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Developing an Equity-Informed Quality Improvement Initiative

Learning Objectives
1. Describe how neglect or oversight of basic items can be a barrier to patient well-being and healing in the hospital setting
2. Identify ways in which inclusiveness can be promoted and protected
0.5 Credit CME

This video is an excerpt from the AMA Advancing Equity Through Quality & Safety Peer Network session on Developing an Equity-Informed Quality Improvement Initiative. In this section, a team from University of Iowa Hospitals and Clinics discuss their journey to equitably providing care products for all patients.

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Video Transcript

James Murphy: [00:00] I'm James Murphy, I'm the Chief Quality Officer at University of Iowa and...we're going to be going... as Katie's indicated, this is somewhat different than some of the other presentations. This is a... fairly complete process that we wanted to take you through and introduce our team.

[00:59] We have Dr Awelewa from pediatrics and ambulatory, we have Dr Butler from family medicine. Part of the team is Dr Del Castillo from psychiatry, Dr Ferguson from dermatology.

[01:13] We have Beth Hannah, who is the director for our quality improvement program. Dr Martinez, who is the vice president for Health Parity here at UIHC, is as well as the associate professor in family medicine, myself, we have Alex Nance, who's the director of patient experience, Jen [last name] ... a project manager... with our the work we've been doing here, as well as the office of health parity. Francisco Olalde, who's our executive liaison here in the [equip department]... and finally, Dr Tate and Dr Van Beek.

[01:52] Dr Tate is from the department of psychiatry and Dr Van Beek in dermatology, and they're really the two heroes... There's a tremendous amount of work done into this, but they've been the two champions that have moved this project along. And, if you move on to the next slide, this presentation is going to be a team effort, as was the work here.

[02:14] I'll just do this introduction and Dr Van Beek will go through the actual body of the work. Then Alex Nance and Dr Welch will go through some of our... grids in terms of structure and short- and long-term actions. Then we'll, as a group, take questions at the end.

[02:36] We only have one chance to make a first impression. People come here, they're in a very vulnerable situation, and what are the things that we can do to assure that we are making this an environment that's welcoming, inclusive, that we are understanding their needs, to form a foundation for developing that trust?

[02:36] Throughout this presentation, some of the questions for discussion that we'd like you to think about are, both at our organization and your own organizations, to look at how do organizations build trust—a sense of belonging, a culture of belonging—and in doing so is how we're anticipating the needs of all of our patients to provide a sense of inclusiveness.

[03:25] Is neglect or oversight of patient basic grooming needs—are those significant barriers to the well being, the relationship, the care that is provided the way patients navigate the system? Then looking inwardly at our organizations to have recognition, acknowledgement about what omissions —as well as clinicians—but what actual omissions are there? And what are the things that we can do to identify them and correct them?

[03:56] Those are the sort of sort of framing questions for discussion that that we'd like to propose. And without further ado, we advance the next slide. I'll turn it over to Dr Van Beek.

Dr Van Beek: [04:05] Hi, thank you, and thank you for letting us have the opportunity to present this to you. I think that the questions for discussion are really important because this really was a profound omission on our part, and come to find out it's an omission that may be happening nationwide.

[04:22] How this all started was, there was a patient that was admitted to the service that Dr Tate oversees, and the patient asked for a comb for their hair and just like what happens with any patient... the staff went to the Omnicell, where we supply patient grooming devices, and presented the patient with a comb that you see right there, which of course was untenable for this patient's type of hair, which is a tightly coiled hair.

[04:54] The patient responded with: "This comb does not work with my hair," and Dr Tate—who is a wonderful advocate for all—became quite distressed by the fact that we provide combs that don't work for some of our patient population. I think she was probably a little aghast that she didn't realize that there is a need for different types of comb or grooming products across patient populations, and did kind of an informal inquiry and realize that, maybe anecdotally, there are practice gaps that are identified in awareness of knowledge across the need.

