Louis Hart, MD: What I'd like to present today kind of a dynamic dichotomy of approaches, one at New York City Health and Hospitals, the nation's largest safety net, in a city like New York, and then another one at an academic center up here in Connecticut that goes across our entire state with various different delivery networks, and extremely different patient populations, rural, urban, and suburban. So with that, really, the point of this is it's everyone's job. I think we're all starting to realize that. It cannot just be Quality and Safety's sole mission, so we need to get everybody into this collective mission. So how the heck are we going to do that? In terms of conflicts, really no conflict of interest to disclose, there's nothing that would...no financial relationships that should come up here and pose a conflict of interest.
[01:11] This is why we're doing the work. I mean it's, look at the... This is why we do this work. It's the people we see on the screen. It's, as a pediatrician, it's the kiddos that I have the privilege of taking care of. It's their families, oftentimes, when you're pediatrician, you don't just take care of one kid, you're taking care of the entire family. We should probably be double boarded in primary care to kids, and then maybe psychology to the entire family. But it's...this is why we do the work. It's not just for our numbers. It's not just for financial measures of our health systems, but it's for the people that represent those numbers on those Excel documents, that represent those numbers and those control charts, that represent those numbers in our safety incidents. People. And that's why I'm so happy to share this slide.
[01:50] So many of us, we said, Alright, the AMA, they're going to help us, they're going to teach us, we're going to learn from some brilliant peer networks, in terms of cohorts... a cohort of other health systems, we're all going to get through this together. And this is just going to be so easy, right? This is an easy thing for all of us to do. We have infrastructure in place, this shouldn't be a problem. And so I think we've done a good job of kind of showing where this work can start. I think we've shown some examples of who can own this work. We begin to describe how these adverse events with bias and inequity lenses can be reviewed. But who does that reviewing is still a question. How are we going to scale this outside of quality and safety? You know, we might have a few champions in quality and safety or within other departments. But how do we, in a systematic way, scale this across our entire health system? And then ultimately, to our neighboring health systems as well. If we're at one hospital, how do we go to the entire system? And then what are those mechanisms? We've heard Rishi talk to us about those different loci of accountability. But how can we start to leverage some examples of things that are, kind of been coming on over the past years, and some ideas and examples that we've learned along the way?
[02:54] So here's how we do it at Yale New Haven Health, and it's a really interesting approach. It's a matrixed environment, as many of you know, in terms of many people report to different places, many different team members are on similar projects that report through different structures. But here you'll see me as the medical director. I'm actually a Yale School of Medicine employee, I'm not employed by the health system. And that was done on purpose, because they noticed a huge silo across the academic side to the health system administrative side. Even though all of our doctors, the majority of our doctors come from Yale Medicine, they are completely separate organizations. So they wanted to purposely embed me on the School of Medicine side to break down that barrier when it came to equity. I report through, on the health system side through the Associate Chief Medical Officer. And that's our VP of care signature, which is kind of like our VP of quality control, like to make sure we're all practicing the same standard of care, and how we can use our EMR with clinical pathways and decision trees to guide that.
[03:52] So we report through the Chief Clinical Officer, who reports right to the CEO. The Chief Clinical Officer is almost like our system-wide CMO. So it's in the office of the CMO where the Office of Health Equity sits. This is just one example. I've seen systems reporting through the Chief Operating Officer, some systems have Chief Health Equity officers, where some of this work can tap into. I'll show you in a second where we record it in York City Health and Hospitals. But you can see we're made up of a medical director, a dyad, and then a administrative director. We oversee community health workers and a lot of our community benefit-based approach. But this is a new office. So we literally decided that we wanted to be...we were planted here not on purpose, but just because that's where Darcy reported to. Darcy reported to Ian, who's now been replaced by Deb. So just goes to show you it can happen anywhere. But it's important that we take the opportunity to get...well, really it's important that we understand that it needs to get to that C-suite leaders plate. They need to be...hearing about this at a steady cadence because they are the direct ticket to the CEO if you don't have that personal relationship. The partner departments that we work with, you can see vast and broad across the entire organization. We don't just have one Office of Health Equity. We do all the work that requires us to have partnerships across the plethora of business owners that we have—Quality and Safety, Patient Experience, Pop Health, Joint Data and Analytics, HR and EEIB, community and government relationships—the community benefit team that does the CHNA, as well as the Yale School of Medicine and their Office of Health Equity Research. So this is just one approach, the approach we took here, but it just goes to show you how we organized this work at this institution.
