 Hello, everyone. Welcome to today's session of the Harvard Organizational Ethics Consortium. I'm Charlotte Harrison. I'm one of the co-chairs of the consortium, along with Jim Saban and Kelsey Berry. I also head up the ethics service at the Boston Children's Hospital. Today, I have the privilege of being your moderator as we hear from three experts on the topic of pursuing equity through assistance improvement. First, a quick note about this series. This fall marks the seventh year since we first convened this consortium at the Harvard Center for Bioethics. Our aim has been to build a learning community around the somewhat underdeveloped topic of organizational ethics in health care in the US. Programs have focused on the core concern of the field, the alignment of an organization's conduct with its values. How do we manage to do what we mean to do? How do we determine what we mean to do when there are many competing interests and values, significant uncertainties, internal cultural complexities, and external constraints? How do we hold ourselves accountable? And how do we respond when sometimes others disagree with what we have done? We hope you'll consider yourselves a part of this community and join us again for upcoming programs, which I'll describe at the end of the session. Back to today, health equity, some would say health justice, is one of the most fundamental ethical challenges for US health care today. As we turn to that issue, we'll have three distinguished leaders to share their experience and reflections. Meanwhile, a word to the audience about your own participation in the program. So there are two ways to participate. One, you can submit questions at any time when anyone is speaking or otherwise. Using the Q&A feature, selected questions will be discussed at the end of the talks and depending on the number. Also, you can use the chat feature to share comments with anyone present. If you have a technical difficulty, use the chat to contact the panelists and someone will be in touch with you. Thanks in advance to everyone for sharing your questions and your thoughts. So now I have the privilege of introducing our first speaker, Dr. Kedar Mate. Kedar is president and chief executive officer at the Institute for Healthcare Improvement, or IHI. He's also president of the IHI Aleutian Leap Institute and a member of the faculty at Wild Cornell Medical College. His scholarly work is focused on health system design, health care quality, strategies for achieving large-scale change on approaches to improving value. Previously, he worked at Partners in Health, the World Health Organization, and Brigham and Women's Hospital. He's published numerous peer-reviewed articles, book chapters, and white papers and received multiple honors, including serving as a Soros Fellow, Fulbright Specialist, Zetima Panelist, and an Aspen Institute Health Innovator Fellow. Kedar. Well, thank you very much, Charlotte. It's a pleasure to be here with all of you and thank you for the invitation to the center for to be part of this session. Before I go further, let me just check, as we have to do these days, that you can see my screen and hear my voice. Is that OK? I'm not. Yes. OK, good. Very good. Thank you. Well, I just, again, I want to say thanks to all of you for joining us today. I look forward to our discussion and very much I'm looking forward to the comments from my colleagues, speakers here, David and Nancy, who will come after me. Just to be clear and to set the table a bit up front, I'm not an ethicist. I'm an internist and a quality improvement in patient safety specialists. I lead an organization called the Institute for Healthcare Improvement, as Charlotte described, which has a 30-year history of improving quality and patient safety around the world and indeed here in the United States as well. I look forward to what I hope will be a lively conversation about how to operationalize the need for more health equity in our health systems through a discussion that around this initiative that we've created at IHI called Pursuing Equity. In the quality and safety sciences that I work in every day, this is the question that we have been answering for the better part of the past three decades or longer. How might we provide a health care service that is defect-free? By that we mean traditionally safe, effective, patient-centered, timely, equitable, et cetera. Such a service would lead to improvements in health outcomes. It's not a bad question, I would argue, but I would also argue that it's probably not enough. This question has led to a lot of what I would describe as fixing and forgetting, incremental changes and improvements, but not the kind of whole system change that we have often sought in the health sector. Here's a slightly different question, a question born perhaps of our moment. COVID, financial losses, racial awakening and our position on the cusp of a consequential election, that comes in I think 11 days, these forces might compel a new question. How might we improve the value of the contribution that health care services make to our peoples and to our societies? This question forces us to recognize that for many people, health care is simply not working. And for many societies, the social contract and sometimes the very real contract that has been written between our societies and our health care systems is under reconsideration. Indeed, the evidence suggests that spending on health care today may be contributing to lowering the nominal investment in education, public safety, transportation and a variety of other public goods and services that we all depend on. So we might ask the question about how might we build a better system? I pose this question now at the beginning of a talk on health equity because as you probably can imagine, I believe that a focus on health equity may actually lead us to a new way of building the health system of the future. But how might that happen? How might a focus on health equity create more lasting universal value in our systems and in our civilizations? This requires a small diversion, if you'll permit me, into this thing that's here on the screen in front of you. Some of what you might recognize in your city streets right now. Until the late 60s and early 70s, the norm in a city like Boston was high curbs. Curbs that were impossible to navigate if you were in a wheelchair. In the 70s, disability activists living in Berkeley, California, led by Edward Roberts, a wheelchair-bound student, grew frustrated that they couldn't use the city sidewalks. In groups, these activists and students went around covertly in some cases in the middle of the night to pour cement, creating their own pads to being able to wheel into the city streets. Now this phenomenon that's here on the screen, curb cut, as it's known, are a given. They're not just used by those in wheelchairs, but they're used with much gratefulness by a variety of other folks. Anyone that has young children and pushes a stroller in the streets of Boston or any other city that you might be in today knows how important and useful these curb cuts are and how much you miss them when they're not on the corner. The elderly, kids on bikes, those wheeling the many Amazon packages that will soon be going around to all of our homes. These curb cuts are a pretty universally appreciated phenomenon. This concept or the concept underpinning the creation of curb cuts was only named 40 some odd years later when another Berkeleyite professor in this case, Professor John Powell, described the theory of targeted universalism, a theory that holds that getting to universally held societal objectives, in this case, better movement throughout cities, requires the use, in some cases, of targeted strategies to help advantage those that have been systematically disadvantaged. The goal is universal, the strategy is targeted. As it happens, when you focus on the most marginalized and the most excluded and the most vulnerable and you build systems from there, they may just offer a benefit to all of us. When you focus on the most marginalized and excluded, we might just create a system that is, in fact, better for all of us and creates lasting value in our sector in healthcare. Before we get much further, some definitions, no talk on health equity would be complete without some imagery that helps to illustrate the difference between equity and equality. And here's my set of images and the definition that we've come to use at IHI, which is the CDC definition. It's also been endorsed