[05:34] Then she contacted Dr Ferguson and myself—were both in dermatology—and I have to tell you that this has been a profound omission because my children are black and have tightly coiled and curled hair. I'm in dermatology now, but I did my internship here and remember that we have these fine-tooth combs that may not work for everybody.

[06:02] We thought, "Certainly, this must be an omission that the University of Iowa has." We called around to other hospitals around the country assuming that Dallas or Atlanta or LA or that sort of thing had some sort of supplier that would accommodate wide-tooth combs, sulfate[-free] shampoos, which I'll talk a little bit later about... and it turns out no hospital that we contacted accommodates any grooming products for a patient population with tightly coiled and curled hair.

[06:37] Both Dr Ferguson and I do some major work with equity in the American Academy of Dermatology, so we contact some of our colleagues around the country and were aghast that people assumed that patients would bring their grooming products from home, which is it a really untenable request. Nobody really plans to go to hospital unless you're about to give birth. I mean, I know that when my children had surgery, emergent surgery, we certainly didn't pack their own grooming products. This is a major oversight that I think is a national issue. Next slide.

[07:16] This workgroup was put together, and a lot of these people were on the face sheet, but I want to just point out a couple additional people. We had some people that were from infectious disease and lots of nursing support on this, we had a couple of medical students, and I really want to highlight Steve Bird.

[07:34] Steve Bird is our supply chain manager and in charge of procurement of hospital supplies, and did all of the heavy work in contacting his contacts around the country at other hospitals to see if, perhaps, there was an option to secure these supplies—the supplies we knew that we needed—anywhere else in the country, and actually did all of the work because we had to start from scratch with making sure that we could source the supplies from a distributor that doesn't necessarily distribute to hospitals. ...None of this would have happened without our procurement person Steve Bird. Next slide.

[08:13] I'm going to walk you through how we actually decided to address this issue. Knowing that this was a profound omission in care, we really wanted to take a comprehensive approach and put together maybe some patient focus groups and some focus groups from even our employees and find out what other major omissions in basic needs have we done that we should also address in addition to this issue? Next slide.

[08:46] We had multiple focus groups, and these pictures are our employees from all aspects of the university setting where we ask some open ended questions about what basic care needs are we are we not meeting?

[09:07] On the next slide, we'll talk about some of the questions that we offer the group: What are some personal care item or services that we do not offer our diverse patient population? Then, which of these items are essential and which of these items should be offered by request? Knowing that there were probably many things that we were not offering our patients that they need in their basic needs, depending on what patient population they identified with, but also knowing that some may be needed to be kept on the floor at all times, and maybe some could be kept on upon request.

[09:40] The plan was to have items that were available to everybody and then items that were available on a menu that people could request to their in-patient staff. The most important thing is: how do we let patients and staff know about the availability of products that they may not be completely aware of? Next slide.

[10:03] Our focus groups were phenomenal, and we really looked at racial/ethnic minorities, religious minority groups, language minority groups, sexual gender, minority groups, groups with disabilities, and realized that there were some specific needs that we were not meeting in basic grooming care and daily habits that we were falling short on that we certainly could address. Next slide.

[10:29] Because the list was quite long, we wanted to make sure that we started with a pilot with one area with the plan to branch out to other areas, and making sure that we were addressing these needs. We knew that this was a large patient population that we were not meeting the needs of. The initial focus was on essential hair and beard care grooming products for a patient population with tightly curled and coiled hair. Next slide.

[11:00] There are significant structural differences between hair types. As dermatologists we know this, but the average person doesn't know this, the average nurse in the inpatient care setting, the average primary care doctor may not be aware of this.

[11:13] The structural aspects of these hair makes them very easily form knots, which is often why patients with these hair types often have their hair braided or twisted or put in a style that stays for several weeks to a month. Because the less that they pull and tug on their hair, the less likely it is to break. The hair has lower water content, so it has to have a thick layer of moisture vapor barrier on the hair to make sure that it doesn't dry and become brittle. Part of that is due to the fact that there are lower amounts of sebum, which is the natural protective oil that your skin and hair follicles secrete. Next slide.

