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Embedding Equity Prompts Into Reporting SolutionsExamples of Implementation

Learning Objectives:
1. Describe an example of how health system implemented equity prompts into their reporting solution
2. Describe at least two strategies for how to create a case to internal stakeholders to build buy-in for this work
3. Identify approaches for overcoming resistance to operationalizing equity in quality and safety
0.75 Credit CME

This video is an excerpt from the AMA Advancing Equity Through Quality & Safety Peer Network session on Courageous Leadership: Embedding Bias/Discrimination into Reporting Solution. This section begins with an example of how the University of Iowa Hospitals & Clinics team implemented equity prompts into their reporting solution. Additionally, leaders from Brigham & Women's Hospital and New York City Health and Hospitals, describe their journey of implementing bias/discrimination into their reporting solutions, including challenges and lessons learned.

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Video Transcript

Kara Schwee, JD: [00:32] All right. So the way that we...the logic behind starting these projects, we actually started them a little bit before we started the AMA. So we started thinking about these last fall. And that was because we had several physicians and staff who had reported that they had been recipients of patient-initiated misconduct based on social identity characteristics, and the patients, or the providers and staff who reported that, said they really weren't sure what kind of responses to give patients at the moment. And also, they didn't really have any options for reporting that they knew of. And they also didn't know where to go for support when they needed that. And so originally, we've already started building some training that we've been giving to fellows and some students about how to respond in the moment to that kind of behavior from patients.

[01:37] But we also have started doing a few reporting options, which is what we're here to talk about today. So we have a safety incident reporting option, which is Risk Connect, I know there are several different types of safety incident reporting systems that different hospital systems might use. Ours is Risk Connect. And we also have a patient relations CRM, customer relationship management system, which is what patients can use to make a complaint or grievance.

[01:37] So I'll do a quick overview of our safety incident reporting system, again, it's Risk Connect. So this is...the initial interest here was for us to collect some behavior of patients, visitor, and staff behavior concerning bias or misconduct as a result of social identity characteristics. So this is where providers or staff can come in and may report a safety incident. And this forum asked several questions about that incident. Our equity prompt related change was that we added the question, "Was the incident related to bias or misconduct due to social identity?" And so that's a mandatory yes or no checkbox field. It's only seen when somebody chooses to enter a visitor event or enters a patient event and then selects patient behavior, followed by selecting that it was an incident reached...that reached patient, staff, or visitor, which you can see up here. And so it's not implemented yet for every incident that's reported. Despite turning this on as a mandatory field, back in November, we have not seen any staff usage of it yet. That's expected to change we...will be rolling out organization-wide training to providers, and staff and everybody who interacts with patients this summer. And so our expectation is that the usage of that option will increase after folks know what it's there for.

[03:56] So this is a screen print of our new addition to the patient relations CRM. And again, this is the one where patients can call in with a complaint or grievance. And the patient doesn't see this screen in this form. This is internal. And so the people who work in our office, Office of Patient Experience, are the ones who see this form and who fill this out on their side. And so when a patient, or a patient family member, or visitor calls in and has an issue that is related to equity, specifically I think what I just...the Office of Patient Experience said those would be...they consider equity issues like when somebody says I was treated differently because blank and so when a patient calls in with a question or an issue like that, then the person on the other side will select equity from this drop-down form. So that was implemented in March of this year. And so far they have...it's been used 10 times.

[05:11] So going forward, education will be key. Because even though this has been forced functionality, it's been pretty passive for the organization as a whole, because there hasn't really been any training about it. So very few people actually know these options exist so far. So we're going to—even though they exist in the current state and production today—we're going to be actually training people about what these options are, when to use them, how to use them, and why to use them. So again, we expect the usage to increase after the training goes out this summer. We also plan on...safety incident reporting, we plan on turning on that bias, or misconduct due to social identity field for more incidents that are reported. And also...and then, we're hoping that our reporting options along with this summer's organization-wide training will help us generate more and cleaner data as far as data collection goes.

