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This video is an excerpt from the AMA Advancing Equity Through Quality & Safety Peer Network session on Ensuring Accountability to Historically Marginalized Patients and Communities. This activity will explore internal (institutional) vs. external (community) accountability for advancing health equity with brief examples provided by participants.
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Rishi Manchanda, MD, MPH: [00:29] Why is institutional accountability for health equity and racial justice so important now? While we measure and expand the ways in which we advance health equity and racial justice, what are the opportunities to build and improve internal institutional accountability to ensure that this work is done well? And then what opportunities exist to improve external collaboration to, as I said, be held more accountable by external stakeholders?
Manchanda: [00:52] Picking up on this a little bit... And we're going to continue to kind of touch on the elements of courageous leadership, right, that are at the nexus of these questions about opportunities to prove internal accountability. And there are a variety of different ways to approach this question. One is this understanding, of course, that—as Lou and Teresa just mentioned and I think as all of you have obviously experienced and are part of managing—there are various internal performance and accountability systems already in place that shape all of your quality and safety efforts, of course. Those include the systems, the incentives, the tools that you and your colleagues use to collect and come together, to analyze data and stories around, you know, how equity shows up, especially as harm. We talked about that kind of structural lens to that question in the last all teams call last month. It's about the system's accountability systems, you have to be able to ensure that you're adequately, effectively stratifying, tracking, and reporting on key performance measures—especially stratifying, by race, ethnicity, and language. It matters in terms of the systems that you put in place to ensure that you're informing and sharing data on equity and the insights that you're generating with key stakeholders, both your patients, your employees, payers, community members—how are you doing that? And it's also about like, how...what systems you have in place to create a learning environment. Where opportunities for staff to identify and address discriminatory practices are more feasible logistically and reinforced culturally—in other words, a long way of saying is, do you have a system of performance and accountability where you're making it easier for people to do the right thing, or to do the equitable thing to approach a problem with an equity lens rather than not? If an equity exercise is a difficult one, it's less likely to happen. So how are you creating the environments for equity, analysis, and action to take place?
[02:46] And then of course, what are the systems you have to hold each other accountable as much as other stakeholders to this work? We talked last time about this, the framework...last month, about how to take some of the structural lens to these sorts of questions and start thinking through how you're identifying events that are manifestations of harm caused by structural inequity. So this can manifest as events within your employee experiences or well-being data. And Normelia, you had brought this up last time, and I—just as a nod in appreciation to you—you had mentioned that, you know, what about employees, and the employee experience? So this is the key kind of addition here, thinking about employees and the systems that we have, the tools that we have to identify harms there. Same thing for clinical experience and outcomes or, of course, squarely within the bailiwick of all you guys, the data that you have on harm and safety events, let alone population health performance measures and community health needs. There's a variety of different ways in which we can analyze these events to be able to identify if there's a pattern of inequity here, and then, with more insight, identify precise patterns, plural, of inequities that are taking place. How do you create that? These are, these are questions of performance, but there's also questions of accountability. How do you create the accountability to ensure that you're answering these questions methodically? Do you have the shared spaces as teams—both within quality and safety, as well as whether your population health or community health or employee or labor representatives—do you have a shared space to come together to ask and answer these questions? And if you don't, then your accountability systems aren't in place. Right? The performance will lag because accountability isn't there.
Manchanda: [04:26] So these are kind of, you know, questions about...this is how accountability shows up. And so one of the things that we wanted to recognize, of course, is that many of you are already doing quite a bit of work on this and what you see on the screen here are some of the things that you will probably recognize from the assessment tracker that the Peer Network, that the AMA team is using, that was shared with you and that you're filling up here as well. And so I wanted to just ask for folks to either chat or unmute here, and just describe some of the things that you're doing already, some of the great things you're doing to be able to improve internal accountability. Tracking with, especially if they track with one or more of the things you see on the screen here. So let me open it up here and just see if anybody can just voice over and frankly, to celebrate and get a, get a chance to kind of grab the mic here and celebrate your work, your team's work, when it comes to efforts to improve internal accountability. Is there something that you're really proud about that you want to just describe in terms of progress towards any one of these actions that you see on the screen or anything else?
Tiercy Fortenberry: [05:37] We have one example to share.
Manchanda: [05:40] Please.