[11:13] Haircare practices vary because people are trying to protect the integrity of their hair, and the curl and coil pattern can have a significant effect on the ability of that hair to break or to be damaged. Most of the products that were the focus of this particular intervention are referring to tightly curled and coiled hair, which are type 3 and type 4 hair. You can see the examples of type 3 and type 4 on the right-hand side both in clinical examples, and then just really looking at the coil the size of the coil and size of the twist.

[12:36] Knowing that we were going to focus on hair- and beard-care products, we wanted to identify a distributor that was BIPOC —black indigenous people of color—because we thought, "Well, what better way to address this issue than to go with a distributor that also supports this initiative?" That was difficult because... to scale on an aspect where you're going to supply a hospital with over 700 beds that is full 99% of the time, that's a heavy lift. Especially when most of these distributors are catering to the individual population with large-size bottles where we want small bottles to be able to use for a short in-patient stay. Then making sure that we were going through the products and selecting the products that were the most scientifically appropriate care for this type of hair. Next slide.

[13:34] We did a lot of vetting and we settled on Cantu Products. This is the package that is available to our patients with tightly coiled and curled hair. You'll notice the thing that started at all was the comb. The wide tooth comb was an absolute necessity for patients with a tightly curled and coiled hair because it prevents breakage—a fine tooth comb is not usable whatsoever.

[14:04] The other aspect of haircare for brittle hair is making sure that they use sulfate-free shampoo—quite honestly, sulfate-free shampoo is better for everybody; as a dermatologist we recommend it to everybody—we talked in our small group where we would provide these products specifically for this patient population, but there is no reason why we shouldn't offer these products to our entire patient population because all of these are actually better products than what we've managed in the hospital.

[14:33] A conditioner, shea butter for skin, coconut oil for the hair, and large shower caps... for the shower but large satin caps to protect them from the pillow because the abrasive cotton pillows that we have in the hospital can disrupt the integrity of hair significantly. Next slide.

[14:53] As well as the hair on your head, the hair in your beard—when it's tightly curled and coiled—can have lots of significant effects. You can get what's called pseudopodia barbae, which has nothing to do with tinea or fungal infection, but has to do with the fact that the curl of the hair, when people shave, curls and grows back into the skin. To prevent those, we recommend a single-blade razor—I know the commercials always brag about 50 blades on one razor, actually one single blade is far, far better for curled and coiled hair— a soothing after shave, and a soothing shaving cream. Next slide.

[15:34] The next problem we faced was distribution logistics. Because all of these came in separate packages, we actually had to package them into individual packages ourselves. Then we needed to make sure that everybody was educated on the availability of these products and the "why" behind why patients need these different products. Next slide.

[15:56] We identified a variety of units—two psychiatric units, orthopedics unit, internal medicine, surgery, HemOnc, and our Children's Hospital, which is our level 11. Next slide.

[16:12] This is how we packaged the products, we were really careful about the labeling. These were for individual use, each patient would get these, and they're all on the inpatient units and obtained through hospitals stores. If you see there's a little microscopic print on some of these slides, and that's the hospital store number that the in-patient unit obtains to obtain these products. Next slide.

[16:35] Then we embarked on a education campaign on the "why" behind the need for these products, as well as patient education to make sure that they knew that they were available. Next slide.

[16:47] We have a really tight network of nursing council, and amazing communication among our nurses in this hospital, so all we had to do was provide the content and the way we wanted to provide the content, and our nursing council and nursing leadership infrastructure really ran with this. This is one of their compliances on inclusive hair and beard products in the hospital setting.

[17:13] They use this compliance to walk through education, they take a pretest, they get some educational content with some slides, and then they take a post test. Next slide.

[17:26] It's also available outside of compliance just in the general nursing education... so it's part of the compliance that somebody could take, but say, a nurse is on a unit and wants to learn more about that just in time, at the time that the patient is admitted, they can click on that, and there's access to that at their clinical stations. Next slide.

