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Panel Discussion: Implementing the Five Focus Areas for Advancing Equity Through Quality and Safety

Learning Objectives:
1. Describe strategies to embed equity into quality and safety operations
2. Recall approaches to build leadership support and buy-in to ensure equity is embedded at every level of the organization
0.75 Credit CME

This introductory course introduces the framework for embedding equity into quality and safety, which was developed by Brigham and Women's Hospital and the Institute for Healthcare Improvement. This activity will provide an overview of the five focus areas and how the framework was implemented at Brigham and Women's Hospital.

This video excerpt was taken from the official Kick-Off of the AMA's Advancing Equity through Quality and Safety Peer Network in January of 2022.

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Video Transcript

Karthik Sivashanker, MD: [00:32] Why don't we just open it up with you, Lou? So, you know, this five ever framework is a general kind of outline in a lot of ways. And so maybe I'd love to have you share about, you know, how did you learn about the work? How did you uniquely operationalize it? What was similar? What was different? Just any insights that you'd like to start off with.

Louis Hart, MD: [00:55] Absolutely. You know, I think it started in residency. You know, I was finishing up residency. I was always passionate about quality improvement, and ways in which we could measure differences. I did my training at NYU Bellevue. So we spent half our time at, you know, a preeminent academic medical institution, well resourced, the margins look great in terms of our financial results. And we were paired up with Bellevue, our nation's oldest public hospital. And one of the--you know, in New York City being one of the wealthiest cities in our country, if not the world, but one of the most segregated as well. And somehow just two city blocks away, the patient populations were night-and-day different. Yet every doctor in Bellevue was an NYU doctor. We behave differently over the air, we treated patients a little differently, we expected different outcomes for those patients. And no one was really naming the elephant in the room. So I said, Why don't I use quality improvement, we can start to measure these things. And so that was always something that I was passionate about.

[01:45] After finishing my training, I ended up staying on at New York City Health and Hospitals. I did a clinical leadership fellowship in the Office of Quality and Safety, where I was able to work with our CQO and our chief value officer to really get a better understanding of kind of systems-level thought and theory, as opposed to just my individual unit-based projects that I'd had so much success and so much joy doing in pediatrics at a couple of our hospitals. And I was, you know, during this process, I was very much—you know, I think I brought this background being biracial, growing up in Canada, just seeing this idea that American health care system is just so inherently unfair. It's just mind blowing to me how we've set it up. And probably just, you know, my own racial awakening, you know, being a biracial, half black half white guy in Canada, you're just Canadian. But in America, I very much knew I was a black man in this country, no matter that my mom was five foot ten, blond hair and blue eyes—it just didn't matter. I guess that's the one drop rule so many of us have heard. And I think there's so many little things in life that have brought me here, like us all, these experiences that make us.

[02:45] And in the clinical leadership fellowship, I was fortunate enough to go to an IHI conference where I heard Karthik speak. And this was our first introduction, and me just being the geek sitting up front, taking notes, raising my hand. I reached out to him—I think it was on LinkedIn, or maybe I had his email address, it was some very—and he ended up just so gracious. He showed me some of the things he had been writing, we talked a little bit. And you know, I was just drinking out of the firehouse at that point. So I said, I'm going to bring those things right back into my fellowship, and I'm going to use that to this project that I've been making called Lessons Learned.

Hart: [03:14] And this was lessons learned from our quality assurance performance improvement subcommittee to the board. And the Health and Hospitals is an 11 hospital, 70 clinic, five nursing homes, we run Correctional Health for New York City—the largest municipal public hospital system and health care system in the country. We—every hospital, every quarter, they present their worst adverse events, things that are so grave that really requires serious corrective actions so that they do not occur to another one of our sites. These would be, you know, a neonate dying after birth, or the passing of a mother or a wrong site surgery, things that really just cannot happen in health care. And all too often, when I talked to the fellow board members, they'd say, “I've heard this case before, like didn't we just talk about it last week, or last month or last quarter at a different hospital?” There was no site-wide learning. And I said, well are there—I mean, they're probably minutes that are sent out, but who reads those? Is there a way that we can invite some type of memorializing these things in a very innovative and exciting way? Maybe it's a millennial hat I'm wearing like, there's got to be a better way to distribute this stuff in an educational way that has risk management at its forefront. And they said, that sounds like a project for you, fellow.

