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Tactics and Techniques for Incorporating Equity Into Case Reviews

Learning Objectives:
1. Identify contributors in harm events with an equity concern
2. Describe strategies for responding to and reframing conversations around harm events with an equity concern
3. Describe the hierarchy of corrective actions and how it is useful for preventing future harm events related to inequities
0.25 Credit CME

This video is an excerpt from the AMA Advancing Equity through Quality & Safety Peer Network Case Review session. This section offers a brief recap of an example case review flagged for an equity concern at the Brigham and Women's Hospital and discusses useful tactics and techniques for addressing the harm event, such as identifying contributing factors and applying a hierarchy of corrective actions.

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Video Transcript

Karthik Sivashanker, MD: [00:26] Hi, everyone. So as you remember, we talked a little bit about intent versus impact. And then there's some other kind of tactics and techniques that we really found very useful. This is based on our experience during the work, and we're starting to name some of these things so that you can start to adopt or adapt it as you see fit. So if we go to the next slide, these, you know, this is our experience. These are things that have come up repeatedly as we've done this work, and we expect that you might encounter as well. So we want to provide you with some strategies for how to respond, and how to reframe and redirect the conversation.

[01:03] So one of the things that's going to come up a lot is “That was never my intention.” You know, “That was never my intention to have the impact on that other staff member, or it was never my intention in creating that policy to have this effect on our patients.” And the response should be that we assume positive intent unless there's evidence, concrete evidence of harmful intent. And if there is concrete evidence, then that's when you start to think about, for example, corrective actions, even punitive actions if needed. This is the thinking about that human behavior, performance, etc, all those different levels. But this is one of those instances where if someone's actually trying to harm someone, then that's a big problem, and maybe they shouldn't be in health care or at your organization. But otherwise, we're assuming positive intent, and it's important when we see evidence of that positive intent to validate it, because this is part of shifting folks away from that blame mindset to a curiosity mindset, and then to redirect and refocus them on impact. So we understand that your intent was action, that you were trying to, in this instance, center the patient and her history of mental health trauma. And the impact was that one of our staff members of color felt discriminated against or was discriminated against. So hopefully, that makes sense. Let's go to the next strategy.

[02:24] This is another thing that's going to come up quite a bit. And this might come up just from the initial report, because you're not going to control how people enter their reports. And oftentimes, in the moment, you know, if it's a resident or a staff member, they're in the situation, they're going to describe it oftentimes in plain language. And, you know, depending on your process, that exact language might get shared with all the folks that are involved in the events. And so folks might feel like another staff member is calling them a racist or calling them a sexist and that's even before you've gotten involved in the case. So it's important at the very beginning of the conversation to emphasize that framing of not personalizing the critique of systems. That's a way of saying, we want to elevate away from that blame mindset for individuals to how do we improve systems and improve systems of care for patients and populations. And so really encouraging that curiosity mindset by redirecting away from interpersonal blame to those system opportunities. And once again, if there's evidence of explicit racism or discrimination, then you might need to consider corrective action. That's going to be the rare situation, when someone just knows it's the wrong thing to do and they're just choosing to do that wrong thing. More often than not, it's going to be implicit bias or unconscious bias. But nonetheless, there are instances where you may need to intervene.

Karen Fiumara, PharmD, BCPS, CPPS: [03:53] So, if I can just add on to that, if we go back to that slide. One of the things that's critically important or was unbelievably helpful in our journey was the parallel between those of us who have been in health care for a while will remember, prior to the 1999 IOM report, it's the patient safety shift away from personal blame to systems thinking. There are systems that are in place that have set things up so that so-and-so feels, or that they were, discriminated against. It's not necessarily you as a bad person, like really making that distinction. And the second thing I want to say is, sometimes when I talk to people about these concepts, they will raise concerns about just culture. How do you do corrective action around somebody's belief values or sets and still maintain HS culture within your organization? And what I would say to that is most of us at our organizations--and if you don't, I'd encourage you to consider this—make sure you have a code of conduct that clearly outlines the organizational expectations from a mission standpoint, as well as what our beliefs and values are as an organization. And therefore you can hold staff accountable to failures in those expectations. Any questions about that, please feel free to reach out, but those are some very tactical things that I think are critical in making this successful.