[17:46] For patient education, these infographics are up on our digital screens, they're available with cards in the room, and that you'll see that there are some QR codes on the bottom. Once the patient gets the packet of products, if they want to answer a survey about whether they thought the products were useful, where we're falling short, they could scan the QR code, and it will take them directly to a survey. Next slide.

[18:16] These are, again, more visibility for our patients. We had these rack cards—in the inpatient rooms are certain informational cards—and so we had them translated into several different languages that you'll see here and each with information on what's included.... in the pack. So, they know that satin hair nets are available, and wide-tooth combs, and that they can ask for them. It's also on our digital signage, on our TVs on our inpatient wards. Next slide.

[18:58] After going through the nursing education, and providing that education, making sure that the hospital staff was aware that these products were available, making sure that we had enough signage in the in-patient areas where patients—if perhaps a staff that didn't have the training, was on the ward and didn't know enough to offer to the patient that the patient could actually ask for it if they saw the display card or the information on the digital screen.

[19:25] We really wanted to make sure, as we looked at patient feedback, to make sure that we had the right products and that we weren't falling short, and then making sure that we followed up with nurses to make sure that the education that they were receiving made sense in the context of the patient. Next slide.

[19:42] Again, there's a nursing provider feedback post-knowledge survey, the patient feedback survey that's available through the QR code on the package of the products, and then post-intervention focus groups. We have done the nursing provider, but we have not done a post-patient focus group, but we are planning to do that. Next slide.

[20:04] You can see under the stat-provider education—the infographic is a little small—but this is the pre-test knowledge and the post-test knowledge after they took the educational session. You can see, by far, that most people thought that their knowledge was very poor. This is basic knowledge about why people need these products, the different aspects of haircare why patients often need to have a style that stays intact for weeks, so they're not manipulating their hair and increasing the chance for breakage, why washing with harsh shampoos is harmful to hair, and why frequent washing, even with safe shampoos, can be harmful to the hair because it is so much drier and needs to be moisturized more frequently.

[20:57] All of that information was in there, and you can see that in the post-test knowledge that they really felt much better educated on this. We've gotten a lot of verbal feedback from staff saying, "I didn't know this, this a profound oversight, we've been falling short on meeting these patient's needs."

[21:15] Then, a bunch of us in this group—Nicole Del Castillo, myself and Dr Ferguson, and Dr Tate—had given multiple presentations to different nursing groups live so they can ask us questions, more in depth about the difference in the hair texture, and why it's important that these products are a significant basic grooming need of a patient during a hospital stay.

[21:37] These are some of the comments we've gotten through the QR code: patients really happy to see these items and [it's] really a nice feeling to have basic products for their hair available. Next slide.

[21:52] After these pilots were completed, we got broad approval by our hospital leadership. Our biggest challenge right now is trying to sustain a product supply, because we've been packaging... these ourselves, we've been obtaining them through other funds, so trying to make sure that we infiltrate into a sustainable process that's through our regular funding process and our regular supply chain.

[22:19] Continuing to educate new nursing staff, as they're onboarded it to make sure that all of our new employees are educated on the "why" in the need. We've had a couple press releases. The AMA wrote a nice story about this. Honestly, I think that the press releases are the most important because when we did this discovery period looking for whether this is available to other hospitals, it really wasn't.

[22:48] This is really a national need for other hospitals to adopt the same process. Because when you think about if you're in the hospital, and you're sick, and you're uncomfortable, and all you want to do is do take care of the basic grooming needs that you would normally do, and you're denied that ability, because you don't have the products that are important to be able to get that done. It gravely affects your care and affects your trust, right?

[23:18] If the same people are intervening and planning to do a surgery or working you up for, you know, fever of unknown origin, and yet they don't know the basic needs that you need to take care of your hair and your skin? That can be a little disconcerting: "How would they know what else is going on in my body if they don't know the basic needs of what I need to do on a daily basis?" Next slide. I think I'm going to hand this off.

