Abstract
Introduction
I would like to welcome everyone to: A Glimpse at How Stakeholders Are Working Towards Achieving Health Equity Expert Panel Discussion. My name is Morenike Ayo-Vaughan and I am the Program Officer of the Advancing Health Equity program at the Commonwealth Fund.
While the Fund has historically supported efforts focused on eliminating health inequities, the Advancing Health Equity Program was formally established in 2021 with the goal of identifying practical solutions to eliminate racial and health inequities within health systems and policy. As a part of this effort, we are excited to support the development of this important special focused collection of articles published in the Health Equity journal, and we thank you for your manuscript submissions.
With increased focus on health equity research, we believe it is important to capture results and solutions so that they can be shared with other healthcare stakeholders seeking to promote health equity within their organizations. I would like to thank each of you for joining us today to share additional insights regarding your work. I am joined by Dr. Laurie Zephyrin, Senior Vice President-AHE who will be moderating our first panel.
The idea here is that improving a health care system—in this case, a clinic for pregnant adolescents—represents a significant effort that could benefit two generations. With that context in place, I want to mention that co-authors on the current paper published another paper in 201810 that describes in detail the specific changes that were made in the adolescent maternity program to integrate a trauma-informed approach. That paper is by Drs. Bethany Ashby, Amy Ehmer, and Stephen Scott and I highly recommend it as a resource for anyone interested in the nuts and bolts of the implementation. In our specific clinic, the departments of Psychiatry and OB/GYN received an endowment from a private foundation which came with a directive to collaborate to provide high quality behavioral health services to perinatal women. Given the Substance Abuse and Mental Health Services Administration's (SAMHSA) efforts in behavioral health integration, the Adolescent Maternity Program's leadership use their Six Key Principles of a Trauma-Informed Approach as the template for how to optimize the support offered in the Adolescent Maternity Program. SAMHSA defines a trauma-informed approach as a program, organization, or system that is trauma-informed, realizes the widespread impact of trauma, and understands potential paths for recovery. It recognizes the signs and symptoms of trauma in clients, faculty, families, staff and others involved within the system, and responds by fully integrating knowledge about trauma into the system's policies, procedures, and practices. And this is the critical piece: it seeks to actively resist re-traumatization.
The six key principles that SAMHSA advocates in their approach are first, safety. Second, trustworthiness and transparency. Third, peer support. Fourth, collaboration and mutuality. Fifth, empowerment, voice, and choice. And sixth, historical, cultural, and gender issues.
A couple of quick examples of how those key principles are translated into real-world clinical changes. The key principle of safety—how the Adolescent Maternity Program embodied changes related to psychological safety—were that we made every effort to ensure that medical care was provided by the same provider throughout pregnancy. So instead of the general standard of care of pregnant folks come in and see whichever provider is available on the schedule that day, every effort is made to have continuity in medical care as well as behavioral health support.
In addition, people have circumscribed roles to avoid duplication of services, particularly related to medical history and trauma history so that patients were not required to retell their life experiences. One of the changes made in the Adolescent Maternity Program was to see every patient who came into clinic, no matter how late they were to their appointment, no matter how many visits they had missed in the past. Patients were not terminated from services based on their rates of no-show appointments. We provided free transportation for patients if they could not afford transportation on their own. We encouraged folks to bring their children into the visits with them if childcare was not available. We used holistic approaches to embody a trauma-informed approach in adolescent maternity care.
The second piece of your question of how to scale remains a really important and largely under-attended to next stage of this work. Given my description of this trauma-informed overhaul, I am sure you can imagine the amount of money, time, advocacy, and dedication across the whole team that this effort took. I think, critically, it also involved taking a big step back from care as usual, and taking a moment to reflect and pinpoint those standard medical practices that could be retraumatizing to our patients.
These clinic-level changes were not easy, fast, or inexpensive, but they really paid off in terms of health outcomes, which is the outcome that we should all care about the most. In terms of how to scale, this involves advocacy on the part of medical systems leveraging the power that they have with the federal and state government, and with insurance companies, to fund clinic overhauls and adjustments like this one. Also, advocating for better reimbursement of mental health services across the board.
It is also important to acknowledge the spectrum of diversity of interested parties from key informants to long-term partners and decision-makers, and the varied investments that they may be able to contribute over time. This goes a long way in working together to understand and agree to priorities, expectations, communication styles, and timelines. We strive to listen first and implement mixed methods approaches in various contexts. This is often where qualitative work can complement and elevate quantitative surveillance like surveys. For example, public meetings or workshops in spaces where community members are active or paired with existing events can be a great opportunity for listening sessions or other formal prioritization techniques like focus groups. Employing best practices for health literacy in all communication including social media and more traditional avenues of communication like signage, flyers, and other materials. We strive to work collaboratively with trusted resources of information like lay community health advisors and other established informal community leaders.