Normella Walker: [06:19] So Karen, you mentioned that at BWH, one of the first steps that was taken there was embedding the question into our Safety Reporting System. So after hearing from UI, what did you think...Or why, excuse me, did you think this step was a priority? And in your role as a patient safety leader at the Brigham, at the time, what steps did you take to convince others that the work is necessary, urgent in not just your work, but their work?

Karen Fiumara, PharmD, BCPS, CPPS: [06:49] It's a great question. And thank you so much for the opportunity to participate on this panel. So the quick one liner is oftentimes, in my role, and in many of those that have similar roles that I do, which is...my formal titles, I'm the Vice President of Patient Safety, but in that role, over patient safety, risk management, and patient-family relations, we often have to balance the difference between being a firefighter and dealing with the in-the-moment crises that are coming up. And what I like to phrase is being a gardener, so really planning for the future, making sure that we're, sowing the appropriate seeds, and having a good process moving forward. Unfortunately, in the day-to-day of things, I find that I'm probably spending 60 to 70% of my time, firefighting, and about 30% of the time gardening. And to be honest, that was the approach that that we took.

[08:00] I'll never forget the day Karthik who many of you, I hope, know participating in the peer network, walked into my office and was like, you know, Karen, we don't have a way to report cases where our staff might be concerned about bias or racism or any type of disparity or inequity in the care that we're providing. And truly, kind of right away, we said, that doesn't make any sense. You know, if somebody came into my office and said, "We don't have a way to report, if there's a retained foreign object in the OR, what would I do? Would I ask for permission to put a box in the safety reporting system to report the risk of a retained foreign object in the OR?" Nope. And to be honest, I felt like it was a very parallel risk that was part of our system, and needed to be able to be captured, whether it was a patient, or provider, or in any aspect of our care.

[09:12] Now, the thing that I think I was...I looked at your question, that was unbelievably courageous about the question that you put in. You guys...the phrase, the phraseology of your question is, was there bias or...I can't remember the exact terminology that you all have. To be honest, the question that we put in is much softer. It is, "Is there a concern for bias or discrimination in this case?" Now we were intentional with adding the word concern, again, because very consistent with every reported case in our safety reporting systems, there's what's reported and then there needs to be an analysis or review, an assessment. And sometimes what's reported is is not always consistent. And I find you actually get better reporting when we're reporting a concern. We're not saying definitively X, Y, or Z, but rather, there's a concern. And so we very quickly added it to our Patient Safety Reporting System, once we realized that it was not there. We did add it as a mandatory field, which I think some of the chats...I think the mandatory fields pieces concerned because it's going to...it's an extra click, it's preventing reporting, if that's added to all of our reports.

[10:42] But to be clear, we added it to everything, whether you're reporting a fall, a professionalism issue, a medication safety issue, a communication of care issue, all of our forms—we have a different system, we use RL Solutions—have that as a required field question. And again, the rationale behind it felt like it was really just a critically important piece of information to collect, because as a potential contributor to risks within our system. And while I wish that there was a more of a path to being a very thoughtful and methodical gardener and saying, "Oh, we're going to put in this question, and we're going to tell everyone about it, and educate everyone on how they have to use it." And I knew, after being at the Brigham for the past, however many...18 to 20 years, I lose track, that that would take six months to a year, and then there's probably going to be committee that's going to be formed, and that committee is going to be vetted by everybody, plus minus the Pope. And that ultimately, it would probably make sense that this is a risk, this is something that we need to do now. And let's start collecting the data. And then we can react as we move forward. Love to get other thoughts on that.

Normella Walker: [12:10] Actually, we're going to invite Lou in at this point. So Lou, what was similar or different about your journey with this? And then how did you convince others to embed this question into your reporting solution, while you also worked on putting all of these larger pieces in place?

