality 2015 Transgender Survey, 33% of respondents receiving health care in the past year reported mistreatment, harassment or other negative experiences. While some health systems have taken initial steps to remedy the problem by offering trainings in trans-competent care, this limited approach would benefit from additional, scalable strategies to ensure comprehensive, consistently high-quality care across a health care system.

In a recent Joint Commission Journal on Quality and Patient Safety article, we detailed a set of TGNC patient-specific initiatives being piloted at Vanderbilt University Medical Center (VUMC), Nashville, ranging from direct TGNC clinical services to development of a system to monitor quality of care provided to TNGC patients. These TGNC health care improvement initiatives, all of which center patient preferences to ultimately improve TGNC health care quality, are detailed below.

Trans Buddy Program 

The Trans Buddy Program is a peer-advocacy program that pairs TGNC patients with trained volunteers who can advocate on behalf of the patient and offer logistical and emotional support during the patient’s clinic, hospital or emergency care visits. TGNC patients can request a Trans Buddy themselves, or providers can request one on behalf of patients with their consent. By directly supporting patients, the program augments TGNC patient services by reducing fear of discrimination, regardless of location within the VUMC system.

Clinic for Transgender Health 
VUMC operates two transgender health clinics, one adult and one pediatric, that provide high-quality transition-related specialty care. Operating on a weekly basis, these clinics offer primary care, hormone therapy and surgery consultation services with a highly qualified team of multidisciplinary providers who work closely with referral services for gender affirmation surgery and mental health care. 

Community Advisory Board
The Vanderbilt Program for LGBTQ Health convenes a community advisory board composed of patients and community members with heavy TGNC representation, offering guidance for Program initiatives, including:

  • the Trans Buddy Program
  • Clinic for Transgender Health,
  • other community engagement initiatives
  • medical education initiatives

The community advisory board is vital, providing a key avenue for TGNC patient and community feedback to guide development and refinement of a variety of TGNC patient care initiatives.

Monitoring and Evaluation System

VUMC has developed several programs to better identify usage and quality of care received by TGNC patients, including Trans Buddy encounter reports and electronic health record identification of TGNC patients through, for example, structured sexual orientation/gender identity (SOGI) data collection. Collectively, these have helped VUMC gain important insights into specific areas of improvement for TGNC patient care and have opened an avenue to recognizing providers/clinics that are providing exemplary service while offering targeted trainings those who are needing improvement.

Future Directions
These four VUMC programs are part of a scalable model designed to reduce the variability in TGNC health care quality by deeply incorporating transgender community feedback and continuous quality improvement into program development. By approaching TGNC health disparities from a variety of angles, from peer advocacy networks to improved tracking of TGNC quality of care, this model has the potential to improve TGNC health care quality received by patients at the health system level.

James M. Ding, MD, is a candidate in the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. 

Jesse M. Ehrenfeld, MD, MPH, is professor of Anesthesiology and senior associate dean and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin in Milwaukee. He is also adjunct professor of Anesthesiology and Health Policy and founding director of the Vanderbilt Program for LGBTQ Health at Vanderbilt University Medical Center in Nashville. Dr. Ehrenfeld’s research focuses on understanding how information technology can improve surgical safety and patient outcomes. His work has led to the presentation of more than 250 abstracts, as well as the publication of more than 200 peer-reviewed manuscripts.