final few minutes here together at this year's Quality Summit. And I wanted to take a few minutes here just to introduce our next speaker, Dru Bhattacharya, who is the Chief Diversity, Equity, and Inclusion Officer at Banner Health. I think you will find that his talk is inspiring, will give us wonderful ideas about how we can move in this direction through our health care system. So, Dru, welcome to the stage. All right, good afternoon, everyone. I feel like I should be music should be coming up here, right? I know we're all at that point. First, I want to thank all of you for having me. I also want to commend you. This is such an important general issue, but it's interesting, a week in this space for me, it straddles everything from what's going on with EMRs as it relates to helping underserved populations all the way up to should we as a company be taking stands on global issues taking place. So it's so much when we talk about health equity across the spectrum. And so I'm glad that I'm here today with you, many of you, all of your clinicians or many of your administrators who can speak to the opportunities we have closer to that point of care. And so thank you for allowing me to be here with you. And hopefully, we'll cover enough areas to speak to that breadth, but just with enough time for opportunity to see where we can be doing better as we go forward. So I want to begin talking about just definitional clarity. I think that people use the term health equity in many different ways. It's become very fashionable in the health care industry over the last couple of years. In a former lifetime, I spent about 20 years in public health, population health, and we've been using this term in a related but distinct way for decades. And so it's helpful to know what do we exactly mean by this, and let's just make that transparent wherever we are. The second is to articulate that scope and the responsibility. And so I'll speak kind of very narrowly to my experience on what we're doing in my system and what I've done in previous systems and kind of welcome you to that space to say there is no right or wrong necessarily, but there is that need to be explicit about what we mean so that we're speaking the same language, so we're not disagreeing on things that simply are not really in conflict. The third is the collection and stratification of data. This is immensely important. So I come to my own role with a very nontraditional background. My background is in clinical epidemiology, population health management, public health, human rights, international, and national health law. And so for me, data means a lot, and I use that to drive everything we talk about, whether it's at that micro level at an individual clinic or all the way up with our system level initiatives. So hopefully I can give some examples to demonstrate how we're doing that hopefully effectively. And then finally, to really emphasize that the clinic is that first opportunity for us to grow. And I think oftentimes we don't speak enough about that. That actually motivated me to go back to school myself. I'm currently pursuing a master's in clinical services operations just for that very reason, because I know that even with what I do know, what I have had the opportunity to lead, there's always room for more professional development. And for me, there's so much happening at that clinic level that we don't appreciate all the time. And so I really want to emphasize that as one takeaway as we go forward. So let's begin. I know this will be with the audience response. I'm being very creative here. So with that, I was directed to ask you to pull out your phones with the app. And I will read out these questions, give you enough time. But let's begin just with that precursor to our definition. So which of these definitions of health equity resonates with you? The first being that everyone, we're ready for the turn soon to the audience response. Everyone has a fair and just opportunity to be as healthy as possible. Ethical and human rights principle that motivates us to eliminate health disparities. Eliminating disparities that adversely affects excluded or marginalized groups, and then removing economic and social obstacles to health such as poverty and discrimination. All right. So the responses are in. And it looks like, as you can see, there's not this single answer that folks have. I know among your cohort here, we have the majority of responses speaking to the fair and just opportunity to be as healthy as possible, followed by a combination of both that ethical and human rights principle, and then the removing of economic and social obstacles. And then even last but not least, but certainly up there, the eliminating of disparities. And so this is very informative. Because as you can see, the words do matter. And it's not an easy this or that. And the interesting about these particular definitions is that all of them—go back to my slide here—all of those four that you just saw were from the same Robert Wood Johnson Foundation. And so there's many definitions of health equity out there. The four that you saw were just from one foundation that were proposed a few years ago. And the one thing I just want to emphasize is some of these are aspirational. Some of them are speaking to broader notions of fairness and justice. Others are operational. They speak more narrowly to how we eliminate disparities specifically, how we remove certain obstacles as they relate to maybe socioeconomic, political, other conditions, structural determinants, et cetera. But it's extremely important that we recognize even this diversity in our definitions, because they can have very profound implications for how we invest our resources. And questions often arise when we're not very transparent about that. And so I want to speak to it from a slightly different angle. There's a common thread no matter what definitions that you see. And the three elements that I see in all the definitions usually speak to the accessibility, the availability, the quality. The one thing that I see not often highlighted, but is very important, is the acceptability. The acceptability of interventions to different communities or population groups. And why is this so important? Well, for two reasons. Number one, we'll show why in certain case studies that it becomes an issue. But for me, just from that purpose of definitional clarity, in a previous life in human rights, they had a model that spoke to all three of those elements plus acceptability. And that model was a commentary that was issued over 20, now going on almost 25 years ago, in what was called General Comment 14. This was a commentary established by the International Committee on Economic, Social, and Cultural Rights, pursuant to an international treaty, the International Covenant on Economic, Social, and Cultural Rights. Eighteen expert members that were speaking about the right to health as it was first put forth in the World Health Organization's constitution, and later by that covenant back in the 1960s. So folks were talking about this 50 years ago, and then much more so in terms of the detail of how to operationalize this about 20 plus years ago. But we often see this kind of selective choice of which components we want to focus on. And there might be very good reasons for that. But some of these frameworks are grounded in very important components. And so it's a great north star, no matter where you fall on, whether you believe in a particular right being operationalized a certain way. But to recognize that looking at this as a north star, it gives us opportunities to make sure we're not missing something that could end up creating a big crack in what we're trying to accomplish. And we'll show some examples of that. So I just wanted to be clear that this model, this framework, posed by that body 25 years ago with a legacy 50 years ago, actually is very helpful, and we'll get to that. For me, DE&I is very simple. Diversity is about differences. Inclusion is about creating opportunity. The one area I feel that we don't talk enough about is the health equity component. And for me, regardless of what definition you want to use, when I talk to folks about health equity, I just put it out