Addressing disparities in health care through education in diversity, equity and inclusion (DEI) has long been a priority for Sarah Kandil and her team at Yale New Haven Children's Hospital. The challenge arises in procuring the necessary resources—notably, finding time in the day with increasingly strained health care workers—to properly present DEI training.
The solution: merging it with existing educational programs.
“I think it was a natural spillover to our simulation program,” says Kandil, M.D., deputy quality and safety officer at Yale New Haven Children's Hospital (YNHCH) in Connecticut. “We wanted to make it a holistic approach to the patient so the team could practice the medical components as well as any DEI components that might be there—it’s important in helping the residents and trainees to really maximize the education process.”
Kandil and her colleague, Gunjan Tiyyagura, M.D., M.H.S., YNHCH’s director of quality and safety of education in pediatrics, began laying the foundation for the DEI-infused simulation program more than two years ago. They garnered leadership approval for the project and assembled stakeholders across the organization. Key in developing their curricula was adding DEI objectives to current simulations without losing any of the medical education or lengthening the time needed to complete the sessions.
The simulations enhance a provider’s knowledge base because of how closely DEI objectives tie with social determinants of health considerations, according to Kandil. For example, traditional simulation modules such as asthma, sepsis and non-accidental trauma are paired with DEI concerns like homelessness, language barriers and racial bias. Each simulation lasts an hour, including setup and debriefing. Some examples include:
- Anaphylaxis and undocumented status or lack of insurance
- Sickle cell acute chest syndrome (ACS) and racism
- Sepsis and microaggressions
- Respiratory failure and microaggressions
- Asthma or supraventricular tachycardia and homelessness
- Sepsis and language barriers
- Abdominal pain and transgender care
- Non-accidental trauma and racial bias
Kandil and Tiyyagura conducted their first DEI-integrated simulations in early 2021 with the goal of increasing the proportion of pediatric resident simulations with DEI objectives from 0% to 50% within 12 months. By the fall of 2021, they attained their goal with a monthly average of 56% simulations. In 2022, they maintained that average while experiencing some months with 100% of simulations including a DEI component.
Sample case development: asthma and homelessness
One of the first cases they developed was for a common medical training, asthma, which allowed them to reach staff from multiple disciplines involved in various levels of care. Goals of the simulation included improving understanding of homelessness and children, identifying how homelessness may affect the patient's health, and identifying strategies to support our homeless patients.
In developing the case, the team researched the topic and compiled an online resource library, created specific objectives for the case, and developed briefs for the facilitator—including key points of the topic, specific language to use and points to make during the simulation. After the case was developed, it was reviewed by at least one or two experts in the topic.
“This was a really critical piece,” Kandil says. “I can't emphasize enough how important this part is in developing any of the DEI cases.” Finally, the team spent time preparing with the facilitators and actors to ensure they were comfortable performing their roles.
One asthma simulation includes an EMS encounter with a 6-year-old boy suffering from respiratory distress. The script prompts the actor playing the boy’s mother to bring up their homelessness, such as how the shelter has exposed him to smoking and how she feels guilty he has missed some of his medications. The point is to provide many points of entry for the DEI topic. The trainee is provided with strategies to help these patients experiencing homelessness, including resource referrals and care coordination in the inpatient setting.
Scaling the program
Though there were some initial concerns to adding DEI objectives to simulation training—primarily their relevance to the medical lessons and time constraints—the feedback to the program has been positive.
“What we’ve heard from both the trainees and the facilitators is that they thought this was relevant, impactful and important work,” Kandil says. “We’ve made adjustments and have done several iterations of the scenarios to make sure they were like real life—including things like terminology to use for different scenarios and how that could affect a family’s perception of a situation.”
The YNHCH DEI team intends to continue scaling the program to include a higher percentage of simulations with DEI objectives in the children’s hospital as well as spreading the initiative across its broader health system. While the program’s ultimate aim is to improve health outcomes for all children in the hospital’s care, Kandil believes more programs like this could also lead to changes elsewhere.
“I think it pushes the industry in general to make things more diverse.”