It started with a pitch.
Karthik Sivashanker, MD, MPH, was a fellow in the Department of Quality and Safety four years ago when he became convinced that health equity needed to be incorporated into the Brigham’s quality and safety work — a kernel of an idea sparked by his participation in the Institute for Healthcare Improvement’s (IHI) Pursuing Equity initiative.
He approached his colleague Karen Fiumara, PharmD, BCPS, CPPS, then the hospital’s executive director of Patient Safety, with a question.
“I basically walked into Karen’s office one day and said, ‘Don’t you think we should be looking at some of these factors — whether a person’s self-identified race, language or insurance type is having any impact on safety events?’” recalled Sivashanker, now vice president of Equitable Health Systems at the American Medical Association (AMA). “She said, ‘Yeah, I don’t know why we’re not doing that.’ She was an immediate ally.”
That informal conversation ignited a transformation, launched in partnership with the IHI in 2019, in how health inequities are identified and addressed at the Brigham. Since then, it has grown, expanded and, most recently, inspired a national collaboration to support other health systems on the same journey to improve health outcomes for historically marginalized populations.
A Systemic Solution
At hospitals around the country, equity was historically treated as a separate domain of health care, with assorted projects or initiatives often executed in isolation from one another and lacking broader, lasting engagement.
But systemic problems — including racism, sexism, ageism, ableism and other forms of prejudice — need systemic solutions. One way to do that, Fiumara and Sivashanker concluded, was to integrate equity into existing quality and safety structures. As a starting point, they led work to update the Brigham’s safety reporting tool so that staff filing a report could indicate if they believed bias or discrimination played a role in an event.
“This isn’t a problem we solve by devoting more resources to new initiatives or programs. These are foundational principles that must be embedded into our infrastructure,” said Fiumara, now vice president of Patient Safety. “Just as we design systems to provide safe care, we need to also make sure they are designed to deliver equitable care.”
From that first initiative, several more have blossomed in the areas of quality, safety, access and patient experience, with the goal of building systems that prevent harm by anticipating and correcting inequities in care.
Exchanging Knowledge and Ideas
To spread the impact even further, Brigham leaders have shared what they’ve learned with peers around the country over the past year as part of a nationwide collaboration.
Leaders from the Brigham partnered with colleagues at the AMA and The Joint Commission to establish the Advancing Equity through Quality and Safety Peer Network, a yearlong mentorship and networking program that has brought together participants from eight health systems who are learning how to apply an equity lens to all aspects of quality and safety practices.
“Quality is not the sole job of the chief quality officer. Similarly, managing and working on health care inequities is not the sole job of the chief diversity or equity officer,” Fiumara said. “It has to be seen as the responsibility of every person in the organization.”
The AMA-led program, which will soon conclude its first cohort, was co-designed with the Brigham. The quality, safety and equity framework that participants learn was designed and tested at the Brigham in collaboration with the IHI. Additionally, several Brigham leaders serve as faculty members for the Peer Network.
“It has simply been a joy to join with others who are also dedicated to cultivating greater equity in health care,” said Normella Walker, MA, CDP, a faculty member for the Peer Network and the Brigham’s executive director of Employee Experience in Diversity, Equity and Inclusion and the Office of Mediation, Coaching, Ombuds and Support Services. “The platform provides a forum for sharing knowledge and deepening understanding and is advantageous on multiple fronts. It broadens our ability to influence change in this area, learn from others’ experiences and cultivate additional allies.”
Through monthly learning labs, peer-to-peer sessions, case reviews, individual coaching and other virtual activities, participants in the Peer Network learn practices and implementation strategies for systematically identifying and addressing root causes of inequities through an integrated approach to quality, safety, equity and operations.
“Our approach to collaborative case review and the ability to explore sensitive issues related to racism in a way that feels communal both facilitate learning and, most importantly, avoid blame,” Walker said. “We have shared our framework for discussing cases in a manner that provides safety and support as we engage in collective problem-solving using the equity-informed, high-reliability model.”
Collaborative Learning Along the Journey
Faculty member Regan Marsh, MD, MPH, an emergency physician and one of the Brigham’s three medical directors of Quality, Safety and Equity, recalled a recent presentation by a Peer Network participant who had identified an inequity in the personal care items patients in their hospital received. The hair and grooming products the hospital provided were not suitable for people with curly, coiled or kinky hair — a purchasing decision that disproportionately affected patients of color. As a result, they felt unseen and needed to buy and bring their own products.
The Peer Network participant shared that after learning about this concern, the hospital changed its purchasing practices to obtain personal care products suitable for more hair types — sourced from vendors led by people of color — and trained nurses and staff on providing patients these products if they wish to use them.
“As a faculty member, it’s been so interesting to see the different approaches people are taking, and it’s provoked ideas on our side, too. It’s very much about collaborative learning,” Marsh said. “This really is a space where the more people are at the table, the better.”
Hospitalist Esteban Gershanik, MD, MPH, MMSc, a Peer Network faculty member and Brigham medical director of Quality, Safety and Equity, agreed that it has been gratifying to support colleagues around the country as they design and implement more equitable systems of care.
“These traditionally aren’t easy conversations or easy spaces for people to be in, and it’s been great to see people support each other, be thoughtful and open, and normalize such conversations in these discussions about advancing their work toward racial justice and health equity,” he said. “We all face similar and different challenges depending on the communities we’re in, but we’re all trying to better understand our treatment of everyone who comes through and who does not come through our doors.”
Emergency physician Nadia Huancahuari, MD, FACEP, also a faculty member and Brigham medical director of Quality, Safety and Equity, said it has been energizing to see so many peers from across the country share an enthusiasm for engaging in this important work.
“While this work may be new for many of us — and that may make us uncomfortable at times — we are all fully committed to it for the sake of our patients,” Huancahuari said. “It’s a journey, not a destination. We have quickly realized that the more curious we become, the more we learn and uncover. For instance, one of our areas of focus is patient experience, where we continue to discover opportunities to address inequities to ensure all patients and families feel seen, cared for, safe and welcome. It’s inspiring to be part of a team that is leading the way in how we define, design and validate more equitable patient care and experiences.”