there, we're here to address an unjust disparity. And the toughest part about that conversation is, well, what makes a disparity unjust, right? And that is where I find where there's often plenty of room for discussion and deliberation, and often we kind of skip over that. There is one particular article that I saw, so I'll put it here in the reference for you, by Powell and Wiley, that provide a pretty comprehensive framework for looking at social determinants of health as it relates to health equity for cardiovascular disease. And so for this particular audience, definitely take a look at that if you want to get into the weeds of unpacking all of these different components. But what they speak to is three kind of pillars as it relates to this. One is structural, broken down by socioeconomic, political, and then the other ones are social conditions and the lived experience. Now I want to speak a little bit about each one of those before we go forward. The first is a good evidence of something structural would be historically like racial residential segregation. So if you look at the history of redlining, mortgage access, and then kind of discrimination in just zoning, and all of those things that led to highly segregated communities with reduced employment opportunities, reduced access to quality education, attendant issues with violence, crime, and poverty, all of those kind of contributed to that. So when folks are talking about that pillar, they're really talking to those broad macroeconomic determinants. That's a really tough one for hospitals and health systems to wrap their head around in terms of what can they do because they have so many other interests. It's impossible to do that one alone. But it's very important. There's also been studies on this. So you'll look and find in the literature African American populations who are within some of those highly segregated areas with 12% higher incidence CBD prevalence compared to white population. So the literature has been established there, but how you actually address it is a little bit tougher when you're at that macro level. Hospital conditions are ones that we're seeing a lot more movement in within hospitals and health care systems across the country. So examples of this, food insecurity, housing, transportation issues, all of that is very relevant. About 10.5% of American households experience food insecurity. We saw this skyrocket to about 38% during COVID. And so even now that becomes a challenge, but it's very important because even with this audience, we know this is associated with many CBD risks. So dietary intake, for example. Stress response, anxiety, depressive symptoms, all of that becomes implicated. Transportation being another one. So closer to home, we have a particular interest in the transportation needs of our cancer patients. We know that over 20, 25% of cancer patients are citing medical transportation as an issue and then attendant risks of like lodgings and also covering the financial assistance for those lodgings when they're traveling long distances. So what are the couple of things we've done in our own system to address this? With respect to food insecurity, we actually have a senior center that we established that provides free meals, medical transportation to and from social activities, other related things that we have done with philanthropic support to establish that community, to address those needs among that community. And then for our cancer patients, we actually partnered with home developers to build eight new homes right next to our cancer center. So for those patients coming from further distances, they can stay there for the duration of their treatment or prolonged hospitalization. So just a couple examples relates to some of those factors. The lived experience bucket is one that's probably a little bit more, I would say, commonly known with respect to what you think about with traditional DE&I. So what are the trainings we can speak to with bias, for example? What are the opportunities in the clinical encounter? So if, for example, we know that there are certain populations that are experiencing disparities, are there things that we're doing during that encounter where we're not recognizing symptoms because of our biases related to that group, right? So there are opportunities there that you see in some of the homegrown trainings or kind of contracted trainings that speak to how you can address the lived experience. Another area that I see a lot of activity in is with patient experience and health literacy tools. And so that's another opportunity there that we'll speak to today. Certainly in my shop, we actually spend a lot of time talking about patient experience and recognizing that there's one way to look at it at a group level, but the real opportunity with patient experience scores is when you start to stratify that data by different groups. And that's where I'll share some of the results of that with you here today. But before getting into that, I just want to reiterate that, you know, with accountability in this space, we want to meet you where you are. So certainly an explicit strategy is particularly important. Strategy changes. I think the most important leadership lesson with all things strategy is saying that you actually care, that you're actually putting it on paper, kind of where you stand at whatever level. So at the systems level, in previous system I worked with, we had a system-wide health equity council. So it was very robust. We had members from our executive leadership team participate on it, SVPs in the different population health arenas, clinicians, ethicists, et cetera, quarterly meetings, clear targets. When you have that kind of level of support, it's kind of easy to lay that out. But even if you don't, even if you're looking at this at a clinic level, just establishing that cadence of being able to say, okay, maybe twice a year, maybe even once a year, we're going to take the time to look at the data. We're going to take that time to really identify, are there gaps or opportunities, trends in care? One of the most important presentations I gave this year was all of our clinical leaderships or our entire medical group, just to sit with the executives and say, this is kind of where we are and where we're going. It was the first time anyone had done that from my space. And so that kind of, to me, just reiterated, we need to have more of that cross-functional collaboration. With trainings, this is something which is a little bit more complicated. A lot of folks will outsource their trainings in many areas that kind of intersect health equity, D, E, and I. I'm not a proponent of that. So when I came into my own space, I actually cut all of those kind of external contracts, too many generic trainings. And we spent the year building homegrown trainings built by us as health professionals for our audience of health professionals. I also don't believe in mandates. And so we already are overwhelming our own system with mandatory trainings, as all of you are familiar with. And so we actually took a more organic process to engage our clinicians and say, here is that kind of array of the different trainings. These are the foundational ones. These are special topics. And I'm encouraged by the progress so far. In the past two months, we've had over 3,500 enrollments, all voluntary. That is not an easy number to get to when it's not mandatory. And so I think all of this is about expectations. I've had some clinical leaders say, I want to make certain ones required for our team. That's fine. We defer to them on that. But there is opportunity. But the most important thing is to be very transparent about the expectations there, because you're not going to be able to get through everything. So what are those most important foundational ones, which are the ones that might be more special topics? And I can give you some examples of that. The third area is action plans. And so how do we identify those gaps? And how do we actually tie in those different milestones? How do we collaborate through data sharing? Those are things that are very important, because the strategy is one piece of it. But when you start to realize where you might have to pivot