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This video is an excerpt from the AMA Advancing Equity through Quality & Safety Peer Network session on Embedding Equity into Organization Structure & Processes. This section describes two approaches that were implemented at the Brigham and Women's Hospital, Top Down (embedding equity into organization goals) and Bottom Up (Snowball Method), that organizations can use to spread equity work throughout the institution.
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Karthik Sivashanker, MD: [00:27] So we're going to talk about how do we spread this work within the institution? And, you know, we've already covered in the earlier session, some of the core things that need to happen: we need to start embedding this into our tools, into our reporting solutions, into our trackers. We need to start building a container for the work. Now we're going to talk about how do we actually start to move this work through the organization? And we're going to offer two approaches based on our experience at Brigham and Women's. That's not to say that these are the only ways you can do the work, but one is more of a bottom-up approach and others more of a top-down approach.
[01:08] So the bottom-up approach is really what I'm calling the snowball method, and the idea here is you follow the case. I think what's really important about this entire methodology is it's grounded in individual harm events. So what we're saying is, let's resist the tendency to always start at the high level and start with the big data. Let's start with the individual narratives and the individual harm events and have that drive the education, the culture transformation, but also how we spread the word. So let's talk about how that would, how we would operationalize that, and then let's also think about what are top-down strategies that may be important, as well. So let's go into the first, the ground-up method, the snowball method. So one of the things we're going to be asking you all to do with the evidence ended already is to think about what's your structure. You know, oftentimes, the structures are complex. And this is just one example from one institution, but you can see in our quality and safety, organizational structure there's a lot of committees and a lot of groups that are involved. And what I want to encourage you all to do is not try to start everywhere at once. That is a recipe for paralysis, because what's going to happen is you start to do this work, and then folks are going to say, well are you doing it here? And are you doing it there? And the answer is going to be no. And you're going to be tempted to try to do it everywhere.
[02:37] So if we can go to the next slide, what we're saying is start with the harm events. So that's on the bottom, you can see that's patient feedback, that's patient complaints, and on the bottom right that safety events. So you now have embedded equity into your trackers into your reporting solution, you're starting to get these events reported. Great. Continue doing that work. That's going to lead you into the investigation part of it, which is something like a root cause analysis or collaborative case review. That's the next place to take the work. And we started to introduce that model to you with our case reviews, with our simulation, where we talked about how do you build this into your standard approach with your case reviews? How do you build it into your template? How do you build it into the framing of the collaborative case review? How do you build it into the identification of contributing factors and the actions as well. If we could go to the next slide.
Sivashanker (continued): [03:40] From there, we went to safety and risk review. So these are our core safety meetings and risk meetings, which sometimes we overlook. We're sometimes so in a rush to get to the work happening out there that we neglect the work that's approximate to us. So let's talk a little bit about how we did that if we can go to the next slide. So the case review meetings are really about bringing our core team, and this is-- Actually if we could go to the slide before, what I want to highlight is: I'm not trying to say that this is your structure. You probably have a completely different structure. When I say care, or QA/RM, that may not mean anything to you. But the point is, you have various committees and structures in place that are relevant to this work, and so what we're saying is, follow the cases as you start to spread them. So if you go to the next slide, our safety meetings, is where we bring together our risk managers, our patient family representatives, our quality and safety directors, and where we're reviewing these events, these harm events that are coming in. And the goal is to prioritize the events, to figure out what next steps need to happen, to elevate other emerging issues. COVID-19 was a big one for a long time. And one of the first things we did, and a simple thing we did was we simply took that work we did with embedding demographics into the tracker, and we brought it into the space. So we started introducing in the meetings, for every single case, we're going to bring in demographics, we're going to bring in an identity-conscious approach, with a goal of systematically identifying any inequities associated with those events. It's a very simple thing, but a very powerful thing, because many teams are just not used to doing this. And bringing identity of patients in this way, in to the room, will raise all sorts of new issues and questions that you'll want to grapple with.
[05:41] Now, if we go back to the prior slide about team culture and resistance, you're going to--I don't know what your teams are like, but you probably have diverse teams. Our experience was that there's a bell curve. There's folks who are early adopters who get it and they're excited and do the work, and then there's, John--I'm just going to make up a person here—John, who does not think the work is important. I did not get hired for this work. I got hired to do quality and safety work, what does this have to do with my job? And you're going to have to deal with the John's and the Julie's I don't know why I'm picking on John and Julia, hope there's no John and Julie's here. So how do you do that? I would actually really welcome any thoughts on that from the group, but one thing I'll offer is--and I think what Karen is, this is why I was really hoping Karen would be here to speak to it is--she really did a nice job of normalizing this as how we do the work. There's a need for the leader of that team to set that expectation of we've been doing it this way for this long, and that has been a failure. That has led to harm, and we are not doing it that way anymore. Moving forward, equity is a fundamental part of the work that we're doing. Period. There's that level setting, and then there's going to be all the work that needs to come at a team level on an individual level to bring people along. So there is an actual like, John, on our team. And I've spent a lot of time with that John, basically trying to get him to understand the importance of the work. And I'll say, it's been challenging at times, but I've seen progress. So there's a, this is messy work at the end of the day. But I just want to elevate some of the things you're going to encounter in every single place that you try to spread this work. Every single place, you're going to have to think about how do we introduce it? How do we make it safe? And how are we going to manage the resistance that's going to come up?