[04:19] So I created this Lessons Learned project where we created--the system that brought those types of adverse events, we actually kind of asked them to be involved with us, our central office quality and safety team--to create an educational module. And we wanted medical students, residents, maybe some junior faculty, and then the quality leads, either the CQO or the patient safety officer, to also sign off on this work. But to really get content experts and then some young upstarts, who very much had leadership conviction in this work, to really craft these kinds of educational modules that would teach a lesson learned from that adverse event that we could then spread throughout GME, that we could spread to all-facility email blasts or different forums, that we can spread to local departmental meetings—so that people can just hear about this. Screensavers—I mean, this was innovative stuff for a bureaucratic public hospital system that we could like, share our bad mistakes, and we can all actually get better from it.

[05:08] At the end of the day, people just loved it. And I think the best part is, as I started to ingrain this kind of equity lens onto it, we said, let's take it a step deeper and let's talk about those intersections. Let's talk about the opportunities where you know, the either the interpersonal bias, the really ugly, explicit stuff, or maybe even people's implicit biases, but how we treat people—you know, those VIP patients in the emergency department, or those frequent fliers, or the that asthmatic in room oh four, or the Sickler down the hall—these types of ways that that might have impacted the care more than just the more traditional approaches that we were looking at quality and safety.

[05:40] I think the brilliant approach of this strategy is that if I just went to the board and said, social justice, racial justice, to some people, they'd say 100%. And there are generational kind of overtones to this type of work where that means completely different things to people who saw what this in the background, and for people like me who only read about it. So I think to that understanding that can be very polarizing. But if we talk about racial justice is just patient safety, and social justice is just quality improvement, it's to people that like, Absolutely, that's—100% that's a priority, we should be doing these things. And if you apply that intentional, kind of purposeful, let's make sure that all patients are benefiting, let's not do the colorblind approach, let's share if our systems are truly resilient and so amazing and we think that everyone can benefit from our quality, let's make sure everyone's benefiting from our quality. Let's do that audit. It's not that much work. We already have systems to collect demographic information in our EMR, we really have people who are doing quality improvement, patient safety risk management work. Let's ask a little bit--just like quality is everyone's responsibility from the person who's providing lifesaving work doing environmental services to the person who's doing food nutrition to the person's at the blood bank, nurse, doctor—everyone's job is quality. Everyone's job has to be equity. So the same way we're kind of weaving this in.

Hart: [06:51] And you know, I think Karthik speaks so brilliant to this, the patient safety movement from that opaque to transparent from that really…let's underreport to now the best unit is the one that talks the most about these types of things, from being individual level blame to really, this is the system that put me in this bad role. It's a Swiss cheese model that let this happen. It starts to... those same lessons learned can absolutely be applied to this kind of ingraining equity movement. So I think that's the unique thing, and that was an educational approach that really, it spread like wildfire, in a good way. It was something that was so--people were excited about it. And when you'd—people that were non-traditional, like you wouldn't think of the CQO at this one hospital would be some pioneering health equity leader—the thing that he would write up with his colleagues there, or that she would write up with her colleagues? Impressive, the stuff that we were getting in terms of the deep dives into medical mistrust, and how that might have contributed, to why we were even worrying about that patient's capacity, and why we went against their will and violated that XYZ order. It was truly impressive, and it really just humanized everything in a way that we were very much afraid of in the past.

[07:51] So I think that's a unique lens that I brought from quality and safety. My wife is a first year Nicky fellow, and that's what prompted our move up to Connecticut. So now I'm up here at Yale in a little bit of a different role. Still ingraining some of these key drivers in our quality and safety, but I'm no longer in the Office of Quality and Safety. I'm in the office of clinical operations where we built a new Office of Health Equity. So it's a little bit of a different take. We have more of a population health or community health focus. As the medical director, I'm more looking at inside of the four walls, our clinical processes, how we collect data, how we utilize that data to marry against process and outcomes—you can see the quality and safety background. But really, it's about kind of moving upstream.

[08:26] And you know, a lot of people will talk about this. There are things in our country that predict. Like we know your ZIP code predicts your mortality more than your genetic code. That's really unacceptable. And it just makes no sense why that should. We talk about inequity, something that's preventable, something that's unjust, and that is insidiously happening all too often. We've heard of redlining. You can literally put up a map a life expectancy and take that same 1937 map of redlining, it's pretty darn matching up. So we know that there's historical things in our country that have put us down this pathway. It's time we acknowledge those, it's time we are un—are comfortable with these things that have happened as much as we can be. It's... at least be comfortable with the uncomfortableness that it is. This is just a reckoning. This is reality, and to some people, this is their everyday. We want to create brave spaces for people going through this? What about the brave spaces for people who are the victims of this type of work? So we have to understand we're all coming from different places, but as long as we have that respect and dignity, we will get through this together, because we're all evolving on this path.