is really with that action plan. And so a couple examples and tips I want to provide just from the field. I spoke to you about our System Health Equity Council. During COVID, we also issued a statement very clearly on just how we equitably distribute vaccine. And I'll get to a story related to that shortly. The other is something that is a little bit more trendy these days, which is the SDOH assessments. There are a lot of systems that are either very invested in this or will be soon. And so they're looking at a lot of different instruments for how we can assess these. And if you look at some of these instruments, there's a lot of questions. So it was interesting. I was looking at a pilot. We had about six or eight clinics one time that were piloted to roll out one of these assessments. And my big fear was that there was just too many questions being asked of our clinicians. And so we realized when you looked at it that way with about 25 questions or so, only a few percent of them were able to get through it. But when you're able to target the questions and say, no, these are the three most important ones for this particular patient mix, then that uptick skyrocketed. When only from a couple of friends, like 35% were saying, yeah, we were able to get through it. So we want to be reasonable and kind of look at that. We have to always be mindful what are the real bottlenecks, operational constraints at that clinic level. When it comes to trainings, again, just to reiterate, homegrown is my personal bias in favor of outsourced ones because I think you know your data best. You know the issues the best. If you can create that psychological safety to develop robust trainings, it's going to get you very far. We have three foundational trainings in my system. So we created one in bias in healthcare decision-making, cultural humility, and then managing multigenerational teams and patients. And then after that, special topics that are more narrowly for particular populations or interests. So for example, promoting gender-inclusive care, looking at social determinants, intersectionality, religious spiritual care, neurodiversity and mental health. So it's a lot of special topics, but they branch off from first saying, here's the foundation. Get the foundation right and then build upon that. And then finally with the action plans, one of the most important things we've noticed is that it's so important to customize them, mindful of those different populations and being very transparent on why you're doing it, how you're doing it, what are those milestones attached to it. And I've noticed in the best practice arena, we've learned a lot in the process. So even in our system, we have 30 patient experience best practices. But when I go around the system and I meet with different leaders, not everyone is aware of all of them. So socializing different best practices and then also saying, well, how can you actually make it so it's not an additional ask of the population? And that requires some nuance. And so I'll give you a concrete example. Some of you might've heard of the one, the Ask Me 3, right? So this is a very popular one that's validated in the field. Well, the interesting about Ask Me 3 is that it's available. It's very easy for those of you who haven't heard of it. You're encouraging the patient either through some signage or a brochure or something to ask the provider three questions before the encounter is over. What's my main problem? You know, what do I need to do? Why do I need to do it? Well, we'd looked a little bit deeper and we were curious, is this being utilized differently by different demographics? And we found that I'll cite one example among the African American population. There was actually 45% of them in a study were found to use Ask Me 3 when they were having some opportunity to write down their notes. And so that very simple fix of saying, okay, you might have a signup somewhere or a brochure somewhere, but if you don't have the means for people to then engage it and then actually utilize it, then what's the point? How's it effective? Right? So just that nuance. And we've seen different kinds of nuance with different populations. So we think through that lens of how can we actually leverage the best practice, but then mindful of some differences that might be there at that demographic level, geographic level, whatever it might be. And so that's been very helpful. So again, tying that into the broader action plan is very important. Let's get a little bit to the data. So I think the most important thing is what disparity you choose is really one of preference. I think that everyone can say that, well, you're going to let the data drive it. Well, there's plenty of health disparities out there. So I don't think that there's necessarily a right or wrong in terms of your rate. it's always going to be limited by the resources you have, depending on the scope of your intervention. But what I will say is that I want to make a distinction, more importantly, with how you collect the data than how you stratify it, and why it can be important. So we're going to start off with some patient experience data, okay? So all of you are aware of HCAHPS, and so one common array of metrics that we look at in HCAHPS is communication. Did your provider explain things understandably to you? Did your provider listen carefully to you? Did your provider treat you with courtesy and respect, right? The traditional approach, which we used in a prior system I worked with, was very simple. Calculate the system average. Calculate then that kind of facility average, and then compare the two. If you're above average, great job. If you're not, all right, maybe we're going to do some purposeful rounding and fix this, right? We're trying to bring you up a little bit. And so very easy to understand, and kind of speaks to the general experience. When I came into my role in this new system, I said, can we try something a little bit different? Can we actually then take that data and then stratify it by the different groups and just see what happens? What can we learn? Is the experience the same? And we all know intuitively it probably isn't. And so we initially stratified by these different variables. We looked at the age of the patient, also by sex, language, even if it was different with their experience with different providers, right, physicians and nurses, and then asked the simple question, if there are differences, they're obviously being masked by the average, but then how can we adjust our tactics in communication, mindful of those differences? So here's one piece of data. So we ask, did your doctor listen carefully to you? You stratify that by the different patient age groups, and you notice there's a 20-point differential between those who are your older patients, 65 and above, and those who are your younger patients, 18 to 34. And so it's very interesting. People have very different explanations for this. But this also prompted one of our senior clinicians to ask a different question, which is very interesting, related but distinct. What role does concordance play in this? So does the age of the physician also then affect this data as well? So that became the part two of what I said, okay, we'll look at that as part two of the analysis, because we weren't really thinking about that on the front end. So it's always interesting to see the conversations that are generated. But one thing that folks did say, for those who have been practicing for a while, is that the differences are real also in the way sometimes that we treat the patients from different age groups, regardless of the age of the physician. So that I just share anecdotally, because I haven't looked at that concordance issue. But it is a related one. The more important takeaway is that the experience is different, possibly different among different age groups, or different other demographic variables, and that was the point of illumination for us. Comparing even among providers, this was the data for the nurses, so it was different. Now, I add a caveat here. When I actually looked at this, even for our whole system, it wasn't always the case. In some facilities, I would see this comparable, physicians and