by other major organizations. The way that we consider and define health equity is that when all people have the opportunity to attain their full health potential and then no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance, health inequities are reflected in differences in health outcome. And such differences might be considered systematic, avoidable and unjust. Again, the definition from the CDC. These may be reflected in differences in length of life, quality of life, rates of disease, disability and deaths, severity of disease, access to treatment in the quality world in which I spend most of my time. Such inequities are costly systematic variation. That is indeed unjust, undesired and costly. As some of you may know, such variation is precisely the system's property that methods of quality improvement, methods of patient safety, methods of system reliability were designed to identify and root out. This talk, let me just pause for a moment and say what this talk is in some ways not about. It's not about proving to anyone on the phone here today that we have disparities in inequities in healthcare. If you don't think this is happening in health and healthcare, if you don't think we have inequitable care or inequitable health outcomes, my guess is you aren't looking hard enough. On this slide or over a dozen points that illustrate the fact, there's a number of citations there if you'd like to learn more, but there have now been decades of research that have been conducted on understanding the prevalence of health disparities and inequities in our systems. What I will say, and the one comment I would like to make on this is that these inequities are not by any means limited to healthcare. They are everywhere. They're embedded in every social system that we have. This graph from the Racial Equity Institute shows the relative risk of poor outcomes for African-Americans in the red line versus white folks who are the reference population in the black line at the bottom and demonstrates a phenomenon that exists across all social sectors. In health, you see infant death being two and a half times more likely for black folks compared to white folks. Being suspended from school is four times more likely for black folks compared to white folks. Being incarcerated seven times more likely. Being denied a loan five times more likely and so on. All of these effects are universally felt throughout our social systems and they have the effect of compounding upon each other. Inequities are variation. Inequities are deeply harmful. But neither of those two points is probably all that surprising or perhaps not even that interesting to many of you who already have known those two circumstances and those two points. So a third point might be worth considering. A point that's best illustrated through an allegory that was first told by colleagues at the Racial Equity Institute which I just referenced Bayard Love and Dina Hayes-Green. And it goes something like this. Imagine you live in a house that has a lake in front of it and there's a fish floating in the lake that's dead. It would make sense if you're curious about why the fish was dead. It would make sense to analyze the fish. What was wrong with it? What killed it? Imagine the fish is a patient who is cycling in and out of the emergency room. We might ask, what's wrong with the patient? Why can't we keep him or her out of the emergency room? Are they getting the support they need at home? But if you check the same lake the next day and half the fish are floating belly up dead in the lake, what might you now consider? This time you've got to ask different questions. You might analyze the entire lake. Imagine the lake in this instance in this metaphor is the healthcare system. This time we'd ask, is there something about that system itself that is causing such consistent, unacceptable outcomes for the fish that reside in it? And if so, how and why? But now picture five lakes around your house and in every one of them, half the fish are floating belly up dead. We might say it's time to analyze what is known as the groundwater. How did the water in all of these lakes end up with the same pollution? On the surface, these lakes look disconnected. They don't look like they have any impact on each other but in reality they're all part of the same system. They're all part of the same groundwater. Recognition of this groundwater forces different questions. Why do African-Americans experience worse health outcomes, get disciplined more in school, experience higher rates of incarceration and lower likelihood of employment? How might doctors, police officers and educators all exhibit unconscious bias simultaneously and that compounds upon each other? Why are we all fixated on fixing fish as we now do in healthcare quite regularly instead of being concerned about how to fix the groundwater? Inequities are variation, inequities are harm, inequities are created by systems. The metaphor here helps us realize that these inequities caused by systems are not due to people's culture or behavior and that our treatments, rescue medicine has almost no chance of long-term sustained success. And because inequities are caused by the groundwater and the systems that underpinned it. So what do we do about any of this? How do we consider this? How do we make a change in the light of these circumstances which again are likely to be somewhat familiar to all of you? At IHI back in 2015, we conducted an analysis of our own work improving healthcare outcomes over the last two decades. We looked at 10 of our most successful projects over that period. These were projects that took place across a wide range of topics, HIV infection, tuberculosis care, cancer care, birth outcomes, cardiovascular disease. They also took place in many countries. Not all of them were located in the United States. It took place in parts of Sub-Saharan Africa and parts of Europe and parts of Latin America. By all measures, these were our most successful projects. We chose the things that we had done the best on. We had achieved quantitative statistically significant improvements in the primary outcome measures of each and every one of these 10 successful projects. But as we looked at these projects, we asked ourselves a slightly different question compelled by the information that we had just considered a moment ago. We asked whether the impact that we had found, the beneficial impact that we had created and seen and registered and that our partners had created was felt universally or whether our work had in fact advantaged one population segment over the other. And what we found was striking. For six of the 10 projects that we looked at, we couldn't even tell. We hadn't ever collected the information that allowed us to stratify the data so that we could even answer the question of whether or not the beneficial effects of our quality improvement work had led to disparate outcomes or a preservation of disparate outcomes. For the remaining four projects, the four projects for which we had enough information that we could reach some kind of a conclusion, two of those projects showed no change in disparities, meaning that we had implemented the project, we had seen a beneficial overall rate of improvement in tuberculosis care or in cancer care, but there was no change in the level of disparity between the advantaged and disadvantaged population. And worse yet, two of the other four, two of the four projects, 50% of those projects had showed that the disparity between the advantaged population and the disadvantaged population had in fact gotten worse over the duration of our endeavor. Our conclusion was the following. It was that without deliberate attention to inequity, without a focused conscious effort to improve inequity alongside of improving median performance, what we thought was a universally useful intervention ensuring reliable evidence-based practice would have the effect of systematically advantaging those that already had such an advantage. So IHI did what we would do in response to this kind of circumstance and this kind of information. We went to school. We sought to uncover what a better way would look like. How could we lead our work in quality in a different way? We studied the work of academics and leaders in health systems. We spoke to over 50 leading authorities in health system leaders, including folks like David who you'll hear from in just a few minutes. We spoke to these folks who were working in some way on inequities in their care