[09:20] So I think the work that I do now is a little bit different, because it's much more of a community health focus, and then there's much more of the work I do around eliminating race-based algorithms, things that use race as a biological variable. Race is a social construct. It's made up by us, and it only gives...it only has the power that we give it. Unfortunately, because of historical racism, certain systems have been built in place to perpetuate different results or different treatment that has produced grave biological consequences. So a silly social construct that was made up to kind of categorize people, a means to an end for political gain, has now actually caused biological harm. So now we have to measure it to ensure that we can start to eliminate it. We almost have to use this same tools to get rid of something that should have never existed in the first place.

[10:03] So, you know, I get so privileged to be around such brilliant colleagues and all of you on the call from all around the country to see how we're going to do this in individual settings, but coming from a safety net public hospital system, to now an Academic Center, it's very different work, but it's very similar. And a lot of the lessons that I learned at the safety net system, I'm trying to apply on a different scale, but not just directly with that quality and safety. I'm not in the office of quality and safety. But I'm bringing some of those lessons learned because again, I think it's insidious and--insidious is negative. It's strategic, because again, if you just come around, you're waving your social racial justice flag, I'm an advocate for what's right, we must defend gay rights, we must defend for those who have mental health and who are being under treated--yes, yes, yes, everyone agrees to that. But that hasn't been enough to activate people. But if we can somehow ingrain the things that we were already doing, that we already hold ourselves responsible for like patient safety, like risk management, like quality improvement, and we just add that equity lens on top, we're not actually adding that much burden on to the workflow as long as we can create those kinds of spaces. And we're only going to be able to create the systems that are then responsible. It takes it off the individual and puts it on all of us to actually advance this work. And I think that's what the secret ingredients, the secrets ingredient to this sauce.

Sivashanker: [11:16] That was brilliant. If you want to hear Lou talk more, which I always do, there's a prior—I think it's a Prioritizing Equity episode with Lou and Kadar Mati from IHI, president of IHI, having a discussion about quality and equity. Thank you, Lou. Karen, I want to go over to you and kind of hear your story about how this began from your perspective, because, you know, all these institutions were at different places. And by the way, we got a chance to see some of the work that you've already started in your in your slide decks and the overwhelming reaction was incredibly impressive, and that everyone's at different places. So maybe we can spend a few minutes just you sharing how did it begin? What did you learn? What was easy? What was hard? Just any insights you want to share.

Karen Fiumara, PharmD, BCPS, CPPS: [12:05] Sure. So Lou, you are an unbelievably tough act to follow. Not at all going to be as inspirational but probably a little bit more tactical, and maybe a smidge more on the operation side. So I think as Karthik mentioned, you know this all started for me and I think for Brigham in a bit of a different way. So I have...I'm a pharmacist by training. It's probably important for you all to know that. I started in the patient safety group, I think it was about 12 years ago, but I've been at Brigham and Women's Hospital for about 20 years. And I never know if it's 18 or 20 but I started in 2001, so I think I'm at the 20-year mark now.

[12:50] The long story short is I really think this began--and Karthik, you can correct me if I'm wrong--but for me, the way that I really remember this beginning is Karthik coming into my office one night and it was late and we were working late. And Karthik said, you know, we have all these equity positions that have been funded at Brigham, but what I really think that we should think about is, how do we leverage the teams and the work that we're doing in a much more comprehensive way to think about equity? And I think we had maybe a 5 to 10 minute conversation that resulted in me being like, "Wait, what do you mean, there's equity? There shouldn't be equity roles, like, it's not a thing that people do." This is...my equity-informed high-reliability training, my safety training, instantaneously kicked in, and I immediately started thinking: systems performance behaviors. Like how...the same way I think about a wrong side surgery, the same way I think about a med error or a dispensing issue--this is not a thing that I think that we should be doing. This is you know, from a structure, process, and outcome standpoint, how do we make—just like safety is everybody's job, just like quality is everybody's job—even more so this just needs to be embedded at the systems level throughout everything that everybody does.