[05:27] So this is a really busy slide and more as a resource for you all, you have access to these slides. What was really important when I first got here, I said, "Well, is it the goal of our Chief Political Officer, the CMO of the organization, does he have concrete goals around ingraining equity into our corporate structure and into our health system?" And if it's not even at least on paper, then we're not going to be doing this...and not to say that just because it's on paper, that there's any accountability, it could just be lip service. But the idea that it was important that we included it as a fundamental pillar, though, I still think it couldn't sit here at the bottom as a kind of as a foundational pillar. It's something that feeds all equity in establishing an academic health system. Equity in access. Equity in making people healthier, not just equity standalone. But I was just happy as a one-month into the system employed to be a part of a process where we put this on the plate of many of the executive VPs' direct reports...those VPs that were reporting through him to make sure that we had more than one senior leader who was looking into this stuff, and that was held accountable to him. So across that continuum was Population Health, was Community Benefit, was Data and Analytics, was Quality and Safety.
[06:36] So it was really important that we didn't just have all of those departments report through our Chief Clinical Officer. So it was important that we didn't just have goals for the Office of Health Equity and no one else. We wanted to have goals that forced us to work together. So it forced Pop Health and Health Equity work with Quality and Safety; to work with Data and Analytics; to work with Community Benefit, so that we were all on the same page. And that it really forced us to break down those silos and not just work on our individual projects. But because so many of these checklist items, these key interventions required us to work together, it really made it impossible, so that we could do this stuff in a silo or fragmented. We had to break those down, which was very purposeful, and it has been really helpful so far.
[07:14] We're not going to go through these; I just wanted you to have them as resources. These are not the best, the only ones, this is just what we chose. And it just goes to show you, you just got to choose something, whatever is meaningful in your organization that is realistic, kind of like SMART games, you have to go for it. So let's not spend too much time on the slide. Let's just leave this as a resource for you all. But just so you know, this is how we kind of instituted it, made it very public and visible. Everybody knows these goals, everybody can access them on a website. So it's important that we all have that clarity and that shared framework. This is the Chief Quality Officer's at New York City Health and Hospitals. This was our approach to how we organized...I really probably shouldn't spend too much time on this slide. And I can talk about it later. But it's really just...there's another way we did this. I was within the Office of...oh, here we go. We have something working a little hard to see. But that's better than nothing.
[08:03] So we all reported up through the Chief Quality Officer, you can see me right here in the middle of the screen as the director...was called Equity Value and Safety when I first got started because I reported to the Chief Value Officer, but later became the Director of Equity, Quality, and Safety. And this red box is supposed to be at the top showing you that all of Dr Wei's, who's our Chief Quality Officer, all of his direct reports had a cabinet meeting. And I was invited to that cabinet meeting that...occurred every Monday morning to ensure that every single direct report had an equity lens in their work. So our Chief Wellness Officer, who was also in charge of performance improvement, had to integrate an equity lens. We'll talk about how we did that. Our Chief Value Officer, about how we were choosing EMR-based interventions around Choosing Wisely recommendations. Our...President and Deputy CQO, our Chief Data and Analytics officer, Corporate Risk Management. This was just a way so that everyone...it wasn't just Lou driving the equity. It was everyone had to prove through their reporting to the CQO that they had ingrained an equity lens into what they were doing. Utilization Management, Strategic Operations.