environments. We sought to understand their better practices from what was available already and we derived this framework. This framework starts with making health equity a strategic priority. Again, it's back to that intention. Without the intention, we knew we would get nowhere in our work. The second area was to build infrastructure to support health equity. Here we focused on the data infrastructure. Again, a finding from our analysis was that for six out of 10 projects, we didn't even have the data to be able to discern whether or not we were preserving inequities or making them better or worse. So we needed the data and we needed human resources to help address the inequities that we would find. So building the infrastructure became the second pillar of our health equity framework. The third was to address the multiple determinants of health and here we meant both the clinical determinants of overall health, including things like cancer care and cardiovascular care and diabetes care and so on, but also the social and non-medical determinants of health that would heavily influence the overall health outcome and health experience of an individual patient and family member. Fourth was about racism and we described it as eliminating racism and other forms of oppression. We chose to focus on racism because it was the cause in more instances than we could, in most of the instances that we looked at, it was the cause of the causes. We were dipping into the groundwater as it were, getting layers and layers deeper and as we dug deeply, we identified at the root cause of a lot of the challenges that we were facing in the multiple determinants of health. Frank and outright racism and bias. And then lastly, we included this notion of partnership, partnership with the community to improve health equity because the only way to really change the groundwater was going to be through working in a multi-sectoral way with our community-based colleagues who had a great deal of insight into how to actually improve health equity in their care settings. In a classic IHI design, we took that framework which we derived from the experience of others in vitro, if you will. And then we sought to validate that framework in vivo. We chose eight systems who were some of the front runners from our research, some of the organizations that had already made health equity a strategic priority and we invited them into a partnership, into a collaborative, as we call it. And for two years we worked with them, tugging and pushing on the framework that I just showed you, validating and invalidating aspects of it, questioning parts of it, questioning the way that we described it and really trying to subject it to a careful and close examination. The framework held up by and large, but of course it went through a tremendous amount of modification that these eight individual systems would help compel over the period. And by and large, we saw some good results. Not everyone was wildly successful but most of the organizations demonstrably improved at least one clinical disparity and in many cases multiple. Here's data just, I'm not gonna show you every piece of information that came out of this work. I'll show you just a couple of pieces of data. This is data from health partners in Minnesota in which they worked on two primary areas. At first, colorectal cancer screening and you'll see that on the left side of the slide from a decade ago to present, they had closed a very significant discrepancy in people of color versus white patients who were getting colorectal cancer screening done. On the right side of the slide, you'll see that there's this difference between the light colored bar and the dark colored bar is median length of stay in their behavioral health units for patients that had limited English proficiency versus English-speaking patients that almost double the rate of length of stay for those that had limited language proficiency, they brought an intervention to bear on that population that involved simultaneous translation. And within a very short period of time, within just over a year, they managed to shrink that length of stay by 75% in their care setting. When you turn your attention to these issues and you pay attention to inequities and you apply modern tools of quality improvement, you can in fact eliminate some of these clinical disparities or reduce them very significantly. Our teams also took on non-clinical areas of work and I'm showing you here information from Vidant Health, a system in North Carolina in which they address one of the major non-clinical determinants of health, the financial stability of their clinical workforce. And what they found when they increased their clinical workforce to a living wage is that most of the benefit accrued, as you'll see here in the middle of the slide, to their black employed population and particularly their black female population who would now benefit from a higher level of compensation and what was in that care setting or in that geographic setting, a living wage. I'm showing you only a small fraction of the results because I wanna get to some of the observations before handing the microphone over to David and Nancy. But here are some of our observations and lessons on working to implement an equity standard in healthcare. First, we selected systems for equity as part of their strategy in some way. For most, it wasn't above the fold. While it was on the strategic plan somewhere, it wasn't necessarily the primary feature, it was buried somewhere in the strategy. To be sure, there were some systems who made really bold choice and for them it wasn't an easy choice in many cases, but they were making a choice to focus on something where their track record really wasn't all that strong, wasn't all that great, but making health equity a strategic priority has become the kind of anchor step in the right direction in terms of starting a process towards moving a healthcare organization towards equity. Second on the data front, we found this incredibly hard, much harder than we thought. We also thought that what we also found is that when quality teams and the quality improvement infrastructure of an organization was tasked to focus on equity, that major strides could be made. Some of the data that we showed you earlier was from organizations that focused their quality infrastructure on health equity considerations. In the third area around multiple determinants of health, what we found as I showed you just a moment ago is that closing gaps can be accomplished when we take a disciplined and rigorous approach to doing so. We also found that social determinants of health could be addressed when an equity lens is applied. With regards to addressing racism, this was critical to our work. We took a race plus approach unapologetically. That means that we started with racism because black people die at a much higher age adjusted rate for nine out of the 15 highest causes of mortality in this country. We took a race focused approach and talked about racism specifically, but it wasn't in the absence of the other forms of the other isms as is sometimes known. And so we talked also about sexism and homophobia and a variety of other challenges that would lead to more intersectoral approaches to health equity. We took what we described as a race first or a race plus approach and we're fully committed to doing that during the course of this endeavor. And lastly, community partnership when done authentically and well is perhaps the most important source of knowledge and experience. And I know my colleague speakers will have much to share on this topic. So I won't focus on it here, but without that community partnership, it's almost impossible to really focus authentically on improving health equity if you're coming from inside of the health system. The work on the first aid systems has now subsequently led to a second generation of pursuing equity. We now have 24 additional teams throughout the country that are working on this. And in fact, two teams from outside of the country in Canada and New Zealand that are focused with us on working on expanding this effort going forward. And we're in the earliest stages of a design process to try to build towards an equity campaign a national initiative to try to reduce disparities in care. This national initiative would have four parts. First to eliminate unconscious bias in the workforce. Second to remediate specific inequities in clinical care some of which we talked about earlier in cardiovascular