Murphy: [23:44] Dr Awelewa was going to take over in one minute to go over this slide. I just want to, again, thank Dr Van Beek for the presentation—her and Doug Ferguson and Dr Tate and all their champions of this.

[23:58] I just want to add one comment to Dr Van Beek's comment, which is: we all look at this from different lenses and having the understanding and awareness of the staff to be able to provide these for patients to care for themselves is one thing, but as an ICU physician, the other thing I just like to point out is often we have patients in the ICU and the nurses take great care and pride in cleaning up the patient, doing their hair, cleaning up their face. It makes all the difference in the world to the patients and their families.

[24:33] Part of that education is that if the nurses who are providing that care in that setting don't have the education and they're the ones doing it... It's one thing to be able to provide the products to the patients and that's important to have the understanding but it's also important for us as the providers to be able to do that appropriately. We are often in the position of doing that basic grooming for patients, also patients at the end of life and you know these little things can make a huge, huge difference in the care that we provide. So with that, I just wanted to add that extra piece.

Van Beek: [25:08] I really appreciate that, and I'd be happy to answer any questions. I really can't emphasize what an omission this really was, I mean, my children are black, I spend 20% of my free time braiding and twisting their hair, and realizing that we didn't have the right grooming products within the hospital, I think, is a profound oversight. And, and then educating—and we do this a lot in dermatology—educating people on the necessity of tightly curled and coiled hair, that they should not wash their hair on a daily basis because health care workers that are not familiar with that hair type make lots of ridiculous assumptions about that.

[25:48] Making sure that the nurses know that because, not only is it damaging to their hair, but that some people have put significant time and resources into the style that must stay intact for several weeks. That is critically important, so I just want to thank you for your time and I'm happy to answer any questions before we go on to the action grid?

Murphy; [26:16] I think we'll do the action grid and the case study action grid, and then we'll do we'll have discussion after that essential.

Van Beek: [26:23] Great.

Murphy: [26:24] So, Doctor Awelewa?

Temitope M. Awelewa: [26:28] I'm going be talking about the action way—it's mostly a summary of everything we've talked about, really. I really liked this presentation because as a black woman myself, I know it's usually a lot of talk in the clinic. If I want to get nurses to come around main clinic, I just start talking about my hair, and they're usually so interested in it.

[26:50] Looking at the action grid, just looking at the framework, different levels—from a structural level standpoint—one of the factors that we identified was a lack of attention for the need of inclusive personal care products for all consumers. Especially being in Iowa, we have a majority of our patient population white, but we do have a significant population of black/indigenous people of color as well, so this lack of attention to the need for this inclusive products: How did we address it?

[27:26] Just like Dr Van Beek mentioned, we started out by doing an awareness on the short term, just looking for what other institutions are doing, and we didn't really find a lot of examples to use to get these inclusive personal care products to start with. Then the medium term action plan that we worked on was to get buy-in from the health care leadership, because we needed to make a case for this product to make sure we can obtain this product and make it available for our patient population. The long term action plan will be to continue to share the need to have these inclusive products and identify the next area of focus.

[28:16] From a social standpoint, from a framework level, one other contributing factor that we found was that the lack of personal care products to meet patients' daily needs can affect how patients perceive the health care system... we can improve that perception by making these haircare products available for them.

[28:48] Patients that are already in the hospital—they're in a vulnerable position, they're sick—and just being in that environment and feeling somewhat alone, like, "I don't feel like I have my people around me," can make things worse... looking from the harm level of patient care. The diverse population of providers or patients on the Advisory Council for the patient experience department was something that we found will be helpful in improving how we welcome people into the health care system, making sure that people feel welcome in their environment. They don't feel like: "I'm alone, nobody understands my needs."

[29:37] The needs assessment was very helpful here because with the needs assessment, were able to see what else we needed apart from the... personal care product that we understand. I really liked the example of having a shower cap. A lot of people don't understand having to cover your hair if you go into the bathroom because you don't want to wash it every day.