[09:07] It was a really cool, accepted way. And it was driven by the CQO. He demanded this of his direct reports. The only other reporting mechanism that I had was to the Equity and Access Council, and...they directly reported to the Equity, Diversity, and Inclusion subcommittee of the board. So not only did I report to the board through the CQO through our Quality Assurance Performance Improvement subcommittee of the board, for our Quality in our QAPI subcommittee of the board, but I also reported through our DEI subcommittee of the board. And that Equity in Access council was made up of various people that were picked on purpose to represent diversity across business lines. So our Chief Nursing Executive, our Chief Population Health officer, our Chief Diversity Inclusion officer, one of the vice presidents of Ambulatory Care, and myself. So not just all quality or all DEI, but again, purposeful selections of people from different parts who were identified and who had...obviously they weren't just voluntold. These were people who wanted to serve, but not people who...100% everybody looked the same. Not everybody was a racial or ethnic minoritized vote. We chose specific...we looked for specific persons to join that represented multiple different social identities so we can ensure we were doing this right.
[10:16] The other thing on the screen are these purple. When we think about building and sustaining chain, or sustaining and building scale, we had capacity building. So I had a clinical leadership fellow that was assigned through me, and this was a person—I did a one-year clinical leadership fellowship before staying on as the director—and this person I was able to groom. Laura Muster Seagal Israeloff, who was a medical student doing a scholarly year with us, as well, as Jennifer Druitt, who was in the office. I was almost able to groom them. So that unfortunately, when I did have to leave Health and Hospitals, we had people who could step into that role, who had received that training, who I had met with on a regular cadence, and who had assisted me with projects, moving some of this work forward. So it wasn't like Lou left, there's only champion, there were other people. We built redundancy through one of our capacity-building programs. That was not unique for equity, it was for clinical leadership. So it could have been in various parts of our health system. But this was just the people who were in the same office as me who obviously I rubbed off most on.
[11:08] Next slide, please. So, at H&H it really started with a simple expectation. We just set an expectation at the top. Being intentional really matter for us, as opposed to... letting perfect be the enemy of the good. We just literally...I went to the chief quality officer, who was a close friend. And I said, "Can we just start asking this question at the board?" We ask every time at the board...a question around psychological safety. "How are the family? How is the staff? How are the people who are involved in this case doing?" That's the first question that every case starts with. So it really sets that tone...they're not just looking for the bad thing. They're wanting to support us and see how we're doing. We had been doing that for two years...embedded...what started off as "Wow, this is weird, this is soft, let's get into it" has now become part of our culture. So we said, "Well, how are we going to make equity a part of this culture at this board? We need to start asking—discuss potential sources of bias or structural inequity in this case."
[12:01] And that expectation at the board led to upstream changes. So now how we did RCAs, how we did investigations to the event-notification process. And then later those corrective actions. All were a consequence of us asking the question. So we started with the prompt, that led to the formation of the Equity and Access Council. Because then we said, "Well, things that are identified, we need to have another governing body that can also supplement the quality and safety leads who might not have that key expertise, who might be able to blend their safety and quality expertise with a health care equity expertise." That led to us thinking about, "Well, if we want to ingrain this across the continuum, we need to update our strategic pyramid." Because our strategic pillars are what identify what efforts we choose. Each department has to report out—and by department I mean Population Health, Utilization, Finance, Managed Care, the various departments of our health system, all quality and safety—all have to see how their work is approaching or addressing a strategic pillar.
[12:55] So we said, "Well, we need to actually add social and racial equity as a foundational pillar." So it's not like you can just do an access-to-care project or a culture-of-safety project, or a health equity project. Health equity has to be in all of these projects. And that was really purposeful for us. And it helped us really start to drive this theme that...this is our work, this is the work we're doing. And this is going to lead to things that we don't even know what we're signing up for right now. But this is a part of our mission. And this is clear as day for everybody internally and externally to see. This is the work that the Office of Health Equity, I'm sure at the Office of Quality and Safety, and the director of Equity, Quality, and Safety helped nudge. But this was broadly accepted as work that needed to get done across the organization, being a safety-net system, a unique culture.