care and cancer care and so on. Third to eliminate some of the race modifiers or the race based modifiers in clinical science. You may have read about some of the efforts that are going on right now in the nephrology community around eliminating race based modification and race based correction for glomerular filtration rates. There are examples of this in almost every discipline of race based corrections. Eliminating those race based corrections may lead to better care for individuals from minority populations. And then lastly, we have to change the way that we produce science. We have to engage a much more diverse array investigators diversify the basis for our research activities and ensure that the voice of the community and the voice of underserved populations is a part of the research prioritization process. These are the ways in which we imagine progressing this work into the future. I'll close with this. Right now a number of quality focused organizations are looking back on 20 years since the publication of the first two reports on this slide. Back in 2001, the Institute of Medicine included equity as one of its six aims for the design of a better healthcare system. But I would argue that in the year since it has often been the forgotten name that was sort of mumbled at the end of the list. I've been asked many times, why do you think that is? What have been the implications of that for healthcare? It was only one of the six aims that it was the only one of the six aims that had a follow on report just two years later called unequal treatment. The last report here on the slide from the Institute of Medicine and yet it was still largely ignored. Why was this? Why do you think this happened? My answer is, why do you think that is? Because systemic organized racism is very difficult to tackle because to change this requires re-examination of the foundations, not just of healthcare but of who we are as a country, who we are as a people. Patient safety to be sure isn't easy. Waiting times and patient centeredness are not easy but neither of those was at the economic foundations of our country. We never legislated on safety or long waiting times. We legislated in equity. It's in our founding documents as all of you know very well. It's so baked in that we don't even know it's there but as with patient safety we can make the invisible visible by naming it, harm exists, racism exists. Then we can quantify it, falls and infections, inequities and disparities and then we can start to change it. At least in healthcare we can work on patient safety and indeed we can work on things like pursuing equity. So with that I wanna thank you all again for listening to me and I look forward to our conversation. I'm gonna hand it back to you Charlotte and look forward to the discussion. Thank you Kedar for that truly comprehensive and powerful presentation. I think we'll all be responding and benefiting from that as we go through the rest of this program and following. So I'll first say for those who joined us after the introduction please feel free to put your questions in the Q&A at any time and we'll take them up together after we hear from our two commentators. Our first commentator is Dr. David Ansel. He's the Michael E. Kelly, presidential professor of internal medicine and senior vice president associate provost for community health equity at Rush University Medical Center in Chicago. He did his medical training at Cook County Hospital in Chicago, then stayed as an attending physician and ultimately the chief of the division of general internal medicine. Subsequently he spent a decade as chairman of internal medicine at Mount Sinai Chicago and another 10 years as chief medical officer at Rush University Medical Center. His research and advocacy have been focused on eliminating health inequities. In 2011 he published a memoir entitled County Life, Death and Politics at Chicago's Public Hospital. And his latest book is The Death Gap, How Inequality Kills, which was published in 2017. As we hear from Dr. Ansel, after we hear from Dr. Ansel, I will introduce Nancy Berlinger. Thank you, David. Thank you for having me and Kedar, it was a great presentation and overview. So a little bit about me personally, I'm now the chief equity officer at Rush University Medical Center. And as a physician I moved into actually got created and I'll tell you a little bit about that in a bit because it's so important that one has equity at the center of an organization's work. Otherwise it's very hard to do this. I wanna reflect back on Kedar's talk in The Curb, The Curb Cut, which we all know is universal and we take for granted now. And but understand sort of why, if you ask why five times, why there's a curb cut, you go back to activism in the disability movement in this country. About 30 years ago, the Americans with Disability Act was passed after many years of activism. It's led to a lot of changes in our environment that we take for granted like toilets that are widely accessible, but the curb cuts occurred because the disability community's approach was an activist approach. And I just say that because we're in a moment of time with Black Lives Matter activists on the street and it's a really important time, organizational, institutional, systemic change only occurs with that. And from this disability movement came a phrase that I repeat quite often was nothing about us without us. And when we think about the work in front of us of addressing systemic racism and other forms of oppression in dismantling health and other inequities, I'm also reminded of going to paraphrase Audra Lord who made the statements that you can't dismantle the master's house with the master's tools. So I framed those, my discussion and reflection with the understanding that curb cuts didn't just happen because someone had a good idea and said we should pass along. Curb cuts occurred because activists stopped buses in block doorways and ultimately one of the result was public policy that is Kedar said specifically designed for one group but universally accessible for everyone. So I did want it to sort of reflect on that as we think about this. As a doctor and a general intern who spent 30 years of my career in safety net sessions and settings in Chicago, it was my reflection after all of those years that the health gaps I was seeing in my patients couldn't be explained just by biological conditions and that we really needed to reframe health and health outcomes through a different lens than the biological. Because as we focus on beliefs, behaviors and biology, we sometimes don't actually see, as Kedar mentioned, the invisible systems that are producing the results we get. So just to take the life expectancy gap between black and whites in the United States from the time it's first been measured in about 1900, there have been 8.5 million excess black deaths in the United States just because black people do not have and have not had and continue not to have the same health outcomes as white people. And yet within our healthcare systems, we've been late comers to thinking about how to address this. And I wanted to give you a framework that we have to think about and this is largely aimed at those who are white in the audience or those who've been assigned white in the audience. Because one of the reasons why systems perpetuate things like racism and structural racism or other forms of oppression or exclusion is because they're designed in a way to continue to produce these outcomes. And as a white doctor and as a white man who practiced in the settings for many, many years, it took me many years to actually name racism as a cause of the cause of these inequities. So if you ask why five times, you can do a root cause analysis on anything. It's a really good tool, it's a quality improvement tool. So I had to ask myself as a senior leader, I've been a division chief, I've been at the department chair, I've been a chief medical officer in an academic medical center. Why did it take me so long having practiced in these settings to name racism? Because if one can't get to it within yourself, how can you possibly think of improving the systems that are producing it? So when I did why five times, number one was, well, I didn't wanna really offend the people around me by starting to say racism or white supremacism in the room. Well, why didn't I wanna offend the people around me? Well, they're a nice group of people. And well, why, you know, why were they so nice? Well, you get down to the why five