Sivashanker: [05:22] Great, thank you, Karen. Couldn't agree more. Next slide. So if you're wondering how to do this, I'm just going to redirect you back to those templated slides that we provided. That's a great place to start. We already have that language in there. So you can choose to use this language or to adapt it to your needs, but it's emphasizing at the beginning, that it's not a fault-finding exercise. In that other slide about the intent not being to blame the individual but to redesign systems, socializing a curiosity mindset. So that's where you can mention something like, “and the goal is not to personalize this critique of systems” and some of the points that Karen made. So next slide.

[06:01] False binary—this is another really useful tactic, or really a redirection or reframe strategy. In terms of this comment of “I feel like I'm being called a racist, or I'm feel like I'm being called a sexist.” So this really is a one-step process. Here, it's offering a reframe, and I'm pulling from Robyn D'Angelo's White Fragility here, it's a book that may be worth reading. But she talks about this good bad binary, where this is a false construct where people are either evil racists, or they're good Samaritan non-racists. And it's a harmful construct because it basically implies that either you're a good person and you have no work to do, or you're a bad person and you're kind of a lost cause. And I would encourage you all to think about that. When you think about folks who are on the opposite side of the political spectrum as you or have very different values than you, we all have a tendency to kind of demonize folks as either just good or bad, myself included. And what we really want to do is encourage us to think about how we're all on a continuum, and we all have our own work to do and who we are, and what privileges and advantages we have, means that that work may look different for each of us. So that's not to say that, for example, a white leader in the organization has the same work to do as, for example, a frontline staff person of color. They have very different sets of advantage and privilege, and so their journeys are different. But we want to shift away from that overly simplistic, but that binary, next slide.

[07:38] This is the last one, this is the counterfactual. And we found this one really, really helpful for generating that curiosity mindset. Because what's going to happen is that people will look at the event, and oftentimes you're going to get back the response, nothing to see here, everything went well. You know, we did everything right. And denial is oftentimes the first sign of resistance in terms of this work. So this is a tactic to encourage people to think about, what are we missing? So basically, the way this works is, let's take that exact same scenario, but let's just change one or two variables. So instead of the patient being, for example, a patient who's experiencing poverty, let's say that this patient is a VIP patient. We probably all have seen these VIP patients, affluent patients who have a relationship with the institution. And then we ask the same questions: would they have received the…? You know, we ask those questions below. Would they have received the exact same high-quality care if they were a VIP patient instead of this poor patient? Would they have experienced the same barriers and challenges? What might have been different in the outcomes?

[08:49] It's a thought experiment. And it's a really useful one because it forces people out of that, well, everything went well, and we wouldn't do anything different. Because the reality is that we treat patients very differently based on what they look like, don't we? Or the privileges that they have. And so we want to get them to start thinking about that. What would it look like to have a system where every single patient is actually treated like a VIP patient? Can we even imagine what that system would look like? And probably that system can't exist, because then we would be, you know, overstretching ourselves in a lot of ways. So, so I'm not suggesting that the goal here is to treat every single patient as a VIP, but really just saying, what does it look like to treat every patient equitably and they get good outcomes, the next slide?

Fiumara: [09:35] Okay, so moving forward, we also wanted to share a little bit about how we've been trying to think about contributors to events. And one of the things that's really important to mention, as the example that we provided, was an example that had an equity component at its core. But I want all of you to know that as we've undertaken this work every single review we perform, we use an equity-informed higher liability lens. So what that means is when I'm evaluating a medication error that occurred in a white, VIP, affluent patient, and what were the system contributors to that event, we use that counterfactual exercise that Karthik was just mentioning, to think through if this patient was in and un-domicile patient from the Dominican Republic, who was non-English speaking, what might be the contributors in that case? And again, that really helps us all shift, not just to the--and I hate this term, but I'm going to use it--root causes of the event you're analyzing, but rather allows you to expand out and think a bit about how our systems are influencing not just the patient in front of us, but all of our patients, and particularly our historically marginalized patients.

