The social justice movements and disparities revealed by the pandemic in 2020 put a spotlight on systemic inequities. This led to a renewed interest among many hospitals in diversity, equity and inclusion (DEI) efforts.
The challenge for hospital leaders is not that inequities have suddenly appeared where few were before, but that inequities have long been—and continue to be—pervasive, even in pediatric health care organizations with long-standing missions to provide excellent care to all children.
The problem of unfairness in care and outcomes is not new, but realizing the full depth and breadth of this issue can feel overwhelming. Where do you start? Is having DEI experts at the hospital enough to handle issues that exist fundamentally in all hospital areas every day? If not, what else can you do?
At Children’s Mercy Kansas City, leaders have supported the growth of a DEI ecosystem for 13 years. The first step, in 2008, was the formation of the Office of Equity and Diversity and the Equity and Diversity Council, which provided a coordinating base for DEI work.
Over time, a broad network of DEI-focused groups was created, including committees, champions and projects in patient care, human resources, faculty affairs, research, community engagement, and more, as well as employee resource groups and an array of patient family advisory councils.
Despite successes coming from this ecosystem, teams recognized almost a decade into the work that, even with considerable progress, the organization was not close to where it needed to be. Stubborn, deep-seated problems remained in the hospital operations and in the care provided. No matter how many special projects or processes were created to address the issues, the hospital needed more than a DEI ecosystem to make health care equity a reality.
Health equity is like safety
A fundamental barrier was identified: Across the organization, leaders and staff members viewed the growing group of champions and experts as problem-solvers who would take care of whatever problems emerged.
Their presence allowed others to go about their “regular work” while the experts focused on DEI-related efforts. The result of this perception was a set of DEI-related advances that were often superficial, temporary or limited to the scope of a special project or effort. They did not get to the root of an issue.
While working with quality and safety teams, the DEI groups had a revelation: Health care equity is like safety. It can only occur when everyone involved in the system co-owns the responsibility to make it happen. No amount of safety experts or special safety projects can make a hospital safe. Safety only manifests when every individual owns the responsibility to be safe in everything they do.
The same is true for health equity—it will never occur unless every member of the hospital community owns it. Regular daily activities must be founded on equitable practices, behaviors and attitudes, just as they should also be based in safety.
This revelation opened new roads toward health equity for leaders, the hospital’s DEI ecosystem, and the hospital at large. In addition to ongoing cultivation of DEI champions and experts, the hospital set a goal to instill equitable practices into every team’s daily work.
Just as hospitals leaders today might be asking, “where do I begin?” when they see the enormity of the task ahead, Children’s Mercy needed to find a place to create and test a new approach to systematic integration of health care equity and DEI. To do so, the hospital turned to its quality and safety colleagues.
Finding a new approach
The first step toward a systematic approach to integration was the creation of The Health Equity Integration Project (HEIP) in 2018. This effort was created to pilot a small-scale consultation strategy for departments within the hospital’s Improvement Center. The goal was to provide a proof of concept for partnering with teams to identify and implement sustainable, meaningful heath equity-focused changes into their daily work. The first phase of the project involved pairing a physician leader from the Office of Equity & Diversity with a project coordinator from the Improvement Center to form the HEIP team. They used Lean and QI tools to create the following approach with each department:
- Meet with department leadership to introduce HEIP goals and assess for interest and readiness.
- Meet with department staff as a group to identify and celebrate existing health equity and DEI perspectives in their work.
- Explore adaptations or additions to their standard work that would better “automate” the inclusion of health equity and DEI perspectives, emphasizing group ownership of the process.
- Choose one new adaptation or addition.
- Track outcomes: Is the activity being carried out as planned? Is the activity making a difference?
- Move successful activities toward sustainability.
The initial integration activity was created in the Clinical Safety Department, where the HEIP team and department staff crafted a DEI-focused question to be included in existing scripted root cause analysis interviews following every serious safety event.
The goal was to prompt reflection by each interviewee on whether characteristics of anyone involved in the event, such as language, culture, race or ethnicity, age, gender, sexual orientation or religion, might have been relevant to what happened.
The verbiage went through three iterations with the help and feedback of the clinical safety officers who conducted interviews of staff involved in an event. After six months, the activity was considered in steady state, with responses to the DEI question used regularly in the analysis of each serious safety event. The approach created by the Clinical Safety Department is now called the “universal question” tactic and has become a cornerstone of integration for many hospital groups.
The Improvement Academy (IA) at Children’s Mercy provides a series of problem-solving courses for various learners in the organization, including teams from any area looking to address a problem using quality improvement methods.
Partnering with the IA team, a DEI checklist was created to accompany the standard problem-solving framework used in all problem-solving courses. The DEI checklist provides four steps for each team to follow, along with detailed guidance:
- Get into a DEI frame of mind. As a team, review concepts related to DEI (10 terms and brief definitions provided on the checklist).
- Think of diversity broadly. Be aware of the broad range of characteristics that contribute to disparities in opportunity, engagement and health.
- Ask at every turn. Consider DEI factors at every phase of problem solving, including breaking down the problem, creating interventions and measuring outcomes.