times and what I could get to was I got invited into white rooms and white spaces in which there were very few black people and actually no discomfort with the fact of who wasn't in the room. And I understood at that moment in time when I finally got to my own root cause that my own unearned advantage. I'm a good doctor and I'm a good leader. I'm not gonna deny that, but it was my unearned advantage that allowed me into the room. And since that moment in time, when I walk into the room, I always look around and say, who's missing from this space? Whose voice will not be heard today because of the way we've designed the room to be? Self-perpetuating room where those who've had historic advantage assigned to them are always the ones in the room. Making that personal self-awareness was a critically first step for me to be able to think at how do we organize this within an organization? So I want to talk, and I think this starts with personal recognition. So this is a leadership issue within an organization. And when I moved from being a chief medical officer to a chief equity officer at Rush, we did two things in our organization. So number one is we said our aim is to improve health, not to be better in healthcare. That was a critically important step. Number two, we named racism as the number one cause of health inequity, certainly in Chicago. And again, as Kader said, not to exclude other important causes, but naming it first. And the third thing we did was make it an organizational strategy. And that work, it was critically important to do that. So if you say like, what's the first step you have to do is it's got to be named racism and ask how it's working here and other forms of oppression or exclusion in your health system. And it's got to be tied to a system strategy. And our work at that point in time was to organize ourself as a leadership team to layer this in our quality structure, but also in our approach to employees and our approach to community. That led us to create a racial health collective collaborative called Westside United with a group of other hospitals partnered with community, nothing about us without us again that equal voice of the community and sharing power and naming it a racial health equity collaborative. But it wasn't until Black Lives Matter in the disproportionality of COVID that we saw and then the Black Lives Matter reactivation with the killing of George Floyd that our own institution was ready to begin the steps to take on racial injustice within our own institution. And we're just at the beginning of this next chapter of the work. So this work is inherently inside outside work. It has to be organized as a strategy. There's many, many ways and many places to measure improvement. For example, we looked at life expectancy as a measure in the loop where it was 85 and if it was a country to be ranked first in the world three stops west of us. Life expectancy was under 68 years old and we made reducing that gap, 16 year life expectancy gap a big aim of our organization. But now with Black Lives Matter we've named eliminating racism within our organization is a strategy. So I'm just wanna give you a little bit of framework for how this work has to be done a little slightly different from KDARs. One is that there's that interpersonal work that we have to do within ourselves to understand how racism work and how some of us have benefited from it and continue to benefit from it. Two, there's interpersonal work that has to go on all across an organization to have conversations about it and asking the question, how is it working here within our structures, our policies, our procedures, our norms and our values? Some of these are rule-based systems that perpetuate it and many times it's just our norms like how does hiring occur around here? Whose voices are around the table when we're making decision? Do we put an equity framework on our decision-making? We have a decision-making process that asks who wasn't around the table or how does this decision perpetuate injustices that have white on top, black on the bottom, the wealthy on top or poor on the bottom? So that becomes critically important. Those things have to be built into your organization. It has to be an organizational strategy led by leaders oftentimes who do not have either the self-awareness or the historical perspective to lead and those leaders need more than just an implicit bias class. They need to be coached and trained and they need to be held accountable for the results of this anti-racism work. The next circle is community. This work has to involve community voice at the table. Again, nothing about us without us not going to the community after you've made a decision but to talk about how we're trying to tackle racism within our institution and making sure community voice is at the table as part of it and last in the realm of public policy. I'm gonna end on this note. When COVID hit the group that we set up to address life expectancy gaps in the West Side of Chicago, West Side United as part of our strategy was asked by the mayor's office when the first 100 deaths in Chicago, 70 were black from COVID to help lead a racial equity rapid response at the city level. And I was asked with others to help create a provider group that sits around the table with the city health department, with the mayor's office and with the community leaders. And when George Floyd was murdered we put out a public statement that's now been taken nationally that is undeniable that racism is a public health crisis. And we made a set of seven commitments that all of our organizations are going to take to dismantle structural racism. We are now in the process of developing a scorecard that can be used to score institutions on their progress towards us because what we measure we can improve and what we don't measure we can never improve. So I wanna end here on this reflection. This work requires more that you get one point in the world for naming the problem and 100 points for fixing it. We have to name it, but then we have to do the hard work of hard wiring this within our organizations and measure the results. So thank you very much. David, thank you very much for speaking so really movingly and practically about what this looks like within an institution and in the coalitions of institutions in a community. I know there are gonna be more questions about that. Now we turn to our final commentator, Dr. Nancy Berlinger. Nancy is a Hastings Center research scholar with longstanding interests and problems of safety and harm in health systems and in healthcare work. Her work on health equity and organizational ethics includes collaboration with practitioners to apply improvement and innovation approaches to immigrant health. The aim has been to mitigate disparities associated with language, socioeconomic status and the consequences of immigration policy. Nancy is the lead author of the Hastings Center's ethical framework for healthcare institutions responding to COVID-19 from March, 2020. She co-edits a monthly digest of key research reports and resources on immigrant health. And a few years ago, she appeared at this consortium to discuss her book, Our Workarounds Ethical, Managing Moral Problems in Healthcare Systems. We welcome her back, Nancy. Thank you very much Charlotte and Jim and colleagues. It's always a pleasure to be part of the organizational ethics consortium. I think of it as sort of my spare brain and a place I'm really happy to be invited to come and speak at and try ideas out with. So I think it's absolutely wonderful that this sort of magical gathering that some of us have been privileged to be involved in has been extended. I hate to talk about silver linings of pandemics but this is a lovely equity move. So I'm happy to be here. So to add to Kedar and David's wonderful presentations, here's just a few comments that might expand this out into the realm of healthcare ethics and more broadly into health justice. I really love the move as somebody who started at the Hastings Center on a project in response to AIR as human. So that dates me. I really love how Kedar has charted the progression so that we're not imagining an outdated vision of how a patient safety and quality improvement work but link it up to these equity concerns that were there all along. Two years ago at the Hastings Center with support from the Open Societies Foundation and this was around the time when the news was breaking about family separation at the border and we were beginning to learn