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Dismantling Racism and Inequity in Health Care: The Critical Interplay Between Equity, Quality, and Safety

two women preforming surgery.Namita Seth Mohta, MD, interviews Karthik Sivashanker, MD, MPH, CPPS, Medical Director for Quality, Safety, and Equity at Brigham and Women’s Hospital.

Namita Seth Mohta: This is Namita Seth Mohta for NEJM Catalyst. I’m speaking with Dr. Karthik Sivashanker, the Medical Director of Quality, Safety, and Equity at the Brigham and Women’s Hospital in Boston. In this role he is focused on advancing a culturally competent health care system that delivers high-quality, safe care to every patient regardless of race, ethnicity, social class, or language proficiency. Clinically, he is trained as a psychiatrist.

We will be discussing the critical interplay between health equity and quality and safety initiatives, which have traditionally been addressed in silos by health care organizations. Karthik and his team at the Brigham have launched a creative, integrative approach that we can all learn from. Thanks for joining us, Karthik. Our audience will benefit from hearing your insight.

Karthik Sivashanker: Thank you for having me.

Mohta: Can you briefly summarize for us how you and your team at the Brigham have reframed this focus on advancing equity, quality, and safety? What is the rationale, and how is this unique from what others are doing?

Sivashanker: I think that’s the best place to start in terms of, how do we shift the paradigm in health care and why is that important? It’s been in the news all the time lately about structural racism and the death of George Floyd and many others, and the riots, and so it is on people’s minds, but we haven’t made that much headway in health care, at least not as much as we should have.

Part of the challenge has been that we’ve taken the approach of historically hiring a few people of color, putting them in a corner of the organization, under-resourcing them, and telling them it’s [up to the] DE&I [Diversity, Equity, and Inclusion] people to solve the problems of racism and structural discrimination in the organization. These are systems that these individuals do not maintain at the end of the day or benefit from, and it’s a setup for failure.

How do we move away from that paradigm and make equity and anti-racism a part of our everyday work? How do we operationalize it? Quality and safety is a powerful system that we can use to advance equity. Part of the reason is that in terms of quality and safety, we’re always thinking about risk at different levels, everything from the individual level all the way up to the system level. When we think about inequities, it’s the same thing.

You have implicit of biases and explicit biases at the individual level all the way up to the systemic and institutional and structural levels. When we think about quality and safety, especially with safety, what we’re thinking about is, how do we redesign our systems to optimize the performance of people within those systems?

An example would be a stop sign. For a stop sign to work, people have to see the stop sign, they have to be awake, there can’t be anything covering the stop sign. If all these different things come together, you will stop, and you won’t hit that pedestrian. But that’s not a resilient system.

What would be a more resilient system would be if automated roadblocks came up so that your car literally can’t pass through, which is something that you see in other countries sometimes. The same thing applies when we’re talking about equity.

The inequities that we see and the risks associated with them in part are being translated by individuals, but for the most part these are structural, these are systemic, they’re embedded into our policies, into our practices, and so we need to redesign our systems.

Just doing, for example, unconscious bias trainings at your institution is not going to be a recipe for success. Rather, how do we take our quality and safety infrastructure — which we’ve built over 30, 40 years — systemically embed equity into it, use that infrastructure to analyze risks, and redesign systems that optimize behavior and improve care for everybody?

Mohta: This notion of reframing, systematizing, and integrating is a remarkable one, and it’s one that you’ve had a chance to test and iterate at the Brigham. What have been some early wins and successes? What have been some of the challenges and the trade-offs you’ve had to make?
Sivashanker: I’ll start with the challenges and trade-offs, because what we’re talking about here is significant cultural transformation. When you think about a risk manager or a patient/family relations specialist, or an HR person, they may be used to analyzing cases where there was a harm, even where an error was made, but when you add on that additional layer of a concern for discrimination or a concern for bias, even though the analysis itself in a lot of ways is similar — we still want to understand was there a contribution at the human performance level or the human behavior level, or at the system level — the fact that it’s a touchy, sensitive topic for some can throw them off and they don’t know how to approach the conversation.

One of the big challenges has been, how do we train our staff who historically have not used their roles as being related to equity to be able to facilitate these difficult or powerful conversations? How do we help them build a container for psychological safety so that you can probe whether there was a harm related to inequity? That has been a challenge.