Louis Hart, MD: [12:28] And thank you for having me. It's awesome to be here. I had a...it's so funny. So I started the journey at Health and Hospitals, large safety net system, serving the best...patients in the city of New York, across 11 different hospitals, five nursing homes, 70 clinics, big system in a in a very fast-paced city. And we had a different approach. We actually didn't start with incident reporting. We started more fundamental, where...what power we had being central office, which was a pure kind of administrative position, not at any one of the hospitals, but kind of the central governing structure of the system of saying, everyone comes to us on a quarterly basis to discuss their worst adverse events, those patient safety stories that really caused terrible, irreversible harm, huge risk to the organization. And we need to ensure we have system-wide corrective action.

[13:21] We can't just keep putting out fires at each different hospital, we need to take these lessons learned and disseminate them broadly. And I was fortunate enough to be in the office of the CQO, and a very bold courageous leader like himself said, we need to start asking when these sites are coming to the board, the QAPI board or quality assurance performance improvement, the subcommittee of the board, when they're doing...going through the process, you know, over the past two years, we've been building psychological safety, just culture, the first question that every system is or every hospital has asked when they present those adverse events, "How are the involved staff?" "How's the family?" "How's the patient?" You know, really building that to two years because in prior leadership that used to be like a firing squad. They come, they tell a bad case, and six months later, they'd be walking out...finding a new job. So that took a lot of...the Deathstar mothership view of central office to more of a...they can actually help us, they can leverage this to my resources to make us not have to build this and reinvent the wheel every time.

[13:21] So what started with building that trust and that confidence that we were all in this together and this is the system's fault, not their fault individually, took some time. We then started with the board question of just saying, "Discuss the implications," kind of an open-ended question so they couldn't just say yes or no, but discuss the implications of bias or structural inequity and how it may have contributed to this event. And we didn't give them any prep time or lead time. We just kind of...just like the psychological safety just started happening. We just did that. And then what started off with like, "Wow, I'm so caught off guard," "The patient was Black," The provider was Black," there was no bias. Quickly led to follow-up questions and conversations and an evolution that now gets deep into chronic homelessness and the bias that providers have about patients with mental-health disorders like substance-use disorder, and those frequent flyer ED patients after a patient died of a brain bleed in our one of our emergency departments, because we thought they were just sobering up, they were actually having a head bleed. And how bias is not just about black and white, but these things are intersectional across so many other different identities and pathologies in terms of behavioral health.

[15:33] So I think the interesting approach that we took was it started very central. It started with one simple line, no training, no reinventing the wheel, no waiting for everything to be perfectly rolled out. Then that led to wow, like, "Hey, you have an Office of Quality and Safety and a medical director of Equity, Quality, and Safety. Can you help us figure this out? So we can be better going forward?" I don't want to be caught off guard when I'm speaking to board members next quarter, then "Hey, can we use that same question and build it into our reporting tool? Can we discuss it at the root-cause analysis? Can we invite social worker and patient...the actual patients or similar patients from key target community or prioritized communities to actually listen in on our RCA and actually attend."

[16:15] And this was like...our general counsel was like, "Okay, like, there's a lot that's going on right here. This is some innovative stuff. I'm in full support of it, but we need to get our ducks in a line." And we did. And we really created it first as an educational module, lessons learned from the board, de-identified the cases, taught it to all of our residents, worked with our DOIs and...DIO, sorry, and GME residents to kind of teach them that these things were happening, made by the local residents and quality and safety departments that were presenting the cases, disseminated and broadly educated and raised awareness around this, and then that led to...now they're doing it on RCA centrally and in the site. Now they're doing it on their performance improvement projects, asking it at every PDSA cycle, how we address equity. So we took a different approach centrally, we knew we only have so much control, what can we control, we can change our strategic pyramid, we can build this culture so that people who look up to us or who look at us can start to walk the walk that we are walking and that we are talking.

[17:15] So it was the natural next step over that evolution to say, "How are we currently reporting these things now? Is there an infrastructure?" If these things are happening, and we just don't know about it, it doesn't make us any better off. How can we fix something? How can we assure our patients, the city of New York, the government that we are providing this outstanding care if we have no auditing structure in place to even identify what's happened? It's almost like if you just turned a blind eye to falls, like, "I don't really know what's happening these things [sic], I get some lawsuits, and I only find out about it at the lawsuit." No, we would never...I mean, maybe that's how we did it 50 years ago, but like now, we want to be proactive, we don't want to be reactive, we want to be transparent. When we didn't have that psychological safety, the best unit was the quietest unit. No reports, everything's perfect, don't look this way. Now, the best units are the units that are bringing forward the most reports that are showing the most opportunities for improvement.