nurses, and others would be vastly different. So if you've seen one hospital, you've seen one hospital, right? You've seen one department, you've seen one department. And I think the most important thing, kind of old school public health, local, is really your true north there. So it's really important to understand, more importantly, what is that local level data? And then similar things with respect to differences among the sex of the patient. Here we see that 10-point differential among men and women. And then here, a much larger differential between those who are limited English proficient and those who are native English speakers. So I want to talk a little bit about COVID, a little case study to kind of drive a couple things home. There's actually two pieces to this case study, and so actually, I want to start with one piece, which we're not talking a lot about today, because we're kind of focused a lot on the outcomes and the patient population. But the other piece of health equity that's also very important is the team dynamics. And that is where the DE&I opportunity comes in as well. And so right towards that height of COVID, when vaccine was made available, scarce vaccine, I was asked to lead a system team, along with our chief medical officer, what was called the patient prioritization team, to develop the algorithm to figure out how to allocate scarce vaccine to our population 55 and up. Within about 72 hours, we had to get that list together and then start sending out those invites. And so what was interesting is that when we set up the team, which was full of our senior clinicians, administrators, we had one young statistician, one young ethicist at the time, and we had scoured through all of the epidemiological literature and medical literature, and we realized, okay, we also know there's a disproportionate burden among our underrepresented communities, particularly the black and brown communities. At that time, our geographic footprint was from South Side Chicago all the way up to Green Bay in Wisconsin. So that was the stretch. And we determined we're going to have a mix of balancing both the epidemiological evidence as well as social disadvantage. And so the epidemiological evidence, we had a good handle on, and we were a team of scientists. We were pretty confident in how we were going to have this ranking system. The social disadvantage piece was a little trickier. And so at the time, there was one metric that had been proposed, and that was the social vulnerability index. And our reaction to it was very reflexive. Okay, sounds good. We see they're being supported by the CDC, and we're just going to tag that on and integrate that into the algorithm. And so there was one concern raised by a younger ethicist at the time as to why we should just kind of reflexively do that, because it had a race-based construct in there. And there were also questions posed by legal. Is that going to open up liability issues? Are we sure that's the right way to go? Are we going to certainly identify these different underrepresented populations accurately? And so we kind of just assumed that it would, but then there was still this kind of quiet rumbling. And so those were as such where we had this younger team of ethicists and statisticians, and indirectly challenging the senior leaders on our team here. And so we actually had to create that psychological safety to keep probing. We wanted to get it right. And so we did that by kind of engaging them offline, asking them questions in that direct way, until it finally got to the point where I said, what is the alternative? Because we can't just knock one thing. We need to embed some metric. And he said, well, there's another metric possibly called the area deprivation index, which is based on census block and not on any kind of a race-based construct. So let's run with that. And I said, okay, then give me the explanation why. Wrote up a nice elegant piece, page and a half to it. I said, okay, it makes sense technically. Now prove it. So we ran the algorithm with that other metric, and counterintuitively, it ended up identifying more eligible patients from the marginalized communities than we had reflexively done. So I shared that story because there was generational diversity issues even within that team. And all we needed to do was hit the pause a little bit. Old school HRO principle, deference expertise, because the biostatistician knew the data better than all of us. And he was able to demonstrate how just that simple pivot, that simple pause, was actually going to end up advancing the health equity more for this population. So that's the part one of the story, just with that first bullet point. And I wanted to stress that, because I feel like many times, just creating that psychological safety is a big obstacle for us to overcome, especially in health care, because so much of it is based on that seniority. And we're kind of brought up in these kind of hierarchical systems. And just breaking that can be an important challenge. This was how we were extending out our invites. Once we figured out who was going to be eligible, we were going to make this accessible, right? Walk-ins, Monday through Friday, nine to six. Many of you probably had similar models available. We're going to make this affordable, no cost to come and get this vaccine. Quality is not an issue here. It's the same vaccine that everyone's getting, right? And then this is what we saw. Within a few weeks here, lowest uptake was among Hispanics. Latinos only 2% invite to uptake upon invitation. What happened? Right? What were we doing wrong? So just to kind of clear reflection back, remember that old framework I was telling you about. So we got the accessibility, the affordability, the quality here. What are we missing? The acceptability, right? And so what happens there? So folks would come to me and they would say, Hispanic communities, vaccine hesitant. They're afraid of the vaccine. They don't want it. We got to maybe do some PR messaging. We got to maybe get out there in commercials, right, and start explaining how important it is. We started out with a very simple question. How do you invite them, right? Well, everything's sent out via email. Majority of those patients had phone numbers, right? Many were limited English proficient. So emails, even if they were received by the few who had them, they weren't in English, so they couldn't read them. Many unable to take off work, had other caregiving responsibilities, employment responsibilities, many other obligations. Just during that time slot, it might have looked convenient to us, but it was not for them. And then the distance was prohibitive, right, even to get to the hospital. So we flipped the model, right? We flipped it and we set up the clinic in the community. And then we had a Hispanic physician and nurse then lead that outreach. And then at the time in my team, we had an entire team of language assistant services and interpreters who were then available on call to then reach out proactively as well to assist. And we said, we're going to have this all on the weekend. And so there was a lot of pressure at the time because everyone was like, don't waste a dose, they would tell me. And so our initial uptake, only 2%. What happens when we switched it? What happens when we made that community focus the centerpiece of what we did? We had 100%, you know, uptake. We had this 95-year-old patient who came out and wanted his picture taken, right, to encourage others to do the same. And that became a big rallying call because then we were able to take this model and then replicate it among other communities like the Hmong community and other communities that we also noticed had these disproportionate effects. And it really drove home for us, finally, this idea of meeting people where they were. Because we saw this as a talking point, but were we really doing it until this point, right? And honestly, I don't think we were. I think it was at this point where it really hit home that we need to be listening and really not jumping to the assumptions of why do we see the outcomes that we see and just generalizing entire communities when sometimes it's not a difficult fix, right? And sometimes that's