[13:39] Next slide, please. So this was the first thing that we looked into: How can we add this prompt to our RL data systems, which was a very a new vendor at the time. We had a prior paper system or a web-based system, but we did not have an organized system for reporting of incidents across the entire organization. And we thought purposefully, "How can we add this as a contributing factor to other traditional categories of safety for medication error, that often have contributing factors?" So could we ask this same question as a contributing-factor inequity or bias as a potential contributor that could then draw a flag for review. Then risk management would know, hey, this case is a little different. I need to make sure I consult the right teams to make sure they're involved. We also want to have a standalone question that allows people to easily report incidents of bias or inequity that might contribute, might have contributed, or might in the future contribute to an inequitable outcome for patients. Very simple question, not going to spend too much time on it. But just again, to give you a resource of one approach we took. Many of you are coming up with language that you intend to take. My recommendation would just be to keep it easy, keep it kiss, you know, keep it simple. Because at the end of the day, the more information that's required, the harder we make this, the more activation energy that's required, the less people are going to report, but we'll talk a little bit about the whole feedback that we give on this.
[14:56] So like who should work on these cases? This is interesting based on colleagues in this peer network, it really got me thinking about what we can start to do here at Yale. So we're starting to build an equity review team that's made up of various departments that can really start to approach those cases that are either a priori identified or identified through a key word, to be able to at least pilot our approach. So it's going to be made up of Safety, Risk, Legal, the Office of Health Equity, a Social Work lead, our community health workers—because they often are closest to patients in our community, and might be able to speak to things that we will never be able to speak to, who spend the majority of our times within the four walls of health care—a colleague from HR DEID, and then patient experience leads. We want to...we haven't done this yet, but we want to add in bias and inequity prompt to RLDatix, which obviously will create that flag to prompt a consult for the equity review team. We don't expect all of our risk managers to be 100% fluid in health equity overnight, but they should at least know the resources that are available and which team to consult.
[15:54] We also want to add in equity to the list of contributing factors in all those traditional safety reporting categories; fall, medication error, things like that, so that people can alert us even if it's something that they didn't think of equity at the start, that didn't prompt them to file that RL, when they're going through, they should at least be able to have the opportunity to say, "Hey, maybe language barrier did contribute" or "Maybe the patient's transportation difficulties did contribute" or "Maybe the providers behaviors contributed." We don't want it to be a blame game, we just want people to over-report things so that it can help us identify. So based on that challenge that our colleagues at Atlantic Health set around keywords, these are the words that we're going to start with: inequity or equity, disrespect or respect, bias, racism, sexism, language, and discrimination. So now our risk managers are told if the report includes any of these key words, that that should prompt a referral by the Equity Review Team.
[16:47] So they are called in as a part of... either early in the RCA or some point during the RCA to be able to weigh in on either what a corrective solution could look like, or...how to assist in the investigation. It's not a big time suck for us. It's often done by email, maybe a short 30-minute zoom just to hear about the case and really provide some potential next steps. But it just taps on a brain trust a pool of people who are thinking about this kind of stuff often. And really, it's just diversity, inviting different opinions into the room and making sure that they have a voice that can lead to that corrective action. Then a health and hospitals when we have changed, that when we had made plans to change the RL data system, we said, well, now we need to if something is reported, and at the RCA, we need to give a toolkit so they can start to look for this.
[17:33] So we've used a similar approach in this peer network around those various levels where bias can creep in. This is what we use that H&H. So if something was identified as bias, either in the incident report, during the investigation, we ultimately made it to the point that every case had to go through each single one of these. And it was just in the toolkit that every RCA had to happen, which...when it comes from central office, it made it happen. Not to say it went perfectly, but practice makes perfect. It's going to stink the first few times you do it, you're not going to be perfect. That's okay, you're going to build that muscle memory and you're going to get better over time. So then when someone new joins that safety department and joins the RCA committee, they're going to think that this is just the way it's always been done. So they're going to be getting better, because they're going to expect that to be the culture. So it's just important to start before you're perfect, just by having those conversations will make you comfortable.