[18:04] But that subtle shift went because we really went from a process of individual blame to system blame, using that just culture using that psychological safety. Absolutely, there are outliers. But that bad apple approach to quality improvement is a very tired approach, in my opinion. And it really doesn't pay attention to the greater systems that people are just acting as representatives of. And if you change the system, no matter who is recruited, or who is in that role, they will...the culture, the system will guide them along the process. And I think we're getting that with high reliability. We're understanding how interconnected everything is, and how we are all team...how we are all members of a team. And how if you change the structure in which the team operates, it's much easier to hold each other accountable for what we all want. In the end, none of us want harm, none of us want risk. None of us want patient safety concerns. None of us want additional burnout on our already burned down staff.

[18:54] So if we can create opportunities to build our cups up by focusing on things that are happening that we all know on the front line are happening, but we just aren't even talking about. And then seeing them on the back end when we're getting sued about them later on anyways. And when we're settling, it just made too much sense. So it kind of it started purely in a central-office approach, and then really came top down. Or top front, I should say there is no down, no vertical, it's a horizontal structure. But that was very our approach in the convincing, it was unique. I'm going to put something in the chat that we were able to do at Yale and the Children's Hospital because of just a smaller, more controlled system. And this is our kind of discrimination reporting pathway that we have at Yale. But at Health and Hospitals, it was very much different than in terms of just who we serve, who we were, what our mission and culture was, than at Yale, which is a different system. Great mission, great culture, but it's different.

[19:47] So you kind of have to tailor your message. We had to tailor our approach up here, still a lot of work to do, and still a lot of work for Health and Hospitals to do on their journey. But it just speaks to the idea that there are certain commonalities that we all are against. Like I said, none of us want more risk. None of us want more patient safety concerns. None of us want to work a workforce that is that is on empty continuously. So what are the ways we can do to support that? We can share or build infrastructures and systems that can make their jobs easier and start to root out these things just like Patient Safety went on that movement in the past 20 plus years?

Walker: [20:20] Oh, there's a question in the chat. I don't know if you saw it, it says, can you repeat a write that question down that you used for safety incidents? Is that in the document that you attached? Or is that something you can answer?

Hart: [20:31] I will, I'll type it into the chat. This new thing I attached was from the Yale Children's Hospital that we built and it's almost like a, an algorithm, a decision tree with some support tools, so that in the moment, publicly available on our website, but in the moment, people would have some resources. It goes along with the education that we're doing in grand rounds in the children's hospital. But I will write that in the in the chat right now, what we did at Health and Hospitals.

Walker: [20:54] Okay, so Andrew, you're up. So Andrew, embedding equity into quality and safety is new for many health systems. Sometimes doing things a new way can be challenging, as you may encounter resistance to change. We mentioned this earlier. This is a question for you, Lou. And Karen, what kind of resistance did you experience? And how did you work through that? How did you gain really the critical buy-in that you needed? And then Andrew, you played an important role at BW H and sponsoring the work. So I'd like to start with you. And then I'd like to have then Karen and Lou chime in.

Andrew Resnick, MD, MBA: [21:31] Yeah, I guess in my perspective, the important thing...Karen described how we sort of started by just doing it without asking permission and putting it in that was...I think, had to happen. Because, as I think Karen and Lou both described, these things are happening, by not allowing people to report them. Putting your head in the sand doesn't make them not happen. And so it really doesn't add any value to wait for some future period where everyone's on the same page or something, the events are already happening, you can't stop them. So you need to know about them, like any other safety event. So I think that was really good that we did that.