about what we had feared was going on. I began to think about, well, how do we make healthcare systems into systems of safety for a harmed population, for a population that is suffering threats and harms to their health? This was going on in legal services and social services and other areas and I was curious about this. And so I got some funding from Open Society to have a public health committee on this with practitioners. And it was very interesting to hear from frontline practitioners like Leah Zalman from Boston and Francesca Ganey from New York and many others together with immigrant health advocates about what sort of framework could work because none of these problems existed just inside of a healthcare system or just in one community. And I remember at one point, Leah Zalman just sort of leaned forward and said, we need a learning collaborative. We need to learning collaborate this problem. And the other doctors picked up on what she meant immediately because they're like, right, that is a proven mechanism. It's a prestigious mechanism. It means that leadership is involved and there are targets. So that thought our thinking together and COVID has unfortunately put a halt to that because so many of the people we've been involved in are frontline workers. But it's been interesting in conversations in the Bronx at Lurie Medical Center in Chicago and in other parts of the country, usually in urban health systems to talk about how you would take the experience sense of being part of safety and improvement in your institution and apply it to something as broad as immigrant health. And one of the first steps was to reframe it as an improvement in innovation opportunity rather than a political problem, too hot to handle, a drain, charity care, something like that. So people were very responsive to that idea because they were used to that idea. Another learning from that process that I've been involved in that I heard from Kedar and David's remarks was you need to consider how to get at equity health justice as a challenge that doesn't fully sit inside of a healthcare organization. It's not owned by a healthcare organization. And some of the challenges here which a health policy scholar, Lauren Taylor, recent graduate with her doctorate from Harvard has talked about are the inequalities of scale between a healthcare system which is enormous, multi-site, enormous budget, and the relatively small community-based organizations that may enjoy high trust in a community that is experiencing the consequences of social inequality and health inequities. So David has talked about how you actually bridged those divides in Chicago. And that's a constant theme that it can't be just fixed by a healthcare system no matter how good your intentions are. This has to be in collaboration with the trustworthy grassroots community where the problem is being experienced. Now, another thing I wanted to mention because this has come up around how do you talk about equity? We've talked about it as health justice. We've talked about it as something that's connected to safety and improvement but it was harder to talk about or visualize. David has said very directly you have to be able to talk directly about racism if you're going to talk about inequity. And I would point you towards some ongoing research from the Frameworks Institute which I think they're sharing via their electronic newsletter. They started it this spring and it's on reframing the relationship between racism and health. And it's been really interesting to see their sort of research notes because they have found that the concept of health equity is hard to track if you don't already work with this concept. People can see it more easily in other areas and they can see it in healthcare. It's a more specialist term that I think sometimes we realize. And Frameworks is always about anchoring social change in a value that people recognize. So they've been trying out the concept of targeted justice to say why would we pick this group or this problem as a goal? And to say, well, this is a group that has experienced injustice in respect to health and that's why we have to focus that. So that's the interesting and it's just a turn that they're trying out. But I know that when you work with clinicians when they've become accustomed to justice as something you can't solve at the bedside and shouldn't try to solve. You shouldn't try to do ad hoc resource allocation but they're very curious about the justice and injustice problems they see and they don't like to practice two tiers of healthcare, one standard and one substandard. So that is going to also be a conversation when you're engaging your clinical and your administrative workforce about how this is not just sort of a free range activity. I know it when I see it kind of creative work around justice but an organized activity that clinicians can be part of. It's not just that there's an equity and diversity task force that's going to deal with us. How is this integrated into normal healthcare work? So I think one thing is being careful not to lump it in with diversity and hiring but to understand equity as a health goal. I mean, they're related but they're not the same thing. And one final question that may set up Q and A that's been touched on as well, especially with the visuals of the curb cuts are what pads to health justice do not go through healthcare systems? They don't go through healthcare financing because it's very tempting and Lauren Taylor has also written about this to look for other sectors to look for healthcare to be the solution because it's such a big budget. And I would wanna suggest a few from my own work. One is housing. There is a grievous need in this country, a deep unmet need for affordable accessible housing affecting many, many sectors, including when you think about millennials and other people who are going to, who are being hit so hard by this pandemic and its economic effects. And we have to deal with this. I'm part of a work that is at the Harvard Joint Center for Housing Studies where we've created an aging housing and public health research and policy network to try to learn from COVID data to bounce forward as my colleagues say. How do we apply this pandemic data showing us what we knew about the disparities to address these longstanding problems of the failure to plan for the society we have which is an aging society, the failure to address the incredible disparity of the wealth gap between people who've been able to buy into housing markets and people who've been lifelong renters. And one interesting issue of course is now that because of lockdowns, we all know that housing is a site of health very dramatically the digital equity challenge but sometimes called the digital divide which has been, there's some very interesting policy work going on this in Massachusetts but it's being studied throughout the country. We definitely has applications to health and wellbeing and opportunities when we see it with respect to education with health I would suggest that it's way more than telehealth. It has to do with social connection and your ability to be part of a community. Another area that of health equity that doesn't necessarily go directly through health justice through healthcare systems is the chilling effects of immigration policy which affect every aspect of the lives of immigrant households. We may have a new administration we may see new policy directions but some of the habits of avoiding any setting where you are afraid you're going to be asked who you are or why you have a right to be somewhere is going to take some time to undo that and definitely I think partnership with community based organizations, FQHCs that are trustworthy among communities that have been made to feel terrified about being immigrants is going to be a long-term task in our society. And then a third is the conditions of work. Decent jobs are often healthcare jobs. Areas of growth are when you see the list of job growth like what is it seven out of 10 or nursing jobs in some way. We need to figure out how to make decent jobs outside of hospitals, especially in the home care sector where there are, this is a profound area of inequity of very racialized type of job where and a very gender type of job where it can be harder to figure out how to improve the conditions of work in part because people may be working for private agencies they may be working in the gray economy working directly for an employer and it's harder to study that workplace. So