what we always kind of fear is that it's going to be too much work to do it a certain way. So I want to pivot here a little bit to speak to the clinical encounter. One of the gripes I have is that sometimes in this space, especially when we're talking about things like bias, we're really making some sweeping generalizations about the implications. Even in cognitive biases, as many of you know here, experts might be in this area, there's over a couple hundred of them, right? So just focusing on one or even implicitly suggesting that we should be looking at many more is not the most practical way to address a lot of the issues that we see. So how can we do this more effectively? I was always fascinated by the idea of having these homegrown trainings that could have a common theme of just challenging assumptions under that value of continuous improvement and then really highlighting what are the good catches? Because the clinical encounter is not just one encounter, right? That entire continuum of care is very good. So oftentimes, even if you've got some areas of improvement, highlight the ones where things were done right and really improve that morale. I had been doing safety huddles, patient safety huddles for years, and I spent just as much time if not more focusing on good catches as I did reporting out on certain slips. And I think that's so important because it's so important for teams to be transparent on how they can do better. And so promoting the awareness of those good catches coupled with the awareness of the resources is very helpful. And so with that in mind, I'm going to switch here. And I apologize for the small font, so I'm going to read the case study to you. Because I think when we think about this very much in the weeds, it really drives home many opportunities where we might be able to work with something from where we are, but also an opportunity to reflect on what are some of the bigger gaps when it comes to our needs. So here's the case study. We have Mai-Lin, a 69-year-old Chinese woman, sitting with her husband, Jun, a 70-year-old Chinese man, at the kitchen table in the morning when suddenly Jun was unable to speak. Mai-Lin presents with Jun at the emergency room. And although both of them had limited English proficiency, the care team relies on Mai-Lin to gather information about Jun's symptoms. Based on that conversation, they determined that Jun was in a normal state of health before falling asleep the night prior. Consequently, Jun was ineligible for intravenous tissue plasminogen activator and no pertinent chondroindications identified. Later the admitting care team utilized a video remote interpreter, or VRI, and determined that Jun was actually seen in his normal state of health, not only before he fell asleep the night before, but also that morning after he woke up. In fact, he had gone about his usual morning routine, getting ready for the day without any incident, before coming home and sitting down with Jun at the kitchen table. The care team determined that his symptoms presented 15 minutes after he woke up. Consequently, he was in fact a candidate for that emergent treatment, but since the care determined the accuracy of when his symptoms presented outside of the critical time window to intervene, he was not offered the emergent treatment. After Jun stabilized and the care team determined that he was ready for discharge, Mai-Lin asked if the discharge instructions could also be made available in Mandarin. The team replied, unfortunately not, but would be happy to arrange an interpreter to assist with follow-up in the event that Jun or Mai-Lin had any questions about his recovery or the instructions that provided them with a phone number, encouraged them not to hesitate to call if they had any questions or concerns before returning home. This is an example that's not at the extremes there. Here you have many opportunities. There's not this massive patient harm that happened, but you have so many opportunities to reflect on improvement when we talk about health equity. The first point is bias at the outset. This assumption that the spouse as a native speaker would be able to effectively communicate on behalf of the patient despite having no formal training in medical terminology or any related area, and then that reliance on that family member to then affect the treatment decision. In this case, the failure to use the professional language assistance services that led to the decision to then withhold that IV tPA in acute stroke setting. But then comes the pivot, which is important, which is here, that's where the team's resilience comes in and say, okay, now that the patient's been admitted, let's use the VRI. This is important for two reasons. Number one, because they recognize that should have been done all along, but also you want to comply with your law and other system policies. Pursuant to 1557, we have to provide that meaningful access to limited English proficient patients through at least three modalities, VRI as they did here, or in person or via telephone. Any one of those three could have been utilized. Then comes that realization of the treatment mishap. In this particular case, the candidate was appropriate for that emergent treatment consistent with the standard of care that's endorsed by both the American Stroke Association as well as the Standard for Emergent Stroke Treatment. Let me pause there for a second. Even up until that point, you can see that with your clinical expertise, you can reflect back on where are those moments where certain biases or assumptions create that cascade, and how does that cascade then affect certain clinical decisions? There are many opportunities for this, and ask any clinician, they can come up with that. The important thing is not one particular example, but the fact that there are many ways where we can see how different assumptions about different things, whether it's just an inefficient workflow or whether it's actually rooted in how we treat that particular patient or patient group that are causing those biases to manifest. Then even later on, we build out the case here, is that we talk about that awareness institutionally of resources. This is something that in my dreams I would not have imagined, but this happens a lot in very big systems, where you have lots of resources, not everyone's always aware of them. Here, the care team had offered instructions that they said the discharge instructions couldn't be translated. In our system, we actually can do that, but you need to know what are the ways to do that. What's that portal? Who do you contact in the language assistance services? What's the process by which you do that? Being able to socialize that has been an important charge of mine as that leadership now reports into me. That was the case when I assumed my role, but in my current role, that language assistance services matrix is into me. We use this as an opportunity to bring more attention to socializing our resources. The other piece of it is the cultural humility piece. In this case, she had assumed that if we just give the phone number, that's going to be enough. With this particular patient population, and it's based on actual real encounters here, we realized that this particular population was very reluctant to actually engage through the telephone, that they actually had preferred working with some direct interpreter on the front end or having the discharge instructions all laid out. It was a very educated population as well. It really drove home for us the need to then re-socialize the trainings. That's what also reified for us the need to have cultural humility training as part of our formal trainings. There's always opportunities to improve. In this way, what we've done, just as a model, is to develop multiple case studies, very robust. They kind of balance. We take the administrative opportunities, the clinical opportunities, and work with our different clinicians to really make it more practical and relevant. Just one example there to kind of drive home that there is so much we can be doing in this space, but it really can begin right there in our own clinical encounter without thinking, okay, we need to have millions of dollars at this