[18:24] At H&H we've been doing that now for about two years. I imagine we're a lot better doing it now than we were when we first started. So these are the levels we use, we don't have to spend time on it. It's a resource, but it's similar to the levels that we're approaching here in our peer network. That then led to "Okay, we have corrective actions, we need to inform our department-wide, department level," and this was at every hospital that reported to the Board had to come up with [sic] corrective actions to their worst safety events. And they usually used a large performance- improvement team to accomplish that. So again, remember, we have our strategic pillars. So each departmental PI that the senior leaders at the respective hospitals in our 11-hospital system, and then our 70 clinics, which are represented by one delivery network, have to report to the board; they all have to do quarterly quality improvement or performance improvement projects. So they had to choose across the pillars. And then, as opposed to just having an equity one so that they could just maybe do that once a year in terms of...every quarter, I do a new pillar, which was the requirement.
[19:20] We said at every point, no matter which one you choose, there needs to be an equity lens to this PI initiative. So oftentimes, it was a priori stratified data, find a disparity, and that's how we're going to choose probably any patient outcome that you're wanting to improve. There's probably a difference in a social group. So you can...start that way, you can start with a known disparity or you can start with any traditional QI project you wanted to do. We just decided to ensure that everyone had to annotate this to the board of how they were explicitly using an equitable smart name or smart T smart, measurable, actionable, reliable, timely, inclusive and equitable. Or realistic, pardon me. And it was really helpful. People at first were like, how? Again, now it's just what we do. So it's just a part of the DNA and the culture. Important that this existed across all of the departmental QI projects, and that no matter what color they chose an equity lens had to be contributing to that corrective action.
[20:18] Then that led us to realizing that our patients were not getting equitable dialysis during one of the system-wide QIs and there was a really bad outcome that led to litigation. And, actually, I don't think it happened in our hospital, it happened in a neighboring hospital. And that really helped us realize we need to see...ensure this is not happening here. We took a look at our data, we overserved a minoritized, population, less than 8% of our population at H&H was white, non-Hispanic. So it was important for us to realize, "Well, how do we manage kidney care?" That led us to the realization Oh, my gosh, we use a race-based approach like the rest of the country. This probably disproportionately hurts us. So we can't be doing this. So the Office of Quality and Safety, in partnership with the Equity and Access Council, you can see the parallel, I was in both. So I played a key role in this. But this was not just me alone. This was many other people leading this effort.
[21:07] We named it "medical racism" to be very explicit and honest. And we decided to look into our algorithms that took race into account. So this came out of the Office of Quality and Safety; it didn't come from Equity and Access, it didn't come from DEI, it came from Quality and Safety as a part of a performance improvement project that said our equity lens and this PR project is to see how this equation is hurting or benefiting our patients. When it was realized that this might not be helping our patients, it was a part of our corrective action, one of the PDSA cycles who said, let's look into how we can remove this from our entire system, because it's a lot harder to remove it just from one site. So as we think about race-based algorithms, it was actually our Office of Quality and Safety that led this. It wasn't DEI or the Office of Health Equity—we didn't have one. We had some champion leadership in quality and safety, we had a governing body in equity and access, we had a reporting structure to the board and through lobbying, and through the subcommittee of ED—equity, diversity, inclusion. So it gave us that opportunity to report this up through multiple layers. So it reached the board, when the board said, "You're using race-based what to do what to who? This makes no sense, it then kind of created that accountability around, "We have to do this work. And we have to be brutally honest. Our patients probably don't know we're doing it. And it's not helping the quality and the safety of our care."
[22:16] Next slide. These are some of those accountability measures that you can leverage. Rishi really did a wonderful job describing them. So you what we did a Health & Hospitals and now at Yale, using some of those board mandates and those reporting mechanisms, what governance structures exist that you can report to on a quarterly basis, how do you get in front of the board—if it's through Quality, if it's through DEI—let's make sure that this is brought up. And so that we can allow these ideas to fester at the top, because I promise you, they will diffuse, you need to have an executive sponsor, it needs to be a C-suite leader that owns this work and wants to put it a part of [sic]...their departmental goals and wants to champion this effort. Without a C-suite leader, it's just going to fall on deaf ears, and it's not going to be as sustainable and scalable. They're not going to have those mandates for direct reports to the deputies of these C-suite leaders to do the work.