that's a difficult challenge but it needs to be on the agenda. And with that I'll conclude my remarks and I turn it back over to Charlotte. Thank you. Thank you Nancy for bringing together all these important threads and strategies that are common to the different worlds that we have represented here. I'm also delighted that you mentioned Lauren Taylor who will be presenting in this consortium in the spring of 2021 so stay tuned. So everyone we are now entering the discussion period which will have three phases. First we're going to invite the speakers to ask a question of fellow speakers if they want to. Then your consortium co-chairs would like to exercise our prerogative to pose one question each and then we'll turn to audience questions which will be curated by Kelsey Barry. So first let me note there that audience folks please we encourage you to use the Q&A at any time. We've reserved a fair amount of time so we really can be responsive to questions and that's often one of the most important parts of these consortia since we really are building a community here. So please feel encouraged. So first do our speakers have questions they'd like to ask each other. I think we'll invite Nancy to go first and work in the other direction from the original order. Sure I think for my physician colleagues one question or observation I would have is and this is again comes from my work in immigrant health and in particular in interactions with the immigrant health and cancer disparity center at Memorial Sloan Kettering which is both a research center but a powerful network throughout the five boroughs of New York city. And when they have they've opened a free plug here their monthly health equity round tables to the public as well. So those are tremendous gatherings. And when I was asked to present to them just before the pandemic hit I was asked to talk about a very, very complex case and it was very interesting to hear from like the interpreters and the pro bono attorneys and other people like that all of whom were experiencing moral distress about this very, very difficult case involving an immigrant household. And one of the things we got at was that none of the norms of good cancer care were possible in this case. You could maybe figure out a way to provide good cancer treatment through charity care and other measures but none of the things that you were told you should do for a cancer patient do for a family caregiver do for a situation where there was a child provide good social support and so on you could possibly do in a situation where there was a deportation order in the family the breadwinner was working at a nail salon and the childcare was also in the nail salon. There was nothing, you know and that was part of the distress. And so I wonder sometimes, you know in terms of flipping some of the these narratives about why where the, as David was talking about whiteness is the default and also middle class or privileged status is the default and insurance is the default rather than saying why don't people take advantage of these things is saying, you know what are all of the ways in which societal inequalities are making it impossible for people to give or receive good care. So that was just one observation that really it churns up clinicians and the phrase moral distress doesn't really capture it. This is David and just the more I'm in this field so naming things explicitly saying the right words which I talked about for many years ago I would talk about other segregation there's disinvestment the words themselves didn't quite name what was going on. So now I talk about white supremacism I talk about oppression and words that, you know if you don't feel comfortable in the audience saying these words practice in front of a mirror like I said saying it doesn't make it better but here's another thing Don Burwick just wrote a terrific editorial on the moral determinants of health. Okay, I just want to put that out there and of course those of us who choose these fields choose it out of sort of this moral ethical impulse and then find us in facing systems of oppression ourselves for their political determinants of health and to think that a lot of people don't think oh gosh I don't want to make this political is that there are political determinants of health and the conditions under which people live, work and play or how power and resources and money are shared or at the root cause of the problem here. Now in an any individual situation we've got to look at the resources of the institution. So we have these boxes, right? We've created these boxes, clinics, hospitals if we're thinking about what Kedar mentioned about taking on the structural in social and other determinants of health we have to think about that our work has to be deeper, wider, beyond what we thought I call it stitching back public health back onto this work but it also includes the getting that voice of the community and advocating for the kinds of resources that people in our community need. It's inherently political, it's inherently economic and it's not been the comfort zone of doctors or nurses or health institutions but we have to push across that horizon. Kedar mentioned that disproportionate spending in this country on health versus the other kinds of services well that's a matter of public policy as well. So I think it's, we have to push our institutions beyond what they're comfortable doing by saying yes or providing services that we otherwise might not have provided because it's critical to the cancer care or other care but also we have to push our political systems to make this more equitable broadly. Most of this is not about healthcare. It's about the other things. And I just add to David's comment that I think this distress that you describe Nancy that the provider would experience in a circumstance like you just outlined trying to provide the best possible care for an individual that's suffering multiple complex clinical, social, economic in the broadest possible sense challenges leads to I think a sense of hopelessness of the individual practitioner or clinician. And the route to that I found to helping to get through that is there's two important things to remember. One is that you're actually not alone in this process. If we think about the assets that are truly available to us and we look beyond the doors of healthcare and beyond the borders of our clinical environment there's actually a considerable amount of asset available to us that could be marshaled to help significantly alter these circumstances. And some of what David's doing in Chicago with West Side United and a variety of other things leads to that type of a wider consideration around allyship. It's this notion that we can all be partnered together on some of this, but in the clinical encounter itself I think we start to ask ourselves importantly what can be done and what truly matters to the individual patient. A lot of this comes back to something that Lachlan taught us at IHI and that others have taught us with this idea of asking the patient what truly matters to them and then building the treatment course and treatment plan around the response to that question. Because too often we come into those clinical circumstances with a treatment plan and we're trying to figure out how to administer that treatment plan to the individual and it runs into all of the challenges that you just described. But instead if we come into that clinical circumstance with the question of what really matters it might alter the nature of our conversation with the individual that we're working with and trying to solve for. And that I think is a very significant difference in how we approach the encounter that is actually not only fundamental to just getting people better care writ large but also fundamental to whether or not we can get through our own unconscious and conscious biases. And you can design this in. So a couple of us, a couple closing points as Nancy has a terrific question, right? So you can systematically design in asking the question. The chief complaint we learn in medicine is saying what's the matter but you can design systematically into your systems what matters by screening people for what matters when they come in the door. Number one, two, design into your systems of care. The resources to support the kinds of thing that matter to your patients and communities by actually asking. And then three, working to change policies that produce these things. I got to tell you, those things are antidotes to