[14:26] And Karthik and I then worked together over a period of time to try to do the tricky work of embedding equity into every aspect of our work, and the even more challenging work, teaching the teams that roll up to me. It might be worthwhile for you all to know this. In my role, I actually oversee the patient safety team. So at the Brigham, and I know everyone's quality departments are set up differently. But at the Brigham, I report to our chief quality officer who just until very recently was Andrew but then he left me to go on to much bigger and better things, so reporting up to Andrew. And I am over the patient safety arm, which is: patient safety, risk management—so the four hospital lawyers, and the patient safety team's probably a group, I should know this, but probably group of like eight to nine--the four hospital lawyers, as well as our patient family relations team, the team that responds to patient complaints and grievances and manages all the CMS regulations. So if a group of [unintelligible] is 25 to...about 25 folks that roll up to me, and so the work was really around, how do we embed equity into absolutely every aspect of our work and everything that we're doing? And the immediate thing that I did--we didn't ask for permission, that's the other thing about all this. I can't remember how many years ago this was. Karthik, you can probably...like, I blink in six months go by so I have no idea.

Sivashanker: [16:02] It was before the pandemic. I measure everything by the pandemic.

Fiumara: [16:05] Very fair, that's a very fair point. There was a time before the pandemic? I had no idea! And the really, one of the really tricky parts of all of this was teaching the folks that--my team--that this is all of our work, and that even though we had a medical director that was focused on equity, thank god Karthik, that it... When we had a case, that was an equity concern, it wasn't [click] volley over to Karthik. It was, this is part of all of our work. My Risk and Safety person who does surgery, like manages the surgery service line, when there's an equity--like this is your work. And more importantly, when you're assessing that wrong-site surgery or that retained foreign object, it's not--one of the system contributors you need to think about is inequities. One of the performance issues you need to think about is unconscious bias. One of the behavior issues you need to think about is explicit racism, and what do people say and how did they interact? And that for everything we do, the same way I think about waiting as a factor with you know, why something might have gotten missed in an OR. Like an environmental factor, you think about environmental factors, think about communication issues, you think about IT issues, you can think about inequities. And that just has to be part of your, your constant process, not just for cases that are clear equity cases, but also cases that on their face aren't anything about that at all.

[17:52] And almost—I don't want to say most importantly, but as important--as you're building your corrective actions around when things go wrong, making sure you're building those interventions to be supportive of our most historically marginalized populations. And one thing that recently came up that I can't believe this--Karthik, this literally came up two weeks ago and I'm like, Karthik is going to be so mad at me that I didn't think about this before—we had a wrong-sided pain injection in one of our pain clinics. And as we were talking through it and you know, the site marking and was the site marked? Yes, but it really wasn't visible. And of course, this—well, not of course, oof, that was that was terrible thing to say—and in this particular case, this was, I think it was a white English-speaking female and we were talking about the site marking and yep, the site marking was visible, but then it instantly...but I'm like, have we, are we sure that the markers show up on all different skin tones? Has anyone really looked into...? After you put it on and then you wipe it off? Like I know on a light skinned person it kind of rubs off, and it's a black marker. On darker skin tones, what happens? And literally I had a few friends I'm like, put it on them and wait, there's an inequity there! And that there's a risk there. And truly before that conversation with Karthik however many years ago, I would never have thought about it that way. And I'm super embarrassed to say that but it's 100%, totally true.

[19:35] And so this is, to me, this is you know, everything that we do with the Brigham in my shop and my lens, it's all with an equity-informed higher liability framework and approach. And it's really not about doing a thing or running a project or having an equity leader here or there. It is about embedding this in the fabric of all that we do, making it our DNA. Whether that's a collaborative case review, or M and Ms, or, you know, our peer review committees, or when we report stuff to the board, and when I report stuff to the Department of Public Health, when I interact with our regulatory leaders, I always talk about this. It's everywhere, or we try to make sure that is embedded everywhere.

[20:27] And again, the piece that I wanted to just come back to for a moment is while--I think we have to acknowledge that while this is for me, for whatever reason, for me, there was a 5 minute or 10 minute conversation, and then it was like, this is so obvious to me, that this is the way that we should do this moving forward, the exact same conversation can be had with others, and it's not. The level of discomfort of my team, with having some of these conversations, and the number of people that I had crying in my office like "Karen, I kind of feel like you're asking me to call that person a racist?" I'm like, "Ehh, nope, I'm not asking you to do that. No, not at all the point here." However, we have to talk about these things. And we have to be comfortable just getting into this. And own that you're uncomfortable, it's okay. Just own that at the beginning of the meeting, say this is going to be strange, might feel strange for all of us. But we're safe. We're here together, we're here to support each other, and this is how we're going to move forward. So the training, the skill building, the socialization of getting teams that are not used to these conversations to a place where they are and that everybody truly sees this as being part of their work. And to this day—and I have a big team—I can't sit here and authentically say everybody's locked in. There continues, we continue to iterate and we continue to get better and better and better, but it's definitely without question a work progress.

I hope that was helpful. Is there anything else you want me to talk about, Karthik?

