This patient safety learning laboratory (PSLL) will address the intersection of two major gaps in the science of patient safety: 1) psychosocial patient harm / avoidable patient suffering, and 2) patient safety for transgender individuals. It will leverage an interdisciplinary team of clinical and systems improvement experts to make an innovative, and sustainable contribution to AHRQ’s patient safety mission. It will also address AHRQ’s call for health services research to advance health equity. Transgender individuals are an AHRQ priority population. We will also address intersectional impacts of transgender status by targeted recruitment from additional AHRQ priority populations: low-income individuals, minority groups and people with disabilities. Psychosocial harm has been largely neglected in the science and practice of patient safety, despite evidence of its pervasive and consequential impact. The TRANS-SAFE PSLL will advance patient safety science by identifying and addressing the systemic causes of psychosocial harm in perhaps the most vulnerable patient population–transgender people. Because of widespread stigma, many transgender individuals live on the margins of society, facing discrimination, exclusion, and violence. Transgender and gender non-binary (TGNB) individuals also experience mistreatment in the healthcare system, leading to direct (psychosocial) harm and indirect physical harm. >30% of transgender individuals report delaying or not seeking care due to discrimination, which may lead to diagnostic delays and preventable disease progression. As a result, they experience poor health compared to “cisgender” (non-transgender) people. This PSLL will improve patient safety for the transgender population through 3 specific aims: Aim 1: Identify the contributing factors leading to avoidable patient suffering in transgender individuals [Problem analysis]. Apply human factors, improvement science, risk management, and biopsychosociotechnical systems approaches to conduct a human-centered problem analysis that identifies determinants of avoidable patient suffering in transgender individuals, including issues such as misgendering, disrespect, abuse, and “getting lost in the system.” Aim 2: Co-design human-centered solutions to prevent and mitigate avoidable patient suffering in transgender individuals [Design, development]. Engage with the full range of stakeholders in an iterative process of co-design and development, using both new and proven tools to produce interventions that address the systemic determinants of psychosocial harm in transgender individuals. Aim 3: Evaluate the effectiveness of proposed interventions in real and simulated and clinical environments [Implementation, evaluation]. Test the interventions designed in Aim 2 in both actual practice settings and in simulation to evaluate effectiveness, acceptability, usability, implementability, and sustainability. An innovative dissemination approach (a certification program in partnership with the World Professional Association for Transgender Health) will facilitate widespread and sustainable impact.

Narrative The proposed research is relevant to AHRQ’s mission “…to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.” It will employ a range of systems improvement approaches to generate evidence to improve patient safety, healthcare quality, and accessibility for transgender patients– thus making healthcare more equitable for this vulnerable patient population. Through an innovative partnership with the World Professional Association for Transgender Health (WPATH), the evidence generated through this research will be translated into a TRANS-SAFE certification program for healthcare organizations, ensuring that the evidence is understood and used at scale.