Fortenberry: [05:41] So I'm Tiercy Fortenberry, I'm from the UMC Vanderbilt in Nashville, and one of the things that we've done in our population health space that we're really proud of is we did look at our data with some of our preventive care measures across our adult and pediatric women's health measures and patient populations. And we've been using control charts to look and see if we had areas that were negative outliers compared to other race, ethnic, and language groups. We were able to identify some opportunities, and we have had that work within our governance structure where our leaders get together, we look at that data as part of our organizational pillar measures that are prioritized. And so we are always updating those groups on where we are. And in some conversations several months ago, they started really asking a lot of questions about that data. So you know, where are some of the other data falling and how do they compare, and what are we doing about it? And where are we setting our goals? And so it really provided a really rich discussion about accountability based on the data they were seeing, and... And really, it was just looking at our data in a different way, prioritizing a measure at the institutional level, and really incorporating it into our existing accountability structures on a regular basis, usually monthly.
Manchanda: [07:22] Thank you. And this is a recap. That was wonderful. And who is, who are the folks who are asking those questions now activated by the data, Tiercy, that you're mentioning? Are they colleagues in the health system? Are there new voices that you're finding coming into this mix as well? Just give us a bit of sense of who is seeing the data and then participating in the accountability process?
Fortenberry: [07:42] Yeah, so the group specifically around our population health governance, our our ambulatory clinic leaders, the chair of our department in pediatrics, the executive leader of our affiliated network. So very senior leaders, as well as some of our clinic leadership team.
Manchanda: [08:11] That's great. That's really great.
Caitlin Donohue, DrPH, MPH: [08:14] This is Caitlin from Dana-Farber. I can just add that, so we have a number of efforts underway in quality and patient safety. One is around our patient experience data—and I think I've shared that in a couple of our breakout groups before—but we've taken our patient satisfaction data, stratified it by different demographics, and then found that there are gaps in experience. And so we're actually bringing together and doing some qualitative discussions with about 15 different respective groups of patients based on that data, to dive a little deeper into the patient experience and try to design solutions using the patient voice. And from an accountability standpoint, we actually have this project built in as a... We have several action teams as part of our ID&E any efforts at the institution. And this is a goal or a project within that group that then reports up through that sort of ID&E structure, which has like a leadership level, an executive level, and at a board level. Additionally, we also have built in some of our other kind of quality projects or efforts into our copy reporting structure, which I imagine a lot of folks around the room here have. So just wanted to add that as well.
Manchanda: [09:28] Caitlin, thank you for that and Tiercy, as well. So I was mentioning like A and B—and Caitlin and Tiercy your, I think your comments I was tracking with at least here as well—I was just curious on this bottom left, if anybody had experiences of efforts to more intentionally now include patients, patient voices, patient representatives, in the information sharing or analysis perspective. And I think Caitlin you alluded to this a little bit, but anybody else have any experiences there? Or efforts that are taking place.
Fortenberry: [10:02] Rishi, one of the other things that I'm not directly involved in, but I know is an effort that's underway is an effort to kind of diversify our patient population when we ask questions of patients about just different topics to inform us. It's called Advise Vanderbilt. And so, and there's been a focused effort to diversify that platform a bit more, so we're hearing from more patients and more voices. And so that's certainly something I'm not in directly but I've heard that we're doing that as well.
Manchanda: [10:40] That's great. What I hope is happening is, you know, as you're seeing this, these represent opportunities for improvement, especially to strengthen the accountability mechanisms. There's a few others that I want to just kind of put in here, and I think in the interest of time I won't spend too much time on this, because I want to see if we can speak a little bit more about external accountability in a second. But the basic question that I think comes up is, in addition to these, these really great opportunities—again, tracking with the assessment tracker, that you can use to identify and start or accelerate your work towards accountability—what are the other ways? Are there other ways to increase accountability to each other for advancing racial justice, and health equity?
[11:28] This is a question about momentum. In the experiences of many of you who have already started to do this work and are making these efforts in your quality and safety efforts to, for example, build internal accountability and performance systems to center equity, you're recognizing the snowball effect, right? That those conversations then create other opportunities, other questions, other like, "hey, what if we," or "how could we" kinds of opportunities that come up in those conversations. So for example, there are other ways now that in those... With the momentum that you generate, wherever you're starting or wherever you're seeing some traction, how are you open to—especially as you know, most courageous leaders, and as those we're trying to model how to create a learning environment, and an action environment around equity—how do you open yourself up to other opportunities here to be accountable to each other? For example, seeing if there is now ways to take the efforts in some of your initial forays to improve accountability and think about other ways to add, center equity measures, data, and goals into organizational priorities. Are there ways to...are you unlocking the fact that a structural analysis is something that actually would benefit not just a quality and safety department but other leaders? And advocate for requiring more structural competency training to be able to better understand some of the institutional social and structural drivers? Are there ways to dedicate even more resources on the performance and quality improvement side to address those inequities and galvanize, and even think about how to support or at the very least learn from worker-led and/or community-led efforts to drive internal actions or accountability.