Sivashanker: [22:11] That was wonderful. So I was having a moment of pride, because you were talking about the beginning of the journey for us together in this work, and I remember when we first started, you were nervous about talking about it, like you weren't sure about what words to use. And you were, you know, do I say it this way or that way? And one of the things that I always really appreciated was your humility, and how you, you were just modeling curiosity. And I compare that to now, and it's such a difference, you're just fluent in it.

[22:43] I'm going to hand it over to Andrew now. And I do want to come back to a couple of things. But Andrew, it's been just a real joy working with you and having a sponsor like you supporting the work. Can you just speak a little bit about what was important in the role? What did you find was easy? What did you not expect? What was hard? Anything that you'd like to share?

Andrew Resnick, MD, MBA: [23:07] Yeah, sure. No, thank you. And it's hard to follow all you guys because A, you're incredible, and B, you've shared a lot already. So I'll try to add just a few thoughts to that. First I just want to echo a comment made earlier, which is, you know, I've been in these kinds of roles at a number of organizations and I've never been in a place that that has both what we had at the Brigham in terms of the equity, and it just not a silo. And I couldn't say that more strongly, that when equity is sort of inherently put in as a silo, however strong a program someone might imagine, it's always going to be something else and we've put in so much effort to not make it something else. And you know, Karen mentioned when Karthik was in his role, and we have three medical directors now and I think they're all on the call, one of the things I tried to do—in fact, when Karthik was in his role, too—is not have it be, you know, now Karthik's going to come and talk about equity or, you know, Karthik as the equity police, you know, coming to debrief the group about equity. Yes, to help facilitate, yes to be the expert, although we're all learning, but not to be the "equity person" and then everyone else is the audience. So equity belongs to everyone and the less of a silo it is, I think, the better.

[24:34] So, I was thrilled to join the Brigham when I did, because it wasn't a silo inherently already, thanks to the work that Karen and Karthik and others had already accomplished. I think just from a, you know, trying to achieve the mission at the Brigham, which is to have equity embedded in everything at every level, there are some tips—and I know, I think we have another session coming up to talk to some of the leaders about that—but you know A, it should be talked about at all levels, right? So this isn't something that just belongs to the frontline or something that just belongs in the boardroom. It's something that belongs throughout the organization.

[25:13] And so we... One goal is to get everyone comfortable with talking about it, which is, as Karthik and Karen's both said, I mean, it's not an easy task to just turn it on, because there are emotions, people are upset about cases. It's so easy to fall in some pitfalls of Alright, let's go talk about how so-and-so it was racist up on the floor when, you know, kicked out this visitor or whatever. And I remember trying to avoid some of those situations with a lot of emotions. So, I think it's really important to try to educate and work through because those things are going to happen. There are emotions, no one wants to be called racist to Karen's point earlier, you know, when someone asked if that's what it was. Obviously just like patient safety, there's very few times where people purposefully do things in the safety world, and just the same, there's very few times where people consciously are carrying out racist activities in our hospitals, I think, for the most part. But there's so much unconscious behavior, and there's so much structural racism, and when everyone understands that our goal is to identify all the contributing factors and fix them all, even if they weren't contributing factors in that particular case. So Karen had mentioned this sort of counterfactual kind of thing where, you know, even if a patient was sent home from the emergency room, and was English speaking and did have commercial insurance and had appropriate discharge instructions, but we hear the story that someone was sent home and had some confusion and didn't fill their meds or didn't understand what to do, we always asked, what if? What if that was someone who didn't speak English, or didn't have, you know, the right safety nets around them, and so forth. And so we could really fix every potential contributing factor, not just the sort of obvious things, and I think that's how, as Karthik mentioned, we got to 200 action items in one year, and, you know, growing exponentially.

[27:16] What else? So at the senior level, you know, I'll just say a few comments about that, and I think maybe we'll talk more about it at the next session. But definitely, you know, it's tricky. And I think at the Brigham, we had the groundwork for transparency, and having pretty robust, transparent discussions in the safety world already. And that's, again, another plug for embeddedness and safety, because our board was already sort of used to hearing about bad outcomes and things that are pretty challenging to talk about. But, you know, even with that, I remember, it was actually my first board meeting, there was a case presented that was sort of broaching the equity world, with a disability case. And it created a lot of emotion. And some of the leaders were, you know, I think embarrassed that the case was brought up. And it created a lot of back discussions and whatever. And the result of that was Karthik actually came to the board and gave a board education on equity, which I think was really, really helpful.