macro level to invest in a broad health equity strategy. If you have that, great. Just from my own experience, I came from a system where my own team was fairly large. I had reported into a chief officer. I had about six or seven directors, and then we had two, three staff for each one. One particular team had 100 people. It was very robust. When I came to my current position, I only had four people, just four. Those four weren't directors. They were all young associates. Some of them not even removed soon out of college. How did we do as much as we did in a year? Cross-functional collaboration. That collaboration is everything. That's the secret sauce in health equity. If you can cross-functionally collaborate and take that extra time to partner with all the different leaders, you don't need to have everything. This is old school public health. You've got to put your ego aside. You can't be afraid of showing up with maybe not having the biggest team, but if you can collaborate with a bunch of folks together, you can move really fast, really far. That's why our health equity program is really as big as it is, is because it's not just housed in one area. It's not looking like one person is responsible. It's really buying in to a broad strategy. The strategy has all of our domains outlined and all of those cross-functional collaborations. That's kind of how we're doing it. Certain departments, I'll give you an example, nursing, they've completed all of their trainings this year, all the foundational ones. The easy thing that they did, they just said, hey, can you come and give all of the trainings during Grand Rounds once a quarter? Just like that, in a period of six months, they knocked them all out. There's many creative ways to reach larger groups of audiences at the system level or the clinic level. I think it's incumbent upon the leadership in those areas to get out there. I also make my rounds at the clinic level as well to do the training. It varies from system to system, but this idea that you've got to wait for something to be developed very formally at some high level is just not true. I just share that anecdotally because I think all of you here have that potentiality wherever you are, whether it's just revisiting what's happening at that individual patient encounter all the way up to the different collaborations you can have, don't underestimate your power to do that. With that, let me go to the last slide here on recommendations, and I guess I'll have a little audience response after this. I think you want to be strategic. Articulate that scope and the approach. Train with tactics. My bias is I've laid out various homegrown studies, but of course, if you do partner with other vendors or other groups, make sure that they're very relevant to your audience. Make sure that your clinicians can look at them and say, yeah, this is practical. It's going to help us adjust some tactics. Use action plans. Be very intentional about what you collect and how you stratify it. That's where a lot of the gaps are, right there in that data. And then always begin, I would say, with that clinical encounter. Don't underestimate what you're going to learn from your care teams. They are so close to the action that they'll be able to demonstrate where those opportunities can lie. And so with that, let me turn here to which of the tactics are feasible in your current role. I don't assume that all of you are at that same space in your own organizations or even your place. So let's ask, you know, which of these kind of resonate with you as something you could do if you just walked out the room when it comes to advancing health equity? Could you develop a strategic plan on health equity if you're at that system level? Could you develop case studies to improve training and workflows or kind of encourage some folks who are in your orbit to do the same? Can you stratify data to identify affected patient populations? Can you revisit, even at that micro level, just a clinical encounter? Encourage staff to discuss bias in healthcare decision making, assumptions that we might see as it comes to our interaction with our different patients? Do you have the time just to look at that? It doesn't have to be every week, but is it something that you could address in some kind of a cadence so it becomes part of the natural value of that continuous improvement? Okay, so with that, we'll turn to the last audience response poll. ♪ All right, thank you. So I'm actually very encouraged by this because I think oftentimes when I listen to folks who are thought leaders in this space, their biases is thinking that, no, we gotta approach this from the top down, all things strategy. And I say, well, you've kind of proven that actually maybe the best place to start is with that data itself. Maybe the best place and opportunity that we have, what we haven't looked at, is to stratify the data with the different populations and revisit that clinical encounter. The fact that 43, right, out of that 55, I mean, not the best of math, I'm thinking that's upwards of 85 to 87% right there, of this group right here, thinks that just speaking to that, you're gonna make some progress. And I promise you, that's where it's gonna start. Now, what you do with that is also important as it speaks to then, well, what should we be focusing on? I'll give you one example from the field where we had to make a value judgment. We were interested, there was an interest in the system at the time of addressing hypertension in the community. And they said that, well, if you look at prevalence, one of our clinicians said, we can't tackle the prevalence of that with short-term results. They said, it could take decades to address that. Well, where we answered to leaders who did not wanna wait decades for results. So then what can you look at? What about uncontrolled hypertension? And that became the reason why they then returned to that metric. And so I think one of the important takeaways also is, even if you see the data going a certain way, you do have to go through that negotiation with your leadership in terms of what can you actually control with certain milestones within a shorter period of time. So even if you have a particular milestone you wanna achieve over a 10, 15 year period, realistically, you have to probably lay out some milestones well within that to get support in this area. So it's not mutually exclusive, but I just lay that out there as kind of anecdotal account of what I've seen because folks do wanna see quick results sometimes in this field. And one of the, I'm afraid, one of the things with public health is generally in population health, generally it takes time to see things at a macro level. So I just put that out there just to be mindful of that no matter where you go with the data, but just kind of looking forward. So with that, thank you for having me here. I wish you all the best going forward. Feel free to reach out with any additional inquiries offline. I know we have no question answer here, but made myself available to you. I know we all have flights to catch, so also safe travels back to where you're from. I hope you enjoyed your stay here. Thank you. Thank you. Thank you, Drew. So I think there are a couple of questions. I'll start with one that I had. How important is it to really know your community environment, to help you kind of get to this strategic plan? It's imperative. I mean, categorically imperative. How do you go about doing that, I guess? Sure, well, one of the most important things you can do is to connect with those community leaders who represent different, and it's not necessarily a demographic, so it could be nonprofits that are serving folks at different communities. Even before the pandemic, we had partnerships with different nonprofits across the system. So when it came time to recognize the disproportionate effect, we would then connect with them, and then they would bring us into the normal cadence of sharing data. So one example, there was a nonprofit group that was a consortium of all the Hispanic businesses in that Milwaukee area, and so about 200 businesses being represented. And so after we started to realize that, okay, there are these disproportionate effects, how