[22:09] In parallel, though, we did start to bring things to our board. And that was super important, because over a couple of years, we went from just reporting it into the safety system, but also doing some board education, and making it part of our organizational goals, starting with having to be part of all safety analyses, and then ultimately having be part of all data analyses. So that was a progression over a couple of years. That was, I think, really important. So we brought a couple of cases to the board. We used to bring patient safety cases to the board. Karen always enjoyed that.

[22:45] But we started bringing equity cases to the board so that they were informed, what those cases looked like [sic]. And at first, that was a touchy subject, because it took...it wasn't overnight that the board was comfortable hearing about patients falling off of gurneys and things like that, for sure. But when they started hearing about disability cases or equity cases...also, they sort of felt like, "Oh, my God," that feeling from 20 years ago, and the safety movement where, "How can you tell these things in front of our board?" We had to coach our senior leadership team through some of that, because they didn't want to feel like all these issues were being left unaddressed, and the board was hearing about them. So I think that was maybe the part of...the courageous part of sort of forcing it to happen, not backing down on it at all, and educating the board as to the why. So Karthik came at one point and gave an education to the board on why we're doing this, and Karen did as well. And that was a really important part of this.

[23:28] And so it wasn't overnight, but the board started being more comfortable with hearing about these cases, such that when we proposed to put it into our goals for the next year that we wanted to measure everything by Real and so G and whatnot. It was...I don't think there was much pushback to including that as one of our goals for the whole hospital, and then the board, to their credit, I remember...I'll never forget a couple of years ago, when we were presenting our normal board data, and they're like, "Why are you telling us coding and CLABSI and whatever data and not giving us demographics? It's supposed to be one of the hospitals, isn't it?" And so we were like, yeah (laughs), and so we quickly started doing all the...every data, putting in putting in the demographics, which, that was just like, a great moment where we knew we had gotten everyone on the same page. And again, it's it's a progression, but I think all those things are important factors.

Walker: [24:01] I do have a question for you about that, Andrew. So how long did it take you to socialize that it really kind of got to the point where that was kind of a normal course of business and the way that you...the shift in how they viewed these things?

Resnick: [25:03] Yeah, so I guess everyone...I love your term, Lou, of out or not top down or whatever top out or some of these so...but in using the old-fashioned terms of top down and bottom up, I think Karen's...what Karen did was nothing short of amazing in terms of pushing equity. It's just part of everything that the safety and quality teams did to start. And that made everyone...in every safety huddle, we started talking about equity and demographics and everything for anything that was reported and people from the frontline level and the management level all started to become A) comfortable talking about those things, but B) it started to be weird not to. So you know, in safety huddle, when people presented cases, it was pretty obvious if you forgot, and people at first had to remember what all variables they needed to present. And we went from awkward to present to awkward not to present, really, and I give Karen and her team, all the credit in the world for making that happen in a way that didn't make anyone feel bad, didn't seem awkward, was fairly quick. I think the whole thing was like a matter of months, I mean, really not years. But that was like the bottom-up kind of approach. And then the top down was what I talked about with the board and senior management that...who came to the safety huddle sometimes. And so that was a good area of of integrating the work in those approaches.

Walker: [26:31] Karen, do you want to jump in at this point?

Fiumara: [26:33] I would love to. I think the if I could do it all over again, and Andrew is always to give me way too much credit. But if I could do it all over again, the one thing that I think I tried to do, but I don't think the message was fully appreciated, was really explain that identifying in disparity of care or an inequity in the health care that we're providing, to truly be synonymous and needing to be analyzed in the exact same way as a contributor, as when we identify a communication failure, or a transitions-of-care failure or a computer failure, that there are systems performance and behaviors that contribute to all of these and with inequities. Structural, right? Organizational. And really making sure that all of...that the analysis into a case that had a contributor that was regulated to an inequity is really identified and seen in the exact same way. It was so...I don't want to say obvious, but I never saw it any differently.

[27:59] So I wasn't, I think, explicit enough in those conversations, to really be like, this isn't anything new. This is a contributor that we should have been identifying all along, and we should be addressing and seeing as the structural...what are the systems issues at play here? What are the performance issues at play here, as well as the behavior issues? I hope that makes sense.