[30:01] The other thing we also identified was: How do we purchase this inclusive product? That was the other thing we made as a medium-term action plan. Then as a long-term action plan was: How do we maintain these personal care products, to make sure we don't run out of this, we keep making these available to our patients.

[30:28] The other factor that we identified from the short-term action of the needs assessment and finding opportunities to engage with community members. We have local community members from different populations in this area, so we wanted to see how we can bridge that gap and make sure the health care system is thoroughly engaged with these community members so that they are involved in the decision level at the patient advisory council level. So that was the medium-term action plan that we had.

[31:08] Then a long-term action plan was for us to continue to foster these relationships with community members to make sure everybody feels welcome in the health care environment. At the system level, supply chain issues, we identify that initially, the main issue in the short term was identifying products that were already being offered at the institution, and trying to see which other products needed to be added to this list and obtaining funding for the additional inclusive products.

[31:49] The medium-term action item here: we determined the products, we were able to identify the distributor, that would be able to give us this product in appropriate sizes because we don't want the bigger sizes, so that would also help with the costs and making it available for patients.

[32:10] Packaging was a major thing that we had as a long term action plan to make sure these products are available in smaller sizes that are available to patients and so that those products can also be stored on the units and we can sustain the funding for getting these products. I think that will be it for my slide, I will hand over to [inaudable].

Murphy: [32:37] Thanks, Dr Awelewa. Continuing with the action grid here: another factor is human performance, and some of the contributing factors here are a lack of diverse hospital staff, as was touched upon, Iowa is predominantly white, our staff is actually typically a little bit more diverse than... the average population around us. Even with that, nursing clinical staff supply purchasers, our administrators, you name it, we are pretty homogeneous and mostly white.

[33:16] That and the patient population around us, again, mostly white in the state contributed to a lack of education and awareness of the harm. Short term actions around that: I think a fantastic job was done with identifying these focus groups that Dr Van Beek talked about and helped to lead, involving members of this. Also determining their current level of awareness...this gap... I think so much comes back to it just being such a blind spot for so many of us that are even of color, or have folks that are in our families that are of color. Then identifying those pilot units, individuals that believe in the patient experience and want to be the first to raise their hand and say "I want to be a part of this and see how we can successfully do this."

[34:12] Medium-term actions were identifying our priorities and launching this, obtaining buy in again from our leadership, and creating staff-facing education materials, not only those cards and the posters that you saw—the... flyers—but also the patient or other staff education that we have out there in our various systems.

[34:39] Then the long term actions: We're coordinating with our marketing and communications group, to deploy those educational materials to staff so that we have a sustained process that continues to keep awareness front-of-mind as we have new team members join UI Health Care.

[34:56] Then from a human behavior standpoint: patients bringing their own products kind of helps to hide this too, because that seems to be the norm across the nation. Truly, also, hiding this is patients are in a vulnerable state—they don't plan to be hospitalized as was talked about—and so a lot of the times, they're also a little bit hesitant to advocate for themselves. They don't want to be seen as maybe difficult. They don't want to cause them to be looked at differently by the care team, any number of different barriers that they may be thinking that might make it more difficult to speak up and ask for these kind of basic tools and resources.

[35:40]Short term actions here are educating, also, our patients that we have these products available, and that they don't need to bring something from home or have somebody, if they're here, bring something from home, that we have, what they can use, and it's going to be a great product and something that is going to be beneficial and take into account their specific needs. Educating, again, staff of what we have available.

[36:06] A big part of this is creating that patient-facing education as well. You saw that with the QR codes and prompts to ask nursing staff for these materials, give us their feedback and so forth.

[36:20] Long term, you know, making sure that we take that feedback and that we utilize it in constructive ways, and soliciting more feedback: Are there other things that we don't have in place right now that would benefit patients? Then continuing to coordinate with our internal partners in marketing and communications to deploy those educational materials—also, throughout our community—so that this is a known factor before you hopefully get to the hospital and a little bit more proactive in that way as well.

Video Information

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.50  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:

  • 0.50 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.50 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
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  • 0.50 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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