Andrew Resnick, MD, MBA: [07:53] Since Karen's not here, if I could just chime in.
Sivashanker: [07:55] Please do.
Resnick: [07:56] There's some muscle, there's some muscle memory that has to be developed with this. And at first, there's the John's, the kind of people who don't want to do it. But there's just, I think, a fair number of people who might just think it's a little bit awkward to all of a sudden talk about demographics, they don't really get it. It used to be something we don't talk about, we don't want to introduce bias, right? So it's a change. And it takes a little muscle memory and the more you do it, the more all of a sudden that group just, it's a normal thing for people that you know, put pronouns after their name or do whatever or talk about their energy level in a meeting. It's all kind of new stuff and after a while, it becomes routine. And then it becomes very odd when you don't do it. And so I think that's, you know, the maturation pathway with this.
Sivashanker: [08:41] That's absolutely right. I've heard a, I don't know if this is true, but that you have to hear a song 10 times before it gets into you and you get hooked on it. Well, you probably needed to hear this like 20, 30 times, and so that's why we've been kind of emphasizing that container work in the introduction so much. It may feel fluffy and like what's the point of it, but until you can roll it off your tongue—you know, Karthik Shivashankar, he series pronouns, identifies Indian American—until you can roll it off that comfortably, other folks are going to be uncomfortable when you're trying to introduce that. So let's go to the next slide. So care is another example. And we're just giving you two examples here, but really just want to highlight some of the challenges that we encounter. So if we go to the next slide, the care meeting is... And actually Andrew, you're here. Do you want to describe care a little bit?
Resnick: [09:32] Sure. I mean, it's a specific committee at the Brigham that really takes in patient grievances and complaints and upsetness about cases and then tries to adjudicate: Is it something that's a sort of a peer review issue that then goes down a peer review pathway, or is it more of an experience issue? And either way, is there something we could do to make it better for the patient, that would be meaningful for that patient? So that's sort of the purpose of the committee.
Sivashanker: [10:08] Yep. And so it has this coordination and communication function with patients and families and we really focus on: is there a need for financial reimbursement? And you may or may not have a group like this. That's not really the important point here. What is important is, this is introducing this equity-informed high reliability approach to yet another space and more challenges are going to pop up. So one of the things we did once again, in terms of introducing it was having that quality, safety, equity lead in attendance. There's going to be a theme, every time you're introducing it to a new space, they need to be there to kind of be there as a spokesperson and champion. And there's that reframe that has to happen from leadership. And so in this case, it came from Karen, and it came from Andrew as the leaders of that meeting, to say this is how we are doing business now. This is the work moving forward, and it's going to be identity conscious.
[11:05] So that gets back to the tracker: this is how we can link to very simple things we're doing with the tracker to the cultural changes. We're going to start bringing the identities of our patients into the room so that we can identify inequities that are harming them, and then we're going to ask every single time, are there inequities associated with this event? You start to do these simple, repetitive things, and it starts to open up a Pandora's box of all these issues. So if we go to the next slide, there was tons of things that came up from doing these simple, from using these simple techniques. So some of the questions that popped up: is the squeaky wheel getting the grease? So is it possible that who we're hearing from, in terms of request for reimbursement, are the folks that are already more privileged and in a position to make the request? Whereas the patients who are most disempowered-- or example, our non-English speaking, undocumented patient--are they going to be filing a request for reimbursement? Probably not. So how do we balance that? How do we make sure that we're not actually exacerbating inequities by reimbursing differentially for the folks who already have more privilege versus those who don't? And how would we track that?
[12:17] This leads to a problem with data: there's a lack of data to support decision making. So one of the things we thought about is, is there some sort of role for affirmative reimbursement? You know, for the folks who need it more, trying to make, prioritize it in some way. But how do we actually know who needs it more? That means that we're tracking data in terms of patient financial information that we can access. And that's tricky. There was a lack of diversity in the committee. And that's going to be a theme in many of your meetings, and depending on the institution you're at. So how do we ensure that we have the right folks in the meeting to get to the equitable outcomes that we're seeking? And then we saw an increase in reports of just explicit and/or overt racism and discrimination. So as we're doing the work in parallel, we're getting more reports. And then we have to grapple with that. So there was a lot of challenges that were also opportunities. So how do we educate the staff? Every time we're going into a new space, we're thinking about how do we give them some baseline education? How do we get them to pivot from that individual-level action to system-level action? So this is where we can start to think about how do we update policies and practices and all that.