Walker: [28:27] Thank you, Karen. And, Lou, I'd like to hear from you on this too.

Hart: [28:31] Yeah, I think once, especially HR, once they heard the word discrimination, it rings different bells, (inaudible) lawsuit. It's like a very charged word in HR, which I had to learn because I'm thinking, I use the words "bias" and "equity discrimination" in such a common vernacular. But ultimately, it's the same thing. But it means very different things from a different...if you have a legal mindset or if you have a operational [sic] in terms of a human resources mindset. But I think the idea of how we could share that these things are happening left unaddressed, they will only get worse. So we need to do something here. Then the biggest concern was okay, well, we're going to we're going to report these things. And I've heard this currently, because we're trying to figure out where the best place for this to fit. Is it HR? Is it Patient Relations? Is it quality and safety?

[29:24] It really needs to be all of us because inequities are all of our opportunities are our responsibilities. We are all accountable for quality and safety. We are all accountable for equity. Those on the frontlines are the ones executing it and us back at house as leaders, we're the ones supporting those frontline heroes and sheroes. So I think the opportunity that we saw was, okay, how...once we've identified these things, is that now worse that we've identified them and we're not doing anything about it.? And I said, that is a natural concern. And I can understand from a legal standpoint, if on discovery, things were reported and you didn't do anything about it, that probably does look worse. But from the fundamental idea of they're happening anyways, unless we begin to acknowledge them, we will never begin to address them. And once we have the transparency that is highlighting these opportunities, it will then come...more resources will then follow this prompt in terms of transparency drives accountability.

[30:14] So if we are not documenting these things, if everyone can still report out, there were no incidents of discrimination. And then we can say, Are there any mechanisms involved to report discrimination? And they say, Well, no, not currently. And I'm like, then how are you really auditing that with any validity? I mean, if we're holding ourselves accountable with a lack of a system, you really can't make any claim about the equity of your processes. So I think it drove this point home around "I understand the liability this can bring us to, I understand how this is bad." You know, PR, this is bad if we find something and don't do anything about it. But the idea is, we need to start somewhere. We need to start reporting these things like we did through patient safety. And look at that evolution through patient safety. Does that make us worse off than we were 20 years ago, when we had no infrastructure? Or are we better off now, in a better position to be able to address these things proactively, as opposed to putting out fires every day left and right?

Resnick: [31:04] You know, just to add to that...the Brigham is a institution that is extraordinarily transparent, and has all sorts of research interests in everything, including equity, these days. And so, to bite off the apple and start doing this work, you don't necessarily have to go as far as...I think the Brigham is about as far as anyone could go in terms of publishing all sorts of papers out there, which generated a lot of national attention on disparities and inequities, and different pathways published for Black patients versus white patients with heart failure getting admitted from the ED and all this stuff wasn't just reported in the patient safety system, but it was on the front page of the news separately, and so you probably can't get more transparent and more public. And even that was okay...even that was okay. And to lose part...not doing it doesn't mean it's not happening. And so, I completely agree with what Lou said.

Walker: [32:09] Thank you. So I'd like to open this up to see if there any questions that the other members of the group have. Does anybody else in the larger group have questions or things they'd like to have these panelists or our wonderful presenters from Iowa share with us? If not, I have additional questions, but I wanted to get an opportunity to get in here.

[32:40] Okay, so we do have a little bit of time left, if you have questions, feel free to chime in. I'd like to ask you if there are one or two lessons or takeaways that you would think would be important for the group to understand about your process and how this all kind of came to fruition for each of you. And anyone can start.

Fiumara: [33:09] Of course, I don't want to jump in. I feel like I've been talking too much already. But we'd love to hear from the Iowa team, you know, what they think is super important from a takeaway standpoint, I think from my position, what I encourage us to do as an important takeaway is (1) not see this all that differently than everything else. And if anything, see it as a bigger risk of bigger vulnerability, a bigger point of concern for all of our organizations than almost...really when I think about my career, and I realize I'm still early in my career...this this is the biggest risk and vulnerability that I feel like came along... I don't want to say came along, because that's so such the wrong language, but that was not systematically evaluated in the way that we really should as part of the health care community.