[28:20] And, you know, we kept at it, we made it one of our organizational goals, to embed equity in every--you know, first in patient safety--and then in everything we measure in the Department of quality and safety. That was helpful. We kept talking about it, we kept presenting data. And, you know it was thrilling, you know, frankly, about, it must have been last summer, so when we were talking about basic quality metrics, like quality and CLABSI, and mortality and things like that, and the board said, "Hey, how come you're not showing us this data, you know, by demographic?" And I know Karen remembers that and Esteban, who's on the call I think, remembers, because we had a quick huddle after that, and we were like, "Alright, what are we doing? We got to, we got to present the board with this data." And did some quick work, and then did that. So I think that was a sign that we sort of had gone pretty far with that, that everyone was talking about it. And I think it basically is in so many of the scorecards and all that and is part of all the conversations now and the fact that Karen mentioned that case, which again, my meter goes to a positive point when I don't have to deal with those safety events anymore. But yes, so great that those things are being asked. You know, it's just so great to hear about. So, you know, I know we'll talk more about it, and obviously, I'm happy to answer any specific questions.

Sivashanker: [29:48] So we got a question from—thank you so much, Andrew. I'm also now feeling a moment of pride. What's interesting is that we've been on a journey and you're all on a journey, so I'm kind of having this meta-awareness moment right now in just seeing how the work is transforming us as individuals. And I think you're going to find that for yourselves as well as we start to do this work, or continue to do the work. But there's a question from the chat. And it was about what are some best practices that safety... that hospitals are doing that large academic medical centers can learn from? I'm going to hand that over to you, Lou. Maybe you can share what were some interesting lessons or initiatives or things that you were doing in New York City Health and Hospitals that we can learn from?

Hart: [30:32] You know, I think it's...there're some serious tactical advantages that safety net systems have, because they tend to be located in the communities--not that academic centers aren't--they tend to be well staffed by individuals who are themselves community members. I know a lot of the academic centers, you can draw a map around New Haven, and then you can see where the senior leaders live, and you really have to get outside of that inner rung of the city of New Haven not to say that some absolutely don't. Whereas in Health and Hospitals, Brooklyn, Bronx, Queens, our CEO lived in Brooklyn, in a part of Brooklyn that 20 years ago, no one would have lived and that was up and coming. It's just... I think there's some serious tactical advantages. So the idea of like, when we were thinking about community intervention programs, we could literally go to our staff, and they, everyone lived in those communities. It was extremely fortunate that around 48% of our senior leadership, we're talking VP or above, were racial or ethnic minoritized folk. And at every level of leadership, women outnumbered men.

[31:24] So this isn't the ultimate unicorn of health systems so--I think that that so much has guided me, and obviously, that's a change of pace now that I'm at Yale. And I continue to struggle with, you know, for those on the call to a term called code switching, and how I can speak to this work. And the idea is that in certain contexts you have to tailor your message and speak a certain way and in other ways you can absolutely speak from a different point of view. And I think this is also generational. And that's why I love having different team members from different generations. Because when I speak to this, I think....and this is my humble opinion, but I do think that millennials and Gen Z just have a different opinion on this work. And going forward, that type of culture that we embed, that we hold, seems to approach these issues a little differently. We tend to get less uncomfortable with these words. When I say racism to some people, it means the ugliest fire hoses and dogs and back of the bus. And to a younger generation, it means not being treated fairly. It just means different things; it means different outcomes. It means...so to that point, when sometimes I'm presenting at Yale and I say something, and I can just see people get so turned off and I'm just like, oh, gosh, I really thought I...I'm Canadian, I did that in a really nice way. I didn't think that I wasn't being too approachable. I by no means...I'm blaming a system. I'm saying that it's, we've all been conditioned to believe this. It's no one—it's none of our faults, it's just the way that we we've been brought up and acculturated. But yet, obviously to some people—you know and to many people—that impacts them differently.

[32:46] Whereas at Health and Hospitals when I was like, we should just ask this prompt to the board, discuss the implications of structural inequity or bias and how they contributed to this adverse event. The CQO looks at me goes, "It's a great idea. We'll do it next week." It was just like, Okay, that's pretty cool. So there's a different culture. Whereas I do that here, they're like, "Oh, well, it's a little different." So it's a different approach. And I'm still struggling with, you know, do I want to be so authentic to myself, but at the same point that might make me a lightning rod or a martyr, and it might actually do a disservice to some parts of the movement that I'm trying to lead here? Or do I tailor my message and maybe even not as authentic to myself? I'm still struggling with that.