can I share the data so then they can then leverage their kind of massive network to share information? How do I get access to the testing? How do I get testing? And what are the considerations, questions? And so establishing those relationships now is always important. Emergent times, absolutely, because you gotta move quickly. But even during non-emergent times, they bring attention to things you can be doing better. And so one example I remember was in Chicago, and we had reached out to an advocacy group for the deaf and hard of hearing community. So we were language assistance services, and so a lot of folks, we had a good reputation, a lot of groups providing interpreter services, but we had not reached out to that community before. And they had a lot to say. They came forward and said, you gotta improve your website. You gotta improve how you interact with it. You gotta make more of these on-site interpreters available as well. So just an example where had we not engaged them directly and then just taken it on the chin of where that improvement was, then we would not have been able to build the credibility and that trust. Trust is everything. This is a very data-driven group here. We have a lot of cardiovascular data. So from your perspective, what type of data kind of helps people get started with this? Is it simple demographics? Is there kind of, where would you start? What kind of data do you look at? So the bias, of course, as all of you know, for folks who are not data junkies, it's always cross-sectional, right? And the problem with cross-sectional data is your causality issue, right? So you're not proving that over time. And so that natural sense of losing the historical context becomes a problem. I'll give you an example. We had this serious problem. So I told you all the COVID stories. Let's rewind the clock six months. We didn't know when the vaccine was gonna be made available. So we were thinking about what other mitigation strategies can we use? So we thought, how about let's set up flu clinics, right? For underserved populations. And so we had all the data. We took that cross-sectional slice. We looked at it by different demographic groups. And we said, okay, here are the communities we need to go out to. The first thing that hit us right across the phase there was why are you here now? And why flu vaccine? And it was kind of like, that's not what we need. And just to address all the mistrust, right? When it came to that, it took us a minute to get over that hump before we then were able to get 8,000 shots in arms over 55 clinics. But the point being the cross-sectional data is often where we start and we stratify demographic variables. But the truth of the matter is, you then have to look at, well, what are those different clinical metrics coupled with that, right? But over time too. And so I believe this is the problem that I've seen. And the epidemiologist goes crazy when I see this switching metrics too fast, right? So if you can agree based on the data that yes, this level of improvement over, let's say three to five years is gonna work. You've got to give time for your interventions to line up to see that out. If you're just gonna switch every few months, we see this with patient experience among the different systems every year or so, it's not gonna work. That really speaks to the need for a strategic plan, right? And then being consistent and maintaining that. No one likes to see the dip, right? And nobody likes to see that. But sometimes it's almost like a good screening plan. Sometimes you don't realize there are a lot more people with the illness than you thought before you had it in place. And so very similarly in that same spirit, be open to saying that, yeah, there might be a little bit of a roller coaster going on here, but you need to have a reasonable period of time to collect and analyze, but also share that with the leadership saying that, even if you see gains in the initial thing, it might not be sustained. Why is that? That cohort effect, right? Laura or Amber, are there any questions from the audience or from either of you? There are. Could you please talk a little bit about what cultural humility is? So this is interesting because the buzzword up until recently was cultural competency, right? And so this idea that you're going to be more patient centered in that sense of being mindful of those different factors that are unique to those different demographics and taking the time to listen first and foremost without assuming what some of those needs are. And that listening to me is the most difficult piece of it because oftentimes there will be these nuances and practices you're just not going to be aware of. So I'll give you one example. So we've had a recent spike in Asian immigrants from Taiwan that have relocated to the Northern Phoenix area, about a few thousand, because they came with a new company that has established their presence there. And so we've had a lot of opportunities to interact with that community to kind of be more accommodating of them. So one of the ambulatory leaders, who matrixed it into me, kind of is a liaison and she's of that community as well. And she was explaining to me how in labor and delivery, a lot of young families, some of the expectant mothers, part of their culture won't take cold water, right? So a certain period of time right after. So just having that in front of them, that sometimes the care teams would misinterpret that as being reluctant to drink or what's going on. And no one had thought just to kind of ask and understand, well, are these some of these things that we're observing, is it really some kind of issue or problem or reluctance or could it be based on some other trends there? So I mean, there's that element to it, which you can't make a repository of everything. So from a practical side, I think there's a lot to learn just by engaging the community, so one of the things we did to do that is, so there's two approaches to this. So one is, and I've seen this in one system, is that you'd almost have like the Encyclopedia Britannica of all cultural practice and believe every single demographic out there. I don't know how realistic it is to have people like refer to that or not in real time, right? So oftentimes it's you switch it around and you say, well, can you at least ask certain questions that speak to that humility, can you at least ask certain questions that speak to that humility that advance that listening? When we did that, then those kinds of examples of different, maybe dietary accommodations, really the spiritual accommodations, the welcoming and physical environment, the translation of resources, whatever, there is a reasonable guess that you can capture many of them just by having those questions and conversations with the community leaders and other team members who are in charge of their care. And so that's the approach we took, is not to say, okay, here's just log into this website and review the entire background and beliefs of a generalizable population, but take a more proactive approach on the patient accommodation side. So we've leaned on kind of making a more robust patient accommodations policy to advance that cultural humility. Do we have any other questions? We do have one more. So there was, I want you to, I'm not sure that you'll be able to answer this, but there was a slide that you presented about HCAP scores. And in that HCAP score, there was one in particular where the elderly population didn't feel like they were listened to. And I think that the question being asked, was there something, did you investigate that? Was there a reason that they felt that way? Sure. I know when I talk to my kids, they're doing this, and I'm like, you need to look at me and listen to me. And I want to take into consideration that their generation, they're like, well, I am listening to you, right? So I'm wondering if the results in the younger generation, 18 to 34, felt like they were listened to, even though the doctor's back was turned to them and the doctor was doing this in the computer, whereas the elderly population wants the eye contact. So I was just wondering if that's taken into consideration looking at those results. I love the