[13:06] There's a health system that we were talking with in Oregon that has been very active in addressing equity for patients, diabetic patients in particular, by being able to work with community organizers to bring community voices. At the same time this institution, many of the staff who were involved in these equity efforts for patients were also identifying discriminatory practices within their own workplace, and had to take part in internal staff-led organizing efforts to push against discriminatory practices. As a courageous leader, are you going to be on the sideline for those conversations or engage in those conversations when some of the necessarily uncomfortable conversations around what to do internally come to bear? To what extent are the incentives that you have and even more importantly, the performance reviews and performance for staff and for leadership, in particular, tied to these efforts? Is this yet tied to your salaries, to the salaries of those that you report to? And if not, why? Or why not? Are there other ways to review even finished performance, or are other practices that might be contributing to inequities and the patterns you're seeing? And so on. There are a variety of other opportunities to now be, to increase accountability. And this is a key thing, I think, in understanding the adaptive learning approach for accountability questions. Accountability often starts and stops with, "how are we going to be in compliance with X, Y, and Z as required by external stakeholder A, B, and C? That's not an adaptive learning or courageous leadership kind of stance to accountability. The snowball effect, the momentum that you already generate, allows opportunities to be able to think about other ways to be accountable.
Donohue: [14:55] Just talking a little bit more about the QAPI structure and leveraging that to drive accountability, and looking at our data. And I was just sharing that, we started to do this at Dana-Farber. First, just really being explicit about like the 6 themes of quality in our QAPI plan, and then working towards integrating an equity lens into our scorecard. So we're trying to stratify some data and then also identify some additional metrics to track there as well. And then having sort of equity-specific goals year over year, as well as having kind of presentations come through our quality committees up through and including the board. So I was just saying, being really deliberate about doing that. And having formed for meeting to substance there. Anything else to add, Lou?
Louis Hart, MD: [15:37] Yeah, and I think that speaks to being so far ahead, and so expert in it, with the work you're doing up there. And when we started this in New York City Health and Hospitals, we literally did not have all the stratified data in the world, we didn't even know what our internal collection practices, or at least we weren't aware of how the opportunities that still laid within them. We literally just added a prompt at the QAPI level: were there any issues of bias or structural inequity in this case? And what started as a, "Oh, gosh, the doctor was Black, the patient was Black, no bias," then led to very formative substantive conversations months later, because then individuals had to go back to their departments and do that internal audit on the equity of their data. And we set a high expectation at the board level—no one wanted to be unprepared for that. We hadn't even done all the background work. But then we all realize there's accountability, let's all figure this out together. And then the next thing you know, my phone's ringing off the hook. Hey, Lou as director of equity, quality and safety, can you show us how to do this? Is this something we have to do for the board? It really was just a small prompt. We didn't do anything else, but a one liner that was in the agenda that every team had to answer. And it was something we started small, and we didn't let perfect be the enemy of good.
Manchanda: [16:46] I'll underscore two points there, Lou, thank you, and Caitlin, thank you for that. There's two things I'll just highlight here as we pivot now to this last section here and about external accountability, because one is the start small and move, right? As you said, wherever you're at, just start and move towards that. That's a part of both the improvement kind of culture and a higher reliability framework approach, just identify where you can and start working towards that. The thing about it is that a high reliability framework and high reliability kind of approach is for me, can only be successful if it's a high accountability kind of framework. And that means there's always opportunities now to approach accountability, not just again, as a compliance question, but as an adaptive dynamic set of questions that inform what it means to be a high performing, high quality, high reliability kind of quality culture, right? High accountability is an ingredient for everything else when it comes to quality and safety, let alone for being able to address the social and structural drivers. So questions, you know, abound like you know, Caitlin, when you mentioned the incredible work of the QAPI stuff. My question is, does that now beget new opportunities to think about how to further align and tie incentives and even performance, you know, related bonuses and other things to for teams, departments, or executive leaders? Are there other ways to engage kind of patients in that experience, like the assessment tracker had, etc? There's all sorts of snowball or momentum kind of effects that take place. And that's what makes this invigorating, frankly, rather than concerning or worrying. It's...this is the kind of stuff that I think all of us are wired to do, especially as courageous leaders in the space. So this is about internal accountability. And I think that's really, the punchline here is—as you guys were just sharing, all throughout and in the chat, as well, and as you continue to update your assessment trackers—there clearly are efforts where you're already kind of leading the way, pushing the boundaries of how to improve internal accountability. And there are opportunities even more to kind of continue on being accountable to each other to advance that work.