[34:10] And, just the absolute urgency and fire to do something as soon as humanly possible. And the second thing is, when there's something that's this important, there's a million and fifteen reasons to not take action, the legal implications, the concern around everyone feeling uncomfortable, the emotional charge of all of this. There's...the list is much, much longer than my arm. And again, to my mind, all the more reason to do something, do something quickly and iterate as we go. We are all also process improvement people. We know that nothing is ever perfect when you start. So important to start and then iterate over time, and get better as you go, acknowledging that there will be stumbles along the way. The first few cases that got reported, we did not handle perfectly at all. And we still to this day do not think the perfectly at all. And I think it's important to acknowledge that and, when it's the right work, not being perfect, I think is okay. And just continuing to acknowledge you're not perfect, and working forward.

Resnick: [35:44] There's a question in the chat about, is this outside the lane of quality and safety? I thought it might be worth talking about that for a minute. You know, because I think the experience at the Brigham, we were fortunate. We started this work pre- pandemic, by a couple years, first of all, and the lane was kind of wide open. I mean, frankly, in health equity in hospitals, a lot of hospitals were hiring chief DNI roles. But those roles were often disconnected from clinical operations. And we're working on some things, but not really the lane of what's going on with clinical operations. And we had an environment of great collaboration, you know, Normella with you and Tim and everyone, working with patient safety. So, I think we were fortunate in that regard.

[36:35] Now for people starting now, there's a lot of interest, I mean, there's extraordinary interest, which is amazing in this work. And there's probably whole departments...and it's a more complicated structure at the Brigham... it's more complicated, too. So I think, to get everyone on the same page, and certainly, I always hope that everything—quality and safety and equity and patient experience, there shouldn't be competition. And "this is my turf, don't do equity work, I'm doing equity..." I hope, but especially in academics, sometimes there is those things [sic], even with topics that you think, Oh, my god, how could there possibly be turf wars, and, you know, quality, but they exist. So I think it is important to know, who's doing what; we've tried hard at the Brigham to align.

[36:36] Starting in the middle of COVID, that first lockdown, there's a number of committees stood up, and we tried hard to make sure everything was aligned. And I think that is important. And it's been...I can't speak to the last six months, hope nothing's changed. But I think it's been easy in the collaborative culture there to make sure that this lane is doing what it's supposed to be doing, which is making sure if there's any vulnerabilities in patient care that we that we find them and fix them, but certainly, at other organizations that might look different. And that collaboration is really important to call on. So it's a great question.

Walker: [37:57] Yeah, it was a phenomenal question. I thought so too. And the truth is, we cannot achieve equity without looking for inequities everywhere, and we know they exist everywhere.

James Murphy, MD, CQO: [38:09] Yeah. Can I? I'd just like to follow up on that. So I think it depends very much on, I think, no matter how your organization is structured, in terms of quality and patient safety, some organizations that includes patient experiences, some it doesn't. But you know, irrespective of that every single quality and patient safety department and every organization, there is a component of this too. So there may be a component that exists in patient experience, that may be a component that exists in HR, there may be a (inaudible) that they're in population health. There are many areas where this where this can be defined and expanded and where those departments exist, will change. But in every quality and patient safety office, there is a role for this, undoubtedly, in understanding what's happening to our patients, what are the interactions, and how are they being hurt? And how can we improve their care? And I don't think there's any question about that.

Walker: [39:12] Thank you, Jane. Lou?