observation, because I just had a discussion this week about kind of electronic overload in the clinic and just our care teams being glued to so many things and by data input and everything that really compromises the kind of quality encounter. No, we haven't analyzed it at that level of granularity, but I think it's a reasonable assumption that it plays a role. And I think it's not just respect to electronic devices, I also think it's respect to the speed at which things are going, right? And so folks are feeling like they're being put along an assembly line. And even for me, it's hard sometimes just to even get through basic registration issues, like even digital and online, not everything is very clean cut and clear. And this has been another thing that, so we recently got a grant to look at how to promote gender inclusive care across our county. And one of the things I realized is, part of the grant, I wanted to improve that kind of engagement and the efficiency. And one thing I noticed with the electronic records is that there's like this misalignment even between like physical forms and EMR center, all of you know this, and just recognizing the frustration that folks have in kind of trying to deal with that. All of this compounds, into trying to figure out what's happening and how can I engage the patient better? If we're not equipping our care teams, with that kind of support to make this as easy on them as possible, then it's certainly gonna carry over into that frustration on the patient's end as well. So I will just say that, without the data, I think you're right. And I think that we're gonna find that out when we actually peel it back. But I don't want to assume that either because I think that there is probably a lot more going on, but I do think it's a fair observation. True. Ask another question. You had put up on the slides about the screening for the social determinants of health and when going down from, I think you said about 24 questions, maybe three. Do you have the clinicians doing that on a per patient basis? So depending on the patient in front of them, they're identifying the key questions to ask or is that a decision that's made more at the clinic level of consistency of questions that are being assessed based on the population you're most likely to see? No, that was done at that clinic level for sure. But let me add another caveat to this, which is even more important. You can assess all you want and have 100% uptake. The problem becomes you need that feedback loop. And so even as you're referring out there, what is actually the services? Are they able to follow up? Who's following up with the patient on both the end of the service provider and then also from the care team? There's a great article out there. If you can't find it right away, I'll forward it to you. I think the study by Kaiser that had looked at how to close that feedback loop really well. And so they had done a great job with it. And I think it's a good example to recognize the assessment is only one piece of the puzzle here. If you can't get to that feedback loop and really close that up and then measure that uptake and where the opportunities are, then all of this is for naught. Another question that I have is, are you seeing any sort of regulatory or compliance requirements around hospitals and health systems addressing equitable care in any way? Sure. Well, let me give you an example at the state level because this kind of threw me. So our system is in about six states or so right now. And when we were first going to design our homegrown trainings, it wasn't as ambitious as you saw the result of it with our 10 trainings that we developed. It was actually just about three. But what happened was about halfway through our initiative, I got word that in Nevada, they had a state legislative requirement that says for all of the hospitals in the state here, you're gonna need to provide training in these nine or 10 special topics and they broke it all down. So obviously that leadership then came to me and says, we need to do this, we don't really have a choice. And so I said, all right, we'll lead that with one condition that after we develop it, we can make accessible to the whole system. We're not just gonna do it for every single state differently. And let's have something that can, we'll address something specific to Nevada, but we're gonna make this accessible, generalizable to all. And so that was the first moment that I had that aha, like, oh my goodness, like legislatively, also this can become challenging, right? Because not everything is structured in a way that makes sense even to me. So for example, it wasn't, okay, here's DE and higher health equity training. It was all under the umbrella of cultural competency or cultural humility, which didn't look right with respect to the training. So we kind of had to balance that out. The other piece of it, which is important is not necessarily regulatory per se, but even with your accreditation requirements. So there are rankings of different hospitals that are now expecting you to have certain trainings in place in certain content areas like the health equity. And so that becomes an issue. I think US News World Health Report does that for pediatrics, that's one example. Joint commission now has the requirements with the action plans as they address health equity and health disparities. And so that was a requirement that went into effect, I believe just this past January, if I'm not mistaken. And so there is that action that's already taking place and audits have already begun to really look at what systems are doing to advance that. And when you say they're doing audits, is there any outcomes for that? Is there penalties for this? Well, with respect to that particular requirement, I don't remember the specific penalty that I'll conceive. But I do know, and this is interesting, is that when you look at the requirements, it will be under that umbrella of health disparities. But when they do the audits, it's interesting that they're asking also about diversity, equity, inclusion. And that's not always obvious when you look at the requirements. So I think one important thing to think about is that as you're preparing for those audits, if you're implicated by them, is to recognize that historically, DE&I was in a certain place and health equity kind of evolved in this parallel stream. And in many places, it's still going in parallel ways. So even if you think that you're getting audited on health equity, you might simultaneously be being audited on your DE&I practices. And so if both heads aren't talking to each other or in it together, you're gonna get dinged at some point because they are going to ask about both. And so that's exactly what I've witnessed. And that kind of prompted me to say, okay, let's start to get more people together and really get into it. Collaboration, though, has been great in our system, speaking to that. All right. Well, thank you so much. You've given us a lot to think about and some things to take back to our organizations as well. So thank you so much. I appreciate having you. Well, everyone, that sort of brings us to the conclusion of another quality summit. And on behalf of myself, the staff, everyone at ACC, we really wanna thank you for being here. And we really hope we will see you next year in San Antonio, September 17th through 19th. And yes, it is a Tuesday, Wednesday, Thursday. So a little bit different, but we hope you'll join us there. And again, thank you so much. And I have to give a shout out to a few people here, our planning committee, we wanna thank them, and our logistics teams, our AV teams, Laura, who is our division vice president, who supports us through all of this, and Maria and Maddie, who really kind of keep us all together and help make this meeting such a great success. And to all of you, for all of your dedication and support of everything you do, we really appreciate you, and we were glad that you could be with us. So thank you, have safe journeys, and we'll see you next year. Thank you.

health equity

disparities

interventions

structural determinants

hospital conditions

diversity

inclusion

DE&I

cultural differences

social determinants of health