The other part of it has been the challenge of color blindness. Let’s say an event happens on a unit and you are having a conversation with that unit director. The typical response of a lot of hospitals is, “We don’t have bias on our unit. We don’t see color on our unit.” That’s an old mentality. It’s a wrong mentality. It’s not going to get us to where we need because there is bias embedded in all of us and it does contribute to these risks.

We have a lot of work to do to get [there]. Kind of like with patient safety 30, 40 years ago, it wasn’t socialized that risks are everywhere and medical errors are happening all the time. In the same way, we need to socialize that inequities are everywhere, they contribute to these risks, and we need to be working on them all the time.

In terms of successes, Covid-19 was a great example of how the system functions and how it can be really potent. Unlike a lot of systems, what we found [at the Brigham] was because we had developed this infrastructure, we had embedded equity into our reporting systems, into where people put in their safety reports or their experience reports, we didn’t have to work hard to figure out what was going on.

In real time we were getting a constant flow of information from these safety reports identifying risks across the organization. Within hours we knew that there might be a discrepancy in who was getting access to our personal protective equipment (PPE), that maybe some of our employees were having a harder time getting access, or that maybe there were problems with visitor policies, or that potentially we’re being perceived as discriminatory, even if they weren’t and it was just a problem with communication.

We were able to figure out that there were language barriers, that there were problems with crowding on shuttles, and difficulty with social distancing. All these different risks — I’m just naming a few of many — were flowing through our quality and safety system, automatically getting triggered in terms of analysis from an equity perspective, and getting escalated up through our incident command structure.

What we found was that we didn’t have to work hard to figure out what was happening, whereas for a lot of institutions they either had to put in a lot of work in real time during the crisis or it just went unrecognized. Probably it’s that latter situation that was most common.

That’s a great example of why this system is a powerful one. It’s a detection system on one level, but it’s also a way of developing systems-level solutions based on individual reports, and it’s a model for other institutions that are interested.

Mohta: What is an example of a solution that was developed and implemented based on some of the findings from some of these reports that you mentioned, whether it be visitor policies or shuttle crowding, or one of those other ones? How did that translate into actionable solutions?

Sivashanker: Language is a good one. We know now that Covid-19 is disproportionally impacting historically oppressed populations, populations of color and non-English–speaking populations. It’s something we should’ve known about and anticipated, but there was still some level of surprise when that data came out. We saw that reflected in our patient population, that we had a higher proportion of patients of color and non-English–speaking patients. Early in the crisis we had robust interpreter services, but even then, it wasn’t quite enough to meet the demand.

Those reports were getting submitted by providers who were having trouble accessing interpreter services in some way. We were able to escalate that to incident command and work with our leadership to, for example, purchase more iPads and to deploy those iPads on the key units so that there were even more opportunities for virtual translation. The iPads were part of a broader solution in the context of Covid and thinking about how we keep social distancing and reducing the number of people in rooms.

Another example would be personal protective equipment. The policies around Covid-19 were shifting a lot early on, and there was a lot of confusion about who should have PPE, who should be getting an N-95 mask and who should be getting a non–N-95 mask, and that information wasn’t necessarily making its way to every part of the organization.

We have employees in environmental services and food services who may be less likely to speak English as their first language, who may be less likely to have access to emails. What we were finding through these safety reports was that some of the staff in transport and security and environmental services were reporting difficulties getting access to PPE. We were able to quickly catalyze or activate our leadership to update our policy, to basically say, “Let’s make this a universal policy; everyone wears a mask,” and to simplify the policy around N-95 masks.

And then, we went a step further and we held 100+ sessions led by our leaders for these groups in person with social distancing — because some of them may not have access to virtual technology — where we went over the data, where we answered their questions, where we connected them with resources, and so on. We did that in five different languages.

Those are two of a number of different examples of how a single safety report or a cluster of safety reports can lead to pretty big interventions.

Mohta: Independent of their organization’s priorities to improve equity, let’s say somebody works as a frontline provider in a place that doesn’t necessarily have the resources or [resources] as sophisticated as these types of systems at the Brigham. What does a frontline provider or clinical leader do within their own sphere of influence to make things better and provide more equitable care to their patient population?
Sivashanker:

The first thing I would say is that it doesn’t have to be a resource-intensive effort in the sense that we already have invested in most hospitals millions of dollars into quality and safety. We have people trained in analyzing these events.