- Record your thoughts. Keep track of how DEI efforts apply to your project on the worksheet included with the checklist.
In the pilot phase, teams turned in worksheets showing how they had integrated an equity lens into their QI projects. The checklist achieved steady state in the first year of use and has been modified for internal and external use.
In the first year, four departments participated in the HEIP, including Patient and Family Engagement, Performance Improvement, Evidence-Based Practice and Education. With all departments, the HEIP team used the mantra, “Health equity, like safety, is everyone’s work,” to highlight that the HEIP team was supporting departments in achieving their goals, rather than asking them to do something for the HEIP team.
At all times, activities were positioned as an opportunity for teams “to make their own work better.” Any time two or more people work together, there is diversity of experience, identity, outlook and need, so no team can achieve optimal results without understanding health equity.
Once activities, such as integrating a universal question or DEI checklist into a team’s daily work were identified, the HEIP team continued to follow up regularly with departments to support and confirm effectiveness and sustainability. When activities were deemed to be in steady state as standard work, they began to move on to teams outside of the Improvement Center.
Health care equity can only occur when everyone in the system co-owns the responsibility to make it happen.
The most immediate outcome of HEIP was the successful integration of health equity and DEI-related activities into participating teams’ standard work. Team-specific metrics guided ongoing revision of activities and helped spread successful tactics from team to team.
Specific outcomes include how many times a question was asked during interviews following a serious safety event, and then tracking the increase of the DEI-related question being asked. In addition, multiple departments described how participation in HEIP created new team dynamics and changed team culture.
In addition to quantifiable metrics, the team collected numerous “impact stories” from leaders and staff that show how mindsets shifted and new habits formed as a result of integration processes. For example, a team member from Evidence-Based Practice reported that she saw a best practice guide on eczema with new eyes because of the HEIP.
She noted to the group developing the guide that all the photos used as examples of eczema were of children with lighter skin, a problem that the group promptly addressed. She said she never would have noticed this before taking part in HEIP consultations.
The Patient and Family Engagement team recognized that while they had previously performed multiple patient/family “tracers” with families who spoke languages other than English, they witnessed how a bilingual staff member could get much deeper, more detailed feedback than they had ever gotten through an interpreter.
Another key outcome was the spontaneous spread of the HEIP approach within and between departments. In Clinical Safety, the medical director took the universal question created for serious safety event interviews and incorporated it into other key conversation scripts, such as code blue debriefings.
Departments outside the Improvement Center learned of HEIP tools and consultation and requested, modified, and spread them on their own. For example, the Chaplaincy group asked for a brief HEIP introduction, elected to adopt the DEI checklist, and then set a goal to take it to all the committees their group members take part in as well.
The successes of the first year led to a busy second year, as the Black Lives Matter movement grew, and disparities became more evident during the pandemic. The team spent the year fielding requests for consultation internally and from other hospitals and organizations throughout the country.
While the need for operational approaches to health equity had become more urgent, effective solutions were scarce. The team presented and shared their tools at the national level, including the universal question approach and the DEI checklist, in a generic form that could be modified to suit an organization’s needs.
The hospital also adapted the DEI checklist for use in Children’s Mercy’s strategic planning process, where 19 strategy teams incorporated the tool into their discussions and reported to leadership on “DEI takeaways” for all tactics proposed across the strategic plan’s five goal areas. Post-planning interviews with strategy team leaders showed good uptake and a clear effect of the tool on strategy team outcomes.
Throughout 2021, goals turned to scaling the HEIP approach for Children’s Mercy’s more than 8,500 employees, while continuing to offer support to outside organizations looking for new ways to advance health equity.
Children’s Mercy Kansas City created a systematic approach to focusing on health equity. The goal was to make it the work of everyone in the organization, not just one team. The organization adopted a quality improvement mindset and leveraged checklists, interviews and a problem-solving framework. Here are four lessons learned while piloting this work.
Teams and individuals must own the work. Incorporating concepts in a team’s or individual’s standard processes can make their work better, but it must remain their work, not that of a consultant or expert from outside the team. If there is a perception that health equity is the job of a specialized team or department, it cannot be broadly realized or sustained.
A consultative approach allows for adaptation. Identify teams’ understanding of how health equity relates to their work and adapt support accordingly. Teams and individuals have different levels of buy-in. Children’s Mercy uses a motivational interviewing model to assess readiness for change and makes recommendations that fit.
Centralized and de-centralized integration methods can complement each other. Hospitals have created or are planning a centralized DEI structure, such as a department. This provides an impetus, initial resources and planning for integration, but decentralized methods foster co-ownership. They offer flexibility and encourage the spontaneous and rapid spread of ideas and practices.
The effect of health equity work goes beyond the quantitative measurement of program outcomes or disparity reduction. The deepest effect of integration is a shift in consciousness and culture within teams and among the larger staff. Children’s Mercy’s goal is for leaders and their teams to understand the importance of considering health equity in every process, every structure, and every project, every time. The organization has seen how a change in mindset opens new perspectives, leads to realizations and changes behavior. Through meaningful connections and careful messaging, health equity integration is improving the care the hospital provides and the relationships and environment that define the workplace.