[33:21] I'm thinking of the first—though I hope I'm not a martyr--but I am thinking about ways in which I will not do a disservice to this movement, but at the same time, can start to push people into that, you know, kind of brew healthy conflict and push people into those conversations where they have to engage, where they have to be a part of this change process that we're all in. But by no means is it easy. And definitely at Health and Hospitals, I think having that community engagement and being—but this is true to academic centers, I think we can learn—starting with employees who live in the communities that you're trying to prioritize, identifying them from HR by ZIP code. Who lives where, asking...inviting them into open spaces that are really much about improvement together, and kind of that shared governance approach—not saying what we can do for you, community. It's community, can you show us how we can help? Can we please be there? Can you allow us to be a part of what health equity looks like for you, not just what's our priority on top of our scorecard this year.

Sivashanker: [34:12] One thing that I'd like to hear a little bit more about is the difference in doing this work centrally within a quality safety team at a system level, versus doing it in a department or a center for health equity. I think that's an important difference about this approach, which is we're saying, I mean, do the work everywhere, but it is really important that we do it in our central system teams, etc. So maybe Karen, you can speak a little bit to you know, what was the power of that? And Lou maybe comments on like, what was the power of that in New York City Health and Hospitals and what's been different or challenging in your new role?

Fiumara: [34:55] Sure. So, at Brigham, when we started to do this, because the department of quality and safety has been well established, was well running, and was really embedded--and I don't want to use the word infiltrated but for whatever reason, that's the word that's coming to my mind--but you know, we did have, we do have connections throughout the organization, both on the inpatient as well as the ambulatory side. And we had those really strong...we had a very strong governance structure as well around the regulatory side of quality and safety and the pay for performance side, and the outcome measurement piece. So it...there's really that structure that's already in place to make sure that you have the connections throughout the entity that you're working at. And so to that end, when it just became equity is part of everything we do--just all of it, it's always with an equity informed lens and we're always thinking through counterfactuals, and all of that work--then, by embedding that...I believe over time you develop a common taxonomy, you develop common norms across various different groups.

[36:24] So it's not a...it's a little bit of a foxhole-by-foxhole issue, but you're already fully integrated, and you have an in and all of those foxholes, so it's not like you have to go to the nurses and start working with the nurses and then go to the docs and start working the docs, and then, ortho versus neurosurgery versus, you know, the department of medicine, versus dermatology, like all different departments at the organization. It's just, you know, you just start it. And then every time there's a review, every time there's an event, anytime there's a safety report filed, there's a mandatory field. Anytime you get feedback, there's an equity informed lens. Anytime you do a coaching or corrective action, you're making sure that you're taking in equity informed principles. So just by embedding it into your systems, really taking a systems-based approach, I believe that that makes it really percolate more.

[37:25] Now, the trick is, if you're at the system level, you don't necessarily have all that direct line of sight into those that are most acutely at the front lines. And the other piece—and I don't know if you all would agree with me, and I'm very open to feedback on this—I do think there is a little bit of loss of what I call street cred when you're at the system level, and you're not hanging out in the MICU, in the medical ICU, and, you know, no one's seeing you in the halls because you're not in the halls of the hospital. The benefit of the work that...when we started doing this work, one of the things that I have to say really did serve me well, is I had a track record of 15 years with these people, you know, with the teams. There was a level of trust, there was a...and so when you start having these conversations that are awkward--and I had no idea how to have and truly, I still think I don't know how to have these conversations, but you just own it, and you work through it—you know, everybody, for the most part knew me well enough to know, I'm authentically coming from a place of curiosity. It's all about improvement, and at the end of the day the true north is always our patient. So I think that this work at the hospital level, I think probably in some ways is, you know...potentially having it led at the hospital level, it's a little bit more maybe relatable because it's not something being done to the... It's like I'm kind of part of the team. Having said that, I don't know if that resonates with anyone.

Sivashanker: [39:14] Yeah, and that's...I've got be clear. When I say system, you know, for some of us, we think of like a Mass General Brigham. The system is Mass General Brigham, and then the institution is the Brigham and Women's. What I was really referring to I—yes, so thank you, Karen, you clarified that well. Lou, would love to hear from you on your experience, and then I'm going to hand it over to Andrew to kind of close us out with any last thoughts, but go ahead, Lou.