Engaging those responsible for implementing the strategies, and those who will directly be involved in participating in those strategies, are key for buy-in, feasibility, and relevance. In particular, community advisory boards (CABs) can be helpful in establishing relationships. CABs can develop agreements on shared and transparent decision-making processes. Compensating community experts with flexibility for the time, travel, and knowledge of their lived experience is essential. This can help to avoid repeating an issue of historically undervaluing these resources.
Finally, the strategies I've described are informed by existing resources, like Community Engagement: A Practitioner's Guide, 12 The Community Guide, 13 Principles of Community Engagement, 14 and many other evidence-based sources that can guide our work. Most importantly, tailoring these to the unique context and partners is essential to inclusion of all those involved and engaged in this work. Service providers have suggested strategies including policies that should be community-focused, evidence-based, and culturally sensitive. It is with effective policymaker engagement with communities that we can move in the direction of health equity.
My first question is for Dr. Eve Higginbotham. From your article, we learned that your health system deployed a Whole-Scale Strategic Planning process as part of its strategy to foster cultural transformation. 16 My first question is regarding which aspects of this process would you say were most meaningful in advancing a culture of addressing racism within the institution?
One of the key elements of this process is to everyone coming together around a common purpose and to listen to as many voices in the processes. And certainly, the common purpose was a need for a change and address structural racism within the organization. We must change because the culture is impacting individuals within the community of our organization differently, so the common purpose was already set. The other feature of this process is that it emphasizes developing the microcosm of the whole, bringing together key representatives from just about every piece of the organization. That was critically important because everyone is impacted differently. Bringing so many stakeholders together in this process also created that opportunity to filter up as many of the best recommendations that we could glean, because form the outset, there were more than 150 we had several recommendations offered by individuals and groups across the enterprise. Actually, in the hundreds, as you can imagine. I think every health system was being bombarded by calls for change from key stakeholders amid the pandemic. The whole scale strategic planning process provided a path forward for us to synthesize the broad input we were receiving, but it gave us, at least, a process by which we could create themes, as well as develop priorities, and succinctly articulate the input we received to leadership. Speaking of leadership, the other key feature to highlight is the is that we had alignment of leadership–and I cannot emphasize that enough—because even though we are an integrated health system where the dean is also over the health system as well, you still have very different cultures within the School of Medicine versus the health system.
There was clear alignment between the CEO of the health system, as well as the dean. That alignment was critically important. I think that is the other feature of the whole scale process, is that you had buy in from other levels of leadership, besides the most senior and the most junior.
We also developed a very discreet governance model so that there were layers of individuals who would sign off on these recommendations. Lastly, clear and interactive communication is required to ensure that those who provided the initial input know that their voices are being heard. I think that is the other feature of the whole scale process, is that you had buy in from other levels of leadership, besides the most senior and the most junior.
So much of this equity work had been ongoing in these organizations, but really, this was our attempt to move toward anti-racism by creating some core values for the larger health system. United Against Racism is a multi-million-dollar platform that essentially thinks about three pillars of work. The first is thinking about our leadership, our employees, and our workforce culture, and that lives under our human resources and our DE&I teams. But clearly, all these layers intersect; those workstreams include things like developing an enterprise-wide anti-racism education. We have 82,000 employees across our organization. You cannot work here unless you have done our Stepping Stones Training, as well as an additional anti-racism training that was developed. Our workforce may speak many languages; English may not be the primary language. And particularly during COVID, how were we getting those messages to our employees in the languages that they preferred? We are also thinking about our leadership and making sure we are retaining diverse leaders.
The work that we do under the Office of the Chief Medical Officer really is in thinking about our patient and community care. How do we ensure that we have equitable patient care experiences in all of the places that we serve our patients and how do we think about achieving equitable outcomes for the communities that we serve? Even if individuals are not Mass General Brigham patients, we do feel very much a responsibility to ensure equity for our communities. And so that work includes foundational things, like ensuring appropriate data accuracy, thinking about language accuracy. How do we make sure that the written information that we are giving to our patients, the ways that we are communicating with them verbally, are in the languages they prefer? And then thinking about digital care and the fact that we have now done so much in terms of virtual care, but still understanding that digital literacy is not evenly distributed among our population. So, standing up things like digital access coordinators to provide at-the-elbow support for those who need it most.
Also, consideration that many of our clinical policies have racism baked into them. So how do we look for those policies systematically and review them with that equity lens? And then change those responsible for excess mortality for Black and Brown individuals, and how do we add extra resources to individuals with uncontrolled hypertension, for example, or who are at risk for cesarean delivery, to ensure the best outcomes?