Sivashanker (continued): [13:30] So we followed the cases, which led to: where do we send this case? There was no home for it. So we went to the group that it made the most sense for, and then we started working with them to educate, to embed this equity-informed high reliability approach, to bring demographics once again, or identity into the space. And that led to lots of opportunities for system-level work. So just some examples of the system level-work that emerged: terminations, you know, we found out as a system that we're terminating our patients at three to four times the rate for Black compared to white from the system. And so that got connected to the PARC committee. There was the case that you all got exposed to a little bit in the first case simulation about requests for discriminatory, sorry, a discriminatory request for accommodations by race or other factors. So a white patient saying I only want to be seen by white providers, because I don't like Black providers, what do we do with that? This led to a whole body of work, and in efforts to update policies and so on in terms of this whole topic. And then we found that we were, for example, potentially calling security events on our patients of color at higher rates than our white patients, so that also got connected to this group. Because at this group, we have our security team and many others there. It's an interdisciplinarity committee.
If we go to the next slide. The final version is, or the final example is PARC. I'm going to do this in a minute. And if you can go ahead and click next. So this is the Patient At Risk Committee, and this is just another example of how we followed the cases. So we started to have some events where patients were threatening, or making, or were in some way inappropriate physically with staff, and those at our institution go to this patient at risk committee. It's focused on physical violence, historically, and threatening behavior to save to physical safety. But then we started to also wonder: we have these events where there's nonphysical violence and nonphysical threats that are happening around racism and sexism and other forms of discrimination, hate-based speech, and so on. How do we, where do we send those cases? And so we felt like it might make sense to send it to PARC, so we went to PARC and we asked them, have you been thinking about how to embed equity into your work and they had. They'd already done some work, but they hadn't applied it to the same level of rigor as we had. So we started to work together to spread this equity-informed high reliability approach down to the patient at risk committee and they expanded the scope to now include reviewing events for nonphysical violence and threatening behavior. And the actions that they can take include things like safety flags, and acute care plans in the chart, and even dismissals of patients.
[16:33] So if we go to the next slide. What I just showed you is a snowball method. And I think what I'm trying to highlight is, it's very easy to get overwhelmed doing this work, because we haven't been doing it with this level of rigor, and the opportunities are going to be endless. Every time you pull up the rug, there's going to be inequities, and there's going to be things that you need to address. So what I want to get you all thinking about is how do you avoid that paralysis or that tendency to try to do everything at once. And so by keeping focused on the events that are coming in, following the events as you normally would, and then in the spaces that you're entering, starting to seed the work that will make it much more manageable and much more organic. And in that way, you can start to spread the culture and the work across the organization. Now, there is a role for top-down work. So if we could to the next slide.
[17:27] We're going to cover a few of the examples that we implemented. And I want to keep it very simple to start: how do you build a sense of your body and safety goals for your department? We're not going to get into how we embedded it into incident command in a lot of detail, but we will touch on it briefly. And then we're going to have later sessions when we get into board engagement. And I'm sure you all have lots of questions like How did you do the education? We're going to have sessions just on that? How do we spread that equity-informed higher reliability education? And so a lot of the questions are things we're not getting into, we will have time later. Next slide. Andrew, go ahead.
Resnick: [18:05] Yep. So yeah, thanks, I'll try to be pretty efficient with this because I know we want to dedicate some time to the smaller group discussions. But um, but just as some examples of the top-down approach, which is equally important to make sure that we have alignment from the board down, pushing things downwards, as well. So the example of a hospital goal a couple of years ago, was really measuring critical events, including demographic data. So we could start working on this process that Karthik described really, but it was a one of the one of the absolute top 10 goals for the organization for the year. So it really had the backing of senior leadership and the board in making this happen. And so you can see the, the sort of subtopics there we embedded it in the patient safety RL system. In our, we had a mortality, a great mortality database and tool and so we embedded it there. Karthik talked about the collaborative case reviews. And so we really thought because of this top-down goal, you know, really had to be thoughtful about what that meant, and how we can embed demographic data in sort of all of our work, in analytics and in quality and so forth. We can go to the next slide.
