Table 4.

Barriers and Solutions to Quality Healthcare for Lesbians and Bisexual Women

Participant-identified barriers	Potential solutions
Lack of disclosure of sexual orientation	Provider level: Encourage training in interpersonal skills for providers by providing education on lesbian and bisexual women's issues specifically.
	Clinic/Systems level: Make asking about sexual orientation “routine” during intake questionnaires; configure EHR systems so that for patients who choose to disclose sexual orientation, the information is immediately and appropriately available.
Gaps in provider knowledge	Provider level: Increased provider training.
	Systems level: Include issues around lesbian and bisexual women's health in quality improvement initiatives.
Poor provider interpersonal skills related to lesbian and bisexual women's issues	Provider level: Encourage training in interpersonal skills for providers with a focus on lesbian and bisexual woman-specific issues.
	Systems level: Collect data on patient satisfaction with interactions that are stratified by sexual orientation and use to feed back to individual clinicians, and for quality improvement.
Noninclusive office/clinic/hospital environments	Clinic/Systems level: Provide training to staff on lesbian and bisexual women' issues.
	This includes all staff who interact with patients on any issue (e.g., those who make appointments, collect information, provide financial counseling/help with billing, etc.); make questionnaires and EHR relevant and pertinent to lesbian and bisexual women. Ensure artwork, pamphlets, magazines, etc. are inclusive of lesbian and bisexual women.
Lack of lesbian and bisexual woman-friendly and woman-competent providers with relevant cultural and linguistic skills to serve minority communities	Provider level: Provider-specific education.
	Systems level: Encourage directories or referral services to link patients with providers who identify as providing these services. Collect quality and patient satisfaction data to provide objective information on providers who self-identify as lesbian and bisexual woman friendly/competent.
Lack of policies or lack of enforcement of polices about hospital visitation and medical decision-making rights for lesbian couples	Provider level: Provider education specific to these issues.
	Systems level: Encourage participation of healthcare organizations in initiatives to improve policies and processes (e.g., Health Equity Index program of the Human Rights Campaign); support system-wide efforts (including her-based initiatives) to encourage identification and appropriate documentation of surrogate decision makers for all patients, including those who identify as lesbian or bisexual women.

EHR, electronic health record.