Lastly, in our community-facing pillar, how do we use our voices and organization to advocate for change at the local, federal, legislative levels? How do we deliver the care that we provide in our brick-and-mortar sites out in our communities, by things like community care vans and others? So that has been the work of the past 3 years of United Against Racism, which hopefully, we will build on going forward.
In this case, it is the Healthcare Effectiveness Data and Information Set (HEDIS) performance measurement set. This enables the group to really understand the gaps they need to close before being incentivized. They had 3 years of Blue Cross Blue Shield of Massachusetts feeding back information from 3 years of performance data to give the groups a very strong understanding of racial inequities in their system, before incentivizing them to improve it.
The second piece that I think was a true facilitator for the health plan was to build on its existing value-based payment program called the Alternative Quality Contract (AQC) which has already incentivized quality improvement with a budget constraint. The evidence indicates that the AQC improved quality of care in these HEDIS measures, while also controlling the rate of cost growth over 8 years. Providers bought into a lot of these components of the AQC which has enabled them to understand the equity incentives in the context of that existing program, so modifications to the program in terms of the incentive formula were made. Otherwise, the program is very similar to the AQC, so it really facilitated buy-in.
The third thing is that Blue Cross Blue Shield was wise to establish a collaborative learning system called the Equity Action Community. As you know, there are emerging evidence-based practices to reduce racial inequities in quality of care, but the field is still nascent, and more evidence needs to be generated. As a result, innovation is going to be required to address these racial inequities and quality of care. We need to expect some failure. Part of the learning process is to identify and share the practices and the policy and organizational changes that were tried. Having the Institute for Healthcare Improvement as the expert convener for this work has been key to provider engagement. Blue Cross Blue Shield of Massachusetts is currently building their own capacity to convene and support identification and dissemination of effective equity-focused interventions. This is the capability that I think a lot of health plans who are going into this space will need to develop.
The fourth enabling condition or facilitator was upfront investment in infrastructure to improve equity. A number of groups have started to embark on this initiative but have very little experience addressing racial inequities. And while MassHealth, the Medicaid payer in Massachusetts, has a very robust equity initiative for Medicaid beneficiaries, Blue Cross Blue Shield of Massachusetts was the only payer making upfront infrastructure investments, so what we see is this is really facilitating engagement. But actions from other payers, and commercial payers, are likely to be needed currently.
Blue Cross Blue Shield is using a payer agnostic approach to these investments and allowing groups to not just focus on their commercially insured patients from the health plan, but also other commercially insured patients and their Medicaid patients. I believe the equity infrastructure investments from all payers will likely be needed moving forward.
The fifth and final facilitator is the alignment of equity measurement and reporting requirements across payers. MassHealth and Blue Cross Blue Shield of Massachusetts are beginning to have alignment in their measurements which has facilitated groups to take action. When there are many different requirements, it is very hard to move equity initiatives forward, so having standardization across payers has facilitated progress.
Dr. Higginbotham, we read in your article that there was an implementation of a balanced scorecard. Health systems are trying to figure out what type of scorecard they should be creating regarding health equity. Would you please share more about the tool, how it was used, and what changes were made based on the results of the scorecard?
We have other demographic identifiers as well, such as facets as well. We look at religion, geography, and sexual orientation. There we look at geography in terms of where they are from, et cetera., so I think it is a more granular demographic characterization that we are seeking, not only for our patients, but also our faculty, staff, and students, as they complete their responses for the Diversity Engagement Survey there. We are also looking at sexual orientation as well. On the systems' side, it is similar to that for patient care, as it is with other systems.
This more specific characterization provides the opportunity to develop initiatives and action items that are focused on specific needs. At Penn Medicine, we have now offered individuals the opportunity to be even more specific in terms of their demographics, so there are scores of social identities that can be registered. It is a matter of giving people the opportunity to self-report in the way they would like to be self-identified and providing them the necessary specific actions to address their needs and concerns.
The balanced scorecard has been around for a while, but I have always liked it as a way to follow and monitor strategic planning efforts over time because it gives us an opportunity to balance the leading indicators of organizational infrastructure and processes with lagging indicators of financial stewardship, as well as stakeholder satisfaction. So, in our case, going back to the Higginbotham article as evidence of the need for more of the leading indicators compared to the lagging indicators, when we analyzed our initial action items which we call Just Do Its, which were required to be accomplished. Within the first 12 months we found that 31% of the Just Do Its were associated with such a need for organizational infrastructure and 42% were categories as well as key processes. Thus, 73% of the initial action items were important to implement so that the results were seeking, represented by lagging indicators will be realized, that more than 70% of our first action items.
I would like to highlight examples of Just Do Its because of the importance of identifying immediate actions before developing the strategic framework. As mentioned, Just Do Its were items that we knew had to be done, like taking down a picture of an enslaved individual that our medical students had been complaining about for years. Just take it down because it is causing people to be uncomfortable. An example of a Just Do It that we would call a process, if you will, for determining what should be hung on our walls. Ultimately there was a committee formed to determine what should be hung on walls going forward.