[09:39] With that being said, I want to be completely transparent and say Brigham and Women's Hospital is just beginning the journey to really start thinking through the structural and social contributors to our cases. Since 2016/17, we've been carefully using a systems performance behavior contributors framework, but the addition of structural and social really came out of beginning with this Peer Network. So I've already taken so much back to my home institution, as I'm hoping that you all are as well. But I just want to be transparent about that. When we're talking about structural contributors. Again, of course, we're referring to any of the macroeconomic, social health policies, the systems of power that shape our hierarchies, and things like that gradient that contributes to harm.

[11:47] Social contributors refers to the individual level: social needs, food insecurity, community level conditions, all those social determinants of health that we're well aware of. And the system performance and behavior contributors--systems many of us in the safety sciences and the safety space are well aware of—or when we think of systems, we know how to dig into that. I do think it's important to call out the difference between performance and behavior. As a reminder, performance is knowledge, skill, ability, anything that affects your ability as a human like, performance and behaviors around human reliability. Performance being: do I have the knowledge, skill, and ability to do my job? If I don't, usually the fix there is remediation, high simulation training, field mentors coaching. Behavior being: I made a choice. There's a known policy and procedure, I made a choice to violate that, and then you go through your just culture framework, right? Is that a choice that others would have made? Is it reasonable, is it…you know, what others have made a similar choice, so on so forth. But we really do think about those differently, and that helps us drive our actions or our potential improvement opportunities, which brings us to the next slide.

[13:06] And the way we think about this at Brigham—and my guess is that many of you and many of your organizations, and I love to learn from all of you, regarding how do you think about our hierarchy of corrective actions? So we think about them as strong, moderate, and weak. Some people I'll be very clear, you know, push back on the use of the term weak as it can be and have a negative connotation. I think it's just, you know, kind of going straight up the, straight up the middle saying, we know that if we're going to put up a warning or sign or we're going to do some type of a memo or write a new policy, the likelihood of that really preventing future events from occurring is low and it's, it's a weak corrective action. While you know, the tactics included here in the moderate bucket, high fidelity simulation, checklists--well-developed checklists. Health care, kind of, you know, after the checklist, manifesto, and many other things, you know, it's shifted to checklists without the rigor that the aviation system have used for checklists. So remember, please know when I say checklist, I mean well-developed rigorous checklists and cognitive aids. And then strong being those things that we always think of in the safety spaces, right? Those forcing functions, even in the face of a human making a human error or choice that we wouldn't want them to make, the system is strong enough to prevent that event from happening.

[14:34] We use these same constructs when we think about our equity related corrective actions. And it helps us as we think about things from the system, human performance, and behaviors framework, and of course, also the social and structural. So I hope that makes sense to all but happy to take any questions. It's also worth noting if we go to the next slide that after every collaborative case review that we conduct at Brigham and Women's Hospital, all action items are assigned short-, medium-, or long-term due dates. We also assign them to an individual owner within the organization. Everything is shared, and there's a closed loop for all of our correction, corrective actions. Last year, we had over 650 corrective actions that move forward across all of our events, many of which were equity related, but across all of our events. And there's a huge body of work around the tracking, trending, and monitoring, making sure that all of that gets closed. And again, I would love to hear from all of you regarding the systems that you have in place to kind of help with that, because, you know, calling things, identifying concerns is issue one. Developing productive and strong interventions is step two, then actually getting those things implemented and executed on is the hardest, and that's step three.

Sivashanker: [16:03] And Karen, can we just go back? Whoever's controlling slides, one slide real quick, I want to add to that, one more slide back, which is, you can almost think about this as also a hierarchy of difficulty, in a way because or even comfort. We're very comfortable in healthcare intervening on the behavioral, and as we move up the system, it gets harder and harder. But then I'll say that, you know, Brigham included, we get really lost when we start to talk about social and structural. And so as we move up this hierarchy, the challenge can get, can increase. Also who's owning the actions will change. This is why we've included our community and population health leaders to see, to think about how can they, how can we connect the work that they're doing, at both social and structural levels, to the work that the quality leaders will be doing, as well?

Video Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 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.

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

0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;

0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and

0.25 CME points in the American Board of Surgery’s (ABS) Continuing 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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