[19:21] So, this is a lot on here, but I think the main summary of this is that our quality, safety, and equity goals should be specific and measurable. So we have those big bucket goals of embedding it in lots of things, embedding it in analytics, embedding it in quality and safety. And like Karthik said, we don't want to sort of take on too much that we can't get anything done and have paralysis, but we need specific targets and when the top-down... When the board and senior leadership pushes and charges all the operational groups in the hospital to take on this work, then you start getting a lot of bottom-up work as well. So you know, we've talked about this, but when we charged the unit-based teams, or basically our quality frontline structures, to take on equity projects and look for inequities in their data, the women's health floor immediately took on breast, exclusive breastfeeding and said, wow, you know, we have...but they didn't have analytics on it. But because we said we need to have analytics with demographics in it, they took on that as a project immediately, you know to fairly quickly produce some analytics that demonstrated profound inequities, as was not a surprise to anyone, and then could start working on what's the root cause of those inequities and putting in non-English speaking people to help new mothers breastfeed, and so forth, and dramatically improve that. And that was, you know, a collaboration between the quality and safety department and operational leaders in the women's health unit. But that sort of is an example of the top-down push meeting the frontline. And you can see a lot of other examples on here. And then, yeah, we can go to the next slide.
Sivashanker: [20:59] And actually, maybe if we go back one slide. I just want to add one more comment, which is, what we have on that right side is...the point of that is we did a lot more work—a lot more work—than is represented in our goals. But what we didn't do was try to represent all of that work in our goals. So what I would say worked for us really well is focusing in on one or two key goals that are process focused, embedding it into your demographic data collection and into your trackers, and keeping it focused in that way will allow you to spread the work through the process and create lots of space to do the type of work you need. If that makes sense. If you focus too much on outcomes early on, you're going to end up limiting where you can and cannot go. So I would say stay focused on process. We want to focus on how we do the work at this stage, not the outcomes. And there is going to be a pressure from leadership to say, well how is this going to work on a close-the-gap one, like the difference between Black and white patients with hypertension? Or how's it going to close our gap in terms of hemoglobin? Anyone see, and you're going to have to resist that and say, we're going to focus on how we do the work, on the process of the work. And that will lead to all the stuff on that right side eventually. I hope that made sense. Let's continue.
Resnick: [22:28] Yeah, then just not to go through this slide, but the point of this is to say that because we had such... You know, it was part of our hospital goals, equity was an important part of our existing quality and safety structure already when COVID started, when the incident command first started, it was not a step to wait and see the inequities in COVID to take action. It was an immediate part of our incident command structure to be proactive about that. And so we had a whole COVID section as part of our incident command from the very beginning of the, you know. Likewise, I think this is the last slide of mine, I'll turn it back to Karthik, but just likewise, the board being involved in senior leadership, being involved, you know, it became very routine at any meeting for the board or for senior operations to say, what about the demographics, why aren't we seeing this? And it just made such a difference. For example, when we were doing so much work, but we were talking about mortality and central line infections and a few key things and the board said, hey, you know, how come we're not looking at this by demographics? Just as a sign of success in pushing this, you know, we had the top-down making us continue our commitment to making this part of everything we do in quality and safety, and also the bottom-up really doing so many projects on it. So I'll turn it back over to Karthik.
Sivashanker: [23:51] As you're starting to unfold this work, you want to think about communication, because a key part of success is: do folks even know that you can report inequities now through safety or identify inequities through patient complaints? There's a part of just socializing work across the institution. And you're going to have to think about how to do it in many different ways. So eight times, eight ways. My suggestion based on our, you know, one institution's experience is to start proximal, and to consider both those bottom-up and top-down approaches. So as you're following cases, you're socializing the work, but then also, there is going to be a need for just getting out some messaging. So some of the things we did, we did a roadshow. We would literally go department to department and start to share the work. And oftentimes, we would do that based on the case. So if there was the case that was on surgery, or if there was a case that was on anesthesia, we would go to anesthesia, and we would talk about the case, and then we would talk about the approach for the work. So once again, keeping it grounded in the individual harm events, which is very compelling to people when you can tie it to real individuals who are being hurt.
[24:57] And then system wide communication—we're going to share some templates with you for how you can communicate this information in terms of, if you're a reporter, where do you go to report? How do you like flag the inequity? What happens after? It's really important as part of the communication that you highlight that something's going to be done and that the reporter, there'll be some follow up with the reporter. Because nothing shuts this down more than feeling like you're reporting something that's sensitive, it goes into a black box, and you never hear about it again. So you really need to make sure that you have a plan in place for how you're closing that loop with reporters and that you're communicating that. And I would say a very important audience early on is going to be your residents and trainees. They're going to be some of the most courageous in identifying inequities. And because there's generational differences, they're going to be more attuned at times to some of these things, some of these inequities. So you definitely want to make sure you're connecting to the programs, the training programs and so on across the institution.
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