[23:05] At Yale, we're beginning to stratify our corporate objectives. This is the plan, these are the things that are linked to executive compensation. So as a carrot reward, we need to ensure equitable outcomes are being delivered. But at least equitable processes are occurring before we can kind of jump from inequality to equity. We need to make sure everyone's getting equal care. And then we can see where equal care is dropping the ball. Right now people are getting such different variations in care it no matter their racial group. And then you look at racialization you see... it's like comparing apples to zebras. So this helps us build equality. So then we can measure where that variation and outcome occurs with an equal process and then start to make solutions that are equitable. Right now, we don't even have equal care. And that just speaks to many layers of how hard health care is. Those external accountability measures around your community health needs assessment, your community benefits span, we'll talk a little bit about government and regulatory requirements, this work, and then national collaboratives. Quickly, I'm going to leave time for questions.
[24:00] So this was the loan Institute, the loan index, I should say, came up with this Lown Institute Hospital Index came up with his fair-share spending. So I imagine if Yale... this was the top 25 that did the best in terms of had the most overspend relative to their tax break. So we spent $56 million more in community benefit than we did in getting tax benefit for being a tax-exempt organization. So I imagine if we were in the bottom 25, we would not be so proud of this. But we use this as a "Hey, how did we get this good?" Many of us didn't even realize we were this good. So what were the things that helped us get to the top 10? And how can we go for number one, so...whether it's you're at the bottom 25 and you want to do better, you're at the top, you're in the middle and you want to do better. I think it's just an opportunity to know that there are growing external accountability measures and benchmarking to compare yourself to other systems to see how you're contributing to the benefit of your community. Far from perfect and the American Hospital Association does not...there's a lot of controversy over whether they accept or they believe with this methodology, but looking at the methodology, I believe it is very strong. And I think it's a good start for how we can benchmark community benefit.
[25:09] Quickly, CMS, Joint Commission, Health and Human Services, these are all things that are coming at the federal level to reduce health disparities to collect better data to stratify data, to not discriminate in our clinical care. So like whether people want to do this or not, they have to do it. These are the laws of our land that contribute to how we pay, how we keep our doors open with reimbursement at CMS, with accreditation, a joint commission, and then with liability around this HHS new proposed rule change. So it's important that we realize this isn't just inside the four walls. These are societal and federal requirements to do this work.
[25:43] This was a national collaborative. We joined the anchor Health Network anchor—the Healthcare Anchor Network, HAN—and it helped us. You know, our state declared racism a public crisis. So we had to do certain activities to prove that as a receiver of state funds, Medicaid, we needed to show how we were actively battling this public health crisis. So we joined a network that treats large anchor institutions, big health care companies that employ a lot of people, that spend a lot of money around play space investing, local retirement, local hiring...living wage, so that these types of ideas, your system should be able to join, and you can learn from each other across the nation. And it helps, again, drive that accountability. Now that Yale has declared racism a public health crisis, racism is not a bad word again anymore, I can get away with saying it because I said, "Hey, our senior leader said it's okay to say this word." So in...a rather conservative culture, it opened the door for more of these constructive conversations and to be a little bit more critical about what got us here.
[26:43] These are some of the things we did at H&H around their clinical leadership fellowship, around the healthcare administrative scholars program, we created a "lessons learned from the board." So reports of de-identified cases that happened, real cases that happened to the board de-identified, sent them to GME so that our residents learned about them, that our local...safety departments were involved in building them. It wasn't just us a central office, and we ingrained equity into each of these lessons learned so that everybody had an equity pearl from every bad outcome that got reported to the board. These were some of those, you know, year-long or two-year-long fellowship programs for our residents or for postgraduate residents so that we could actually start to teach them these skills and retain them and then hire them. It's a lot easier to hire someone junior there, you have to pay them less than trying to go and find a chief Health Equity officer and a big team around him or her or them, so it's really cool when you can start to train and groom your more junior workforce into this work for many reasons. And that's what we're doing at Yale. We're creating this health care equity quality and safety designation GME certificate program. So our residents can become quality and safety specialists. But we would be remiss if we didn't make them equity quality and safety specialists.
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