Hart: [39:15] No, I just think it's such a great point. And I think I've heard this many times that like, all these upstream, the SDOH, the social drivers, they're not within our control, and I go like, do we pay a living wage? That's in our control. Do our patients, or do our patients who are oftentimes our staff get treated differently in the health care? The health of our staff is within our control, what health plans what access they have, especially around you know, we don't provide certain gender-affirming procedures here, and yet we have a health plan where they can only get their health care at Yale. So for our patients who are sexual or gender minoritized individuals, they have to go out of network and out of their own pocket. There's so many things within our control in terms of being corporately social not just responsible but accountable organization's mission and anchor networks, but I think when you're talking about internal operations, the quality, the safety, the experience of your care that is 100% within our hands. That is not upstream, that is a downstream driver of inequity. And when we see some patients get admitted to general medicine, some get to cardiology, some patients go to this clinic, some to this bill, the average length of stay, the lost-to-follow up rates, these are things that we can build around. Yes, they're driven by other things. But if we are not at the table, addressing both the upstream causes, and then the things that 100% are no one else's responsibility but our own, until we can commit to doing both of those things, then we will continue to just propagate status quo. We have to be bold, we have to. It's not our sole responsibility. It's a societal effort. But as one of the biggest contributors to GDP in our nation, if we are not at the table with a microphone and a leading opinion, then why...who else is going to take that pulpit?

Walker: [40:50] Thank you. You're right. It's all of our responsibilities. Caitlyn, do you have a question?

Caitlin Donohue, DrPH, MPH: [40:55] Thank you. Just a question for you regarding...back to the conversation around this theme, you know, everyone's role in everyone's kind of...not just to quality and safety, or not just population health, or just finance, etc. I totally agree with you and trying to get our organization sort of to that same level of bias. And I think one of the questions that I did have was just around knowing that all these groups may be addressing equity or inequity in their specific sort of realms, or I worry about silos and how we can pull up some of those efforts and connect and learn from each other. And I'm curious about if any of you have had experience doing that, like raising from quality and safety or experience in HR and bringing those things together at that system level. I want to be curious about how you might have structured that or approached it?

Walker: [41:58] Well, I can actually answer that question. So actually, so we haven't done that quite at the Brigham. Yet, that's something I think we're still working on. But prior to working at the Brigham, I was at the Cleveland Clinic. And in that way, every department actually had a diversity, equity and inclusion council where they worked on some aspect of equity in their department. And then we would bring the leaders of those departments together, quarterly for meeting, where they would share what they were doing. So that was a way that everybody was engaging in the process around observing, paying attention to data collecting, addressing equity in some way. And it was also a way for them to share best practices, share information. So that's one way you could do it. There are certain structures that you can put in place to do that, where you bring people together through forums or some kind of shared reporting, but there's certainly ways to do it. And I would encourage it, so that we are kind of sharing information, the left hand knows what the right is doing, we're all appreciating really all the the collective hard work that's happening in the space.

Fiumara: [43:12] If I could just build on that a bit more...and again, I can apply this to disparities or inequities in healthcare as well as various different other areas, I always feel, always, that we have...I'm going to make up numbers...$100 000 worth of problems and 10 bucks to solve them. And I have no interest in being the budget that controls the $10. So to my mind, I hate silos, it drives me bananas, I feel like it ends up creating redundancies and it's just not efficient.

[43:55] And yet, I kind of love that everybody wants to work on stuff so I actually don't have an issue with it. To me, it's work, work, work and yes, anybody who wants to do anything, do the work, whatever that work is. And then the reason to have the structure, the making sure that there aren't any silos of course is to get economies of scale of the work, but I do...and again, I'm tough because I'm a firefighter when I think most are gardeners. To me...put out the fire, just do whatever you got to do. Throw some water at it and eventually, making sure that the water source is all coming from the right place is fantastic, but put out the fire as you need to. So the reason why I mentioned this is I wouldn't...I personally, if I ran a hospital, I wouldn't hold up progress in the space in silos for the benefit of our really defined structure and clear lines of accountability and everyone marching the same. Of course, there's economies of scale to be gained from that and huge benefits. And there's local fires that should be doused.

Walker: [45:20] Yeah, there are pros and cons to both and frankly, if you can find a way to have people doing what excites them and what's important to them in their space and sharing that information, I think that's the best of both worlds.

Donohue: [45:31] Totally. It's a "both and," and that's kind of what I was hoping to, yeah.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.75  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

  • 0.75 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.75 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.75 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.75 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.75 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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