Hart: [39:37] Yeah, no, I mean, I just love being in such a good company. So many things resonate to it and it speaks to something that I'm talking with a lot of clinicians about and I'm like, we don't have nearly enough clinical leaders in health care, people who actually were at the bedside, and now we're having that bird's eye view. So there is something...it's like becoming a general with a lease. I mean, yeah, you can go to Officer Candidate School but you start a second lieutenant and work your way up. Sometimes we have generals who just came from other institutions, other fields of our...other sectors of the economy just because they have operational skills or leadership skills, but they, they're not humbled every day by being able to see a family or patients going through things that are so preventable, these injustices in our country that limit someone's ability to understand the way I'm trying to explain a medication, or even their access to medication, or even their transportation or their safety. I'm discharging a patient at the same stoop that, unfortunately, that they were a victim of violence at, and I can patch them up and put all the band aids in the world, but I'm still discharging them to that same stoop.

[40:30] So how can we break these cycles? I think the biggest piece that I think is something I'm learning here is that it's so ironic that in this work, we often aren't doing enough of this strategically, but like when we were trying to increase the adoption of vaccines across all groups, equitably, in certain minoritized populations, we were talking about—I'm thinking Black, Hispanic, Latinx, Native American—we were thinking, we need local trusted voices. We need people who look like those types of patients who—and by those type, those who potentially have that visible diversity, those who might have some cultural congruence there—to be able to take that community health worker approach. So in this—and everyone thought that would make a lot of sense, and I think it absolutely rings true—but in this work, too many of health equity leaders are often individuals with either visible diversity or invisible diversity that they make very visible. So the trans leader is the one leading the LGBTQ movement, and the Black physician is the one leading this campaign. We need to have trusted voices by people who potentially do not represent that marginalized status.

So when I have...when I'm giving a speech on this stuff, some people are like, "Yeah, that's great. Dr Hart's do such a great job." And some people are like, "Here's just another Black man talking about something." And I've just gotten feedback on this, but when my colleagues who have blond hair, blue eyes, dark hair, have fair skin, are women, men, but potentially they just bring a different perspective, when they just bring this a part of everything that they do on a daily basis, people look at that differently. And they go, "wow, that's a trusted voice to certain communities that might have never prioritized that or never thought about it through a perspective." Everyone's going to have a different perspective, and the perspective I bring to this work is only my own. I don't represent anybody else. But it's important to know that we make these assumptions, we have generalizations. So when you see a white man cisgendered, straight, talking about trans rights of the Black community, I mean, it's going to be a completely different message than if you had someone else leading it. So that speaks to the importance of allies who are not the ones who are underrepresented. Nothing for us without us—obviously, you want to have a trusted team—but it speaks to that we all have roles to play in this. And that's what's going to get us to the finish line.

Sivashanker: [42:32] That is such a brilliant point. And Karen, that's something I think that we did well, in terms of strategically using, or putting ourselves in places. So there might be conversations where we would say, Karen, you're the right person to get this message across. And oftentimes, it was you because you were trusted and known. And because you look like the folks that are in the audience and so we would work as a team to figure out how do we get the message across? And yeah, so really, really appreciate that point. We're at break time, but I do want to give you, Andrew, just a moment to share any closing thoughts before we go to break.

[43:12] Yeah, I don't know how to add to that one. You know, sometimes, as a white man, you know, sometimes that definitely resonates what Lou said and, you know, sometimes I felt challenged actually to sort of be the leader advocating for all this stuff, but it was always great to do it in a team the way that Karthik just described. So, that definitely resonated. Back just for one second about the structure piece. Because I think—you know, having been in number of organizations—I think structures are very different. And I love the structure at the Brigham because it brought patient safety and risk patient family relations, all the all the bad stuff, as I used to tell Karen, it brought it all together, so it could all have the same framework and it put Karen central to everything so that she was a trusted person and it had the same methodology and approach for all things.

[44:00] But there are organizations where, you know, the risk function lives under Office of General Counsel, and it's a totally separate function from quality and safety. And I don't know, you know, in fact I'm so happy, we're having this conversation—it's a learning peer network, and I'm glad we're all learning together because, you know, when we say it should be embedded in patient safety, and the approach fits so well with patient safety—absolutely true at the Brigham, couldn't, agree with that more--it might not exactly work the same way if risk was like, a negative function. And I'm not saying all risk is negative function if it's not in quality, but I've been in some organizations where it sort of was, and if it's, "Oh, the risk police are, you know, calling for an RCA so I have to go to this room and get dragged in there" and it's a little bit negative, that might not be as great of a fit, you know, to sort of roll out anti-racism and health equity into that. So, but the function exists no matter what it's called, and so I think embedding it in the performance improvement, quality and safety, whatever is the trusted group for an organization is probably the most important part but it certainly might be called different things in different organizations.

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Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Credit Renewal Dates: November 17, 2022

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.75  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.75 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
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  • 0.75 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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