It’s the additional layer of asking that question, “Are there inequities associated with this risk?” That’s as simple as it could be, and that simple version is still powerful in itself because if you’re not asking the question, you’re not going to identify things. There is of course a lot more that you can add in.

You can add in, how do you standardize the question of stratified data? How do you build this into your databases and your reporting structures and all of that? But at its root, all we’re saying is simple: Do what you’re doing with quality and safety, and now add this additional layer of thinking about equity every single time, with every single case.

I’m harping on this as opposed to the individual because it’s easy for institutions to make an excuse and say, “We don’t have the resources” and to put it on the individual. But here’s the reality: Our individual providers, they’re burnt out, they’re overwhelmed. It’s not fair to continue to ask more of them. That’s not to say that we shouldn’t be asking them to treat their patients in a just, equitable way — we absolutely should and there’s a lot we can do there with the individual provider — but when we’re talking about addressing these deeper-rooted inequities that are built on policies and practices, an individual is going to have a challenging time trying to, for example, overturn our contracting decisions. I can give you all the training in the world as an individual provider, but that can’t change the fact that you won’t be able to accept a patient because your institution hasn’t contracted with whichever carrier.

Long story short, there is no excuse to not do this work. This is the work. There is no such thing as high-quality, inequitable care. This is the work of every health care institution in this country.

For the individual provider, what they can do, I would argue, is to start submitting safety reports with equity concerns. Even if your quality and safety department isn’t thinking about it, force them to think about it. They’re going to start getting those reports, and they have to look at them. Force them to start questioning some of the things that are happening. That, in itself, can be a simple way to start a domino effect because once they start to get these reports, hopefully it’ll start to pique their curiosity and it’ll go from there.

Mohta: What are you most optimistic about going forward in relation to advancing in a systematic, sustainable way the provision of equitable care to all our patients?
 
Sivashanker: What I’m most optimistic about is witnessing firsthand how organically this model evolves for institutions. I’ve only witnessed it being unfolded at the Brigham, but I have been working with New York City hospitals to start to spread the model, and I’ll be working with the IHI [Institute for Healthcare Improvement], and they’re working with 26 other organizations. In the next 1 1/2 years, we’re going to get a chance to test it with all these other organizations.

What I’m encouraged about is that once you’ve started this process of embedding equity into quality and safety, it takes on a life of its own. It’s almost like the simple act of starting to ask the question then leads to more reports being identified, more reports being identified leads to more discomfort and more questions, which then leads to more experts being brought in, and then the realization that there are processes that are not working, and then the development of efforts to address those policies.

It builds on itself and it doesn’t all have to happen immediately, but it’s a gradual change that can quickly spread. I’ll give you an example of an important success that highlights that.

We recently discovered that we had been terminating our patients of color at different rates than our white patients. Now, this is a complicated question. I don’t think it’s as simple as saying our providers are biased against patients of color and they’re terminating them from clinics at higher rates — it’s not that simple. There are things like, for example, transportation. If you can’t make it to your appointments and you’re no-showing a lot, a practice might terminate you. There’s a lot that goes into that.

That we even discovered this as a problem was not because of me and it was not because of our DE&I colleagues, it was because our CMO, our Chief Medical Officer, and our Executive Patient Safety Director independently got curious about what’s happening with terminations of our patients, asked for the data, asked for it to be stratified, and identified that there was this potential inequity.

They then handed it to ambulatory leadership and activated us in Quality, Safety, and Equity and said, “Let’s work on this together; let’s figure out what’s going on and address it.” That has now led to a significant research in quality improvement effort.

That happened within 6 to 8 months of us starting this work. I couldn’t imagine something like that happening 2 or 3 years ago, and I think it speaks to the power of the model: When you start to embed this into your quality and safety work, into your operations, it socializes, it grows on itself, and it will lead to that change where the people who are leading operational work see it as their work. That’s really the type of change that we need.

Mohta: Karthik, thank you for speaking with NEJM Catalyst, and more broadly, thank you for your leadership on this work. It is inspiring.

Sivashanker: Thank you.

Karthik Sivashanker, MD, MPH, CPPS

Medical Director, Quality, Safety, and Equity, Brigham and Women’s Hospital; Assistant Professor of Psychiatry, Boston University School of Medicine; Consultation Liaison Psychiatrist, VA Boston Healthcare System

Namita Seth Mohta, MD

Executive Editor, NEJM Catalyst; Faculty, Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health; Assistant Professor of Medicine, Harvard Medical School

Source: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0598
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