[18:47] Let's pivot actually to thinking about external accountability. And this is where it's not so much about building on the internal work you're doing and thinking about how to continue as opportunities, this is now just a couple of minutes just to introduce a little bit of a brain stretch here. So park your, park your brains for a second here, lean back in the chair, take a sip of your coffee or tea or whatever you have at your, your desk there. And now think with me a little bit about opportunities to also improve the opportunities for your counterparts, the courageous leaders among your patients, among your employees, and as importantly, among in your community, the communities that you serve and which you're based, right, your communities. How can those courageous leaders outside of your institution, help hold you accountable to be able to reach this, these goals that you're setting for yourself and that are being set for you?
[19:45] Essentially, it's this: you know, as we're, as many health care systems begin and as you guys are leading efforts to implement health equity strategies, what's the ability of stakeholders external to your system, to hold you accountable to that? We have to get past, I think some of the implied theory of change that comes through a lot of discourse in health care these days about leaders holding ourselves accountable as being sufficient. That is necessary, absolutely necessary, as we we've been talking about for the last 15 minutes, but it's insufficient, right? Like true accountability, especially for issues of equity, especially issues that require both uncomfortable conversations and absolutely necessary kind of structural transformation require a balance of heat and light—the light from within of leaders, but the heat from the outside to make sure that change happens. And so there are a variety of different forms of heat, right, and external accountability systems, sometimes that are felt. Sometimes the heat burns, and sometimes it's generative, it helps to push forward and help us grow. But there are a variety of different external accountability systems that exist as you guys can all attest to from federal and national level, state and even local institutional level, including informal mechanisms, like the ways in which constituent or employee or community organizing efforts participate in holding health systems accountable. These are, this is part of what accountability looks like, as you know.
Manchanda: [21:14] And so let's focus a little bit on this latter part, the external accountability section for a second and really ask this: to what extent are you and your colleagues actively working to strengthen external opportunities, opportunities for patients, employees, community members, and other external stakeholders specifically to hold your system accountable? Let me kind of provide a teaser, or little bit of a frame for external accountability opportunities or mechanisms to hold our health systems more accountable. Over a year and a half ago, Health Begins along with partners across the country started convening roundtables to really ask this question: what are the ways in which stakeholders, external stakeholders can improve accountability within the existing external accountability systems that exist? The slide I showed before about the state, federal, and community level and of things in place? What are the opportunities to improve things? And what we narrowed down after a deep dive both in the literature of organizational accountability and with input from a lot of key leaders, including the former head of CMMI, and others, was a set of five different categories of mechanisms: Community-centered governance and monitoring mechanisms where there's more opportunities for constituents and beneficiaries with lived experience or patients with lived experience, who belong to historically marginalized communities. To what extent are you creating mechanisms for them to—and are supporting mechanisms—for those constituents to make key governance decisions and be involved in monitoring how well the institution's advancing this?
[21:16] This is, above and beyond. This is an example of some sample questions that that we posed in the roundtables and that came about as questions that can be helpful for the conversations both within your institution and with partners in your communities, about ways to identify where you're at. Of note, community governance is different from patient advisory, right? This is beyond advisory roles. This is beyond patient and family advisory councils that don't necessarily have governance structures. This goes towards governance, and sometimes in the form of community consultative boards, or governance partnerships, or constituent LED boards. A great example are FQHCs. FQHCs, by design, as many of you know, have to have 51% representation of community members as part of the governance. It's an example of actually an institutional approach to baking in community centered governance into the institution itself. A provocative question would be, how many of our health systems create mechanisms for participation in governance and not just advice for those with lived experience? So there's, there's mechanisms there for redress. There's transparency and answerability. To what extent can you take better steps to not just collect data and identify inequities, but also make that data, those insights, and the decisions about how you address those inequities transparently available for public scrutiny above and beyond what's being required of you, and this is, again, through external creditors, or regulators, etc. There opportunities to continue to kind of support those in the community who are looking for this information and can actually become partners in providing that balance as necessary for internal-external accountability.
[22:49] Same thing for compliance. To what extent are there mechanisms for compliance? And how do we strengthen those? This is, again, where external creditors and regulators, along with industry groups can be helpful in ensuring compliance, but also community organizations. There are fascinating models that exist around the country of community stakeholders, community councils, community governing boards playing a role as part of that compliance, and there's an opportunity there for improvement. And finally, what are the consequences, both positive and negative, for implementing these these processes that you're talking about? Beyond how you're going to hold yourselves accountable to each other within your institutions and to each other in this peer network, to what extent is there a mechanism in place or are there mechanisms in place to be able to hold you accountable, both with rewards and also a downside, negative consequences for failing to kind of move forward on this? This is a question for the industry, not just for each of us as individuals.
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