Another initiative we did immediately was to require unconscious bias training. Over 97% of our 45,000 employees underwent unconscious bias training. We tracked it. We quantified it. And now, new employees must have that as a basic understanding of what is important to work in our space.
Those are just a few examples. The attention to infrastructure and processes, guided by the e balanced scorecard ensures that we are putting the attention where it's we needed to put into organizational infrastructure, as well as key processes to ensure that we have sustainability of our efforts.
Dr. Bryant, in line with the work that Dr. Higginbotham's team has been doing, we saw in your article that your health system developed a virtual “Upstander” training, where staff can report instances of racism. 20 How are these instances being addressed when they are reported? Is there a systemwide analysis happening?
Instances of racism and discrimination will occur within the many worlds of our health system whether it is from one staff member to another staff member, staff to patient, patient to staff, etc. We wanted to build robust systems to collect and track, and to truly invite people to let us know what was happening so that we could adjudicate and reconcile them. I will say we have a long way to go. This work is very nascent; there is so much we are learning.
But one of the things that we did was to be able to respond to a patient who acts in a way that is discriminatory or racist toward a staff member. We now have a Patient Code of Conduct that guides us, where we can turn to the patient and say, “That is not how we behave in this environment. If you continue to repeatedly violate that, we may terminate our relationship with you. You may not be able to get care within our Mass General Brigham sites” (Supplementary Data). This happens within our safety reporting systems, so many people are familiar with safety reporting in their hospital systems. In several of our hospitals, we now have an icon, the Safety Reporting Platform, that says, “Was this an episode of discrimination or racism?”
If there was a medication safety event, within that context, was there any discrimination or racism at play? Someone can check that off. The idea is that those cases, where racism is flagged, that we should be having a special equity review of those cases and instances. We have the same thing in place if it is staff to staff and it happens within our concerned management system, for example. Then Upstander is a way to make sure that those individuals who are most likely to receive those reports are not racism deniers—that the first thing that does not come out of their mouth is, “That didn't really happen,” and to help them to understand ways that they might help to reconcile some of these events. So far, we have trained about 1300–1400 of our staff members—mostly in managerial roles—but I think that what we are understanding is that staff are just as likely to turn to a peer and let them know that something has happened, and so we really need to broaden out our efforts for Upstander training.
In terms of your question about quantifying, we have not yet built in many robust systems of understanding how this work is being taken up. We do have ways to track the number of safety reports. In those organizations where we have piloted the safety reporting icon, we have seen a dramatic increase. As we have built it, people have come to let us know that these cases are happening. We are hopeful that over time, we will have an increase but then hopefully, a plateauing and even a decrease as we help to adjudicate and build this culture of equity across our organization.
I believe that we need to build the evidence and characterize how best to support equity work. I think organizations are struggling with how to do this best and are looking to one another and examples from the field. I think it is a major cultural change in organizations in how to elevate it and how to support it well.
The other one that has been talked about a lot here is the routine collection of race, ethnicity, and language data. This is a key infrastructure to engaging in this work, both to monitor and measure equity, but also to implement targeted and tailored interventions. In the absence of these data, groups have used demographic data to inform targeting, but I have found that this tends to be a barrier to action in terms of not having the perfect data. Other groups have relied on the claims data from the health plan to help them understand their disparities. I think that has been a cultural challenge: the need and the importance to routinely collect race, ethnicity, and language data. We have been taught, as good public health professionals, to think about systems improvement, and that by improving systems, we are going to lift all boats. But lifting all boats means that you are not reducing the inequities, so targeted and tailored interventions are often needed. However, I think groups are banking on system improvement to get them to reduce racial equity. The jury is still out in this initiative, whether that approach is going to truly reduce the inequity, or just keep it the same and lift all boats.
I have not seen as much tailored and targeted interventions to racial and ethnic groups that I would expect. Underscoring that systems improvement is the primary way that the groups are undergoing this change, so that is a challenge.
The other challenge that I have seen in diverse contexts, even though we have a lot of evidence about racial inequity and quality of care, is that there is a tendency for groups to think about other vulnerabilities, including sexual orientation and gender identity. I think that it is important to recognize intersectionality, but not to dilute the focus on advancing racial equity because that is where the starkest disparities exist. I think the discipline to stay focused on race has been a challenge, given the key stakeholders' influences on prioritization.
Closing Remarks
Footnotes
Author Disclosure Statement
M.A.-V.: no conflicts of interest. A.N.-Z. received support from the Walton Family Foundation; Colorado Health Access Fund; and the Maternal Infant Early Childhood Home Visiting Program. All other Expert Panel participants have no conflicts of interest to declare.
Expert Panel