Equity Case Review: Contributing Factors, Actions, and Case ResolutionExamples From Brigham and Women's Hospital

Nadia Huancahuari, MD: [00:27] There was certainly a need to address this right away. So I wanted to share some of those things that happen right away. So we call this the immediate resolution strategy. And one of the first things that needed to be addressed is a debrief with a care team on how honoring race-based patient preferences was in direct conflict with organizational priorities. So it was important to acknowledge that competing priorities about patient experience and how we've been socialized to prioritize that always. But then thinking about that in relation to organizational priorities in terms of how we want to support all of our employees. So the resolution was very clear at that time, and the decision was made to continue with the same care team, so not to honor the request by the patient. And we wanted to affirm that the requests and demands for specific types of health care providers by race was discriminatory. And it was inconsistent with our mission of delivering equitable care to all patients. Through a diverse and talented workforce, I think that needed to be really made really clear right from the get go. Of course, we needed to support the patient and to support the team.

Huancahuari: [01:42] So that brings us to number two, having a plan for how we're going to then discuss this with the patient. Now, as you recall, the patient was originally sedated. So there needed to be a period of time where we were waiting for the patient to wake up so that these conversations could be held with the patient, when I'm sharing with the patient, exactly like the resolution piece number one, and the impact of that. But we also didn't want to leave the patient alone in this experience. So we provided additional support through psychiatry, social work, bedside nursing. We wanted to ensure that the patient who'd had their primary psychiatrist—and at that time we were doing all these virtual appointments—could have the opportunity to have more appointments with that therapist, while they were hospitalized, and also reassure the patient that the nursing team at the bedside would be there to support her should the patient develop worsening anxiety if they were triggered again. And the other step that needed to be implemented right away was talking about the impact of the request on our staff. And when that happened, after having these conversations with the patient, the patient actually requested to speak to the phlebotomist to apologize.

[03:00] So that was something that that happened. And it was it was interesting to see the response of the patient, once it was clear of the impact that had occurred. And lastly, we wanted to ensure that all the team members had a referral to our employee assistance program right away so that as the days progressed, they could have that support. So those are the immediate things that happen. And now we're going to go on to [sic] that contributors to have it in the format that we've been discussing it. We do want to be…I do want to say that when this case happened, we didn't address structural contributors or social contributors, because it was not part of the of the review at the time. The issues, the contributors that we discussed were systems performance and behavioral contributors. You'll see a lot of the things that you came up with in your groups were the same things that this team came up with. So for my systems contributor, it was clear that this event just raised broader concerns that we didn't have an institutional-wide precedent for addressing this. If anything we actually had precedents for honoring patients' requests and some examples are there like patients firing a nurse or female patients requesting only female nurses. So then it became really clear that we were honoring all of these requests. And now we're coming to this part where we weren't going to honor this request based on race. We didn't have a procedure for how to manage it either, like a policy or procedure on how to manage it.

[04:41] The actions that were taken to address this gap were: (1) the development of a policy on how the institution was going to handle these requests. And you already know the resolution that we came up with. And just for clarity, we did borrow a policy from another institution to review so that we can develop a further sort of Brigham-wide policy on bias and discrimination of patients towards care providers. So that was implemented at the time. I do want to give an update on this, as many of you have said, it's not just about a policy because then a policy may not be…people may not know about it. So in the current time, we're working on further guidelines. And now it's an effort at the MGB level, where we don't just want to have a policy, but we also want to have a guidelines on what to do exactly when it happens, who to call and what teams can come to support you. So that is in progress currently. The other thing I wanted to mention is when you're making these large changes, when you're addressing the system contributors, one of the things that happened at that time, was that this case was brought to the board or Quality and Safety and again, elevating this to the hospital leadership level, so that there is awareness of what has happened, and there's awareness of how we're planning to improve it.

[06:11] In regards to performance contributors, it was learned that there was lack of training on how to manage these requests by the frontline teams. It was unclear, like what the expectations were, and also how to escalate it in real time to nursing leadership per se, like there was no guidance or training on this. So then the actions around it were further discussions and further training with staff regarding how do you escalate? How do you explain not just to nursing leadership, but also to hospital leadership in real time? And lastly, be behavioral contributors. What was identified? Was it the nurse made a choice to unilaterally enforce a patient request for no Black male staff to provide care? So the nurse was provided coaching and feedback from the manager, and the nurse was also offered a referral to employee access to the employee assistance program.

Karthik Sivashanker, MD: [07:11] So thank you, Nadia. And maybe I'll add one more comment, which is, one of the things we uncovered was just how complex this topic is. So I'm going to put it out there: there is no policy that is going to be sufficient for this topic at large of how do we accommodate patient requests for specific providers by race, gender, etc. Because what we found and we did a very…so we ended up escalating this to our patient-at-risk committee. And as part of that we did a very comprehensive literature search, we looked at the medical-legal precedents, and the ethical precedents and all of that. And basically, what we found is that it really depends. It's a very different situation if it's a patient with a disability, asking for a provider with a disability who can understand their experience, versus a patient of a specific language asking for providers of that language, versus a patient of color requesting a provider of color, because there's some evidence that that type of race can coordinate care may provide some better outcomes for communities of color, which begs the question of what's happening in terms of providing high-quality equitable care for our white providers, versus a white patient asking for a white provider because they don't like patients that call it those are all very different situations. And it's hard to have a policy that can, in a blanket sort of way, direct staff on how to respond. So I'm just putting that out there to say that sometimes what you'll find is that things get messy and complicated, and it's not always going to be a simple policy that's the answer. It might require much more than that. And so that's what we're grappling with.

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