burnout. When you feel like you have the ability with others to make system change together. And I do think so when doctors are reduced to just what they've been trained to do, it's really painful the burnout and the despair and the moral distress and nurses as well they feel but when you can be activated in a broader community that's why I'm such an optimist in this work as my career has taught me that community and engaging in these broader ways can bring change. It's not always easy, but it also along with it is a spirit of hope. We often operate in this country from a deficiency versus an abundance frame and we have an abundance if any country does to solve these kinds of problems. I have a question. So this is, I'm gonna be a provocative question. So, since I learned about my whiteness I'm very sensitive to like how things get set up and why. So I wanna ask the question why when we set up this panel did we not have a person of color voice at this table? And then was that part of a consciousness of setting this up or voice of the community at this table? Just to think of, we're talking about ethics and equity that how our tables get set up is a critical question. So just to put out there for all, now I didn't ask and I say my bad for not sort of asking that in the beginning say, gosh, wouldn't this panel be better if we did this? And maybe I wasn't on it and someone else was. So I wanna just put that out there for our panelists just to reflect on for a second. I mean, by me a person of color those who've not been assigned whiteness in this KDAR to you, please, you know. But I do wanna just put that out there as a kind of a provocative question like how do we get here today on a panel with this topic with us? Well, I mean, so to address my ethnicity or race in the comments. So I am Indian-American, yes, but you're right. I've enjoyed many of the benefits of white privilege as well. And I think that's really important to understand. To be clear, I've experienced some of the benefits or whatever the antithesis is the negatives of not being a white person. But I think it is important to understand that there are ways in which we construct all of these environments. And this one included in which we don't necessarily include the voice of the community to be short which is certainly not present in the dialogue and at least in the panel as it is represented here. It's a good question. I think it's a really important question for that we should always be asking whenever we construct these kinds of discussions So I did ask the question with the idea that there's a little bit of an answer for this for the future, just a way to think about it. As I'm thinking as a white man who's been in white spaces and just discovered my whiteness relatively recently and that we've developed an equity tool that you can use. So in patient safety, there's a just culture tool that's widely used. It basically says if there was an act with a terrible outcome and it was a malicious act, you need to punish the individual. But if it's a system process, you have to actually address the system. And so there is a way to frame when we make decisions all of our policies or all of our decisions is to ask a question like how does this and I'm doing this is not to criticize anyone on this phone, there's a way for us to think how does this decision we've made to assemble this group of people reflect historic injustices that perpetuate white on top, black on brown on the bottom, men on top, women on the bottom, it's a lens if we could all and so we're trying to apply these lenses now to our policies, our policies, our patients, our policy about our employees. But if think about if we really want to dismantle systems of oppression, if this was an all male panel, we would say something drawn with, I'm just saying there's a frame that we can all use. But again, a structured approach to thinking about the way we do our work because these are systems of oppression without a perpetrator. And the way we do this dismantling is through active processes, process improvement and checklist. So patient safety and equity are parallel movements that require us to apply form structure to our decision making. And if I could just add a little bit to that, I think the question which we have to just keep asking is what else has to change in order to make a space inclusive and welcoming? I was asked a few months ago to give a talk to a patient and family advisory council at a specialty hospital. And one of the questions that people got around to is, and I couldn't see everybody on screen, but they said, everybody here is white. And we never are able to get anyone who is non-white to join the patient in fancy. Specifically, they said, why doesn't anyone black ever join the patient advisory council? So that was seen as like, I've talked with colleagues who are black bioethicists and they'll say, we really don't love the language of underrepresented, it suggests we're not showing up. Like we're not doing our fair share or something. So we should be aware of that. Like that wasn't, that, whose problem was this? Like we're not diverse enough, it's not doing, so you have to solve the problem. So we talked and talked and talked. And at this hospital, I happened to know that there was a very active program supporting immigrant families. And fortunately, there was a person from that program who by luck was at this patient and family advisory council meeting. And she made the suggestion, I work with lots of patients and families who are black and brown and they have immigrant status and often under insurance in common. Perhaps if you would change certain things, the white norms about how this group operates, there could be an opportunity for a different way of thinking about patient and family advisory councils. But it wasn't just the both groups were going to have, the one group was gonna have to feel safe that it was okay to take part in something. They were used to being with a very trustworthy group at this hospital that was focused on immigrant health. But also the other group had to decide that its goal wasn't just diversity. They had to, they had to, and they were giving it a think, it was going to be a process. Yeah, and I think that's a really important point, Nancy, I appreciate what you're saying there. Could I ask my third question perhaps, Charlotte, or do you wanna go somewhere else? I could just respond also to, add a comment to David's really important question and to Nancy's response and yours, I would just say, and the same is true for panels on any topic, doesn't have to be about equity. And that has been part of our thinking about planning the whole of this academic year. And you'll see varieties of diversity in different programming here. But I just think it's really important that we are aware of the talent that exists as well as the need to hear from people and that it be incorporated completely. I think our whole consortium co-chair group agrees that this is important and I'm glad that you raised it. And maybe before Katie goes to the last point I wanna make is whose job it is to raise the question and you could say all of ours. It's up to those who've been assigned whiteness to act to do that. And oftentimes the safety feature, the safety in the room who's feeling unsafe is often white people. We just have to get to the root of this and all of us in how we do this work because we can't advance our systems without doing that. So thank you. Thanks. Katie. Yeah, you know, one thing that struck me Nancy when you were speaking about the collaborative that you're working on in Chicago and in the Bronx and you're talking about the experience of safety and the language of safety and quality as it referred to immigration and refugee health. And in some ways what I maybe I heard you say was the fact that the language of quality and safety removed the politics I think is what the phrase that you use. And it took some of the heat out of that on some level and it made it a solve perhaps a solvable problem. It took some of the difficulties of a massive social problem like immigration reform or refugee health and it distilled it into solvable elements. And that's the beneficial side of that, that illusion to quality or that reference point to quality and safety. The negative is that it sanitizes the story a little bit. And I struggle with this a bit and I'm asking both you and Dave and this question. And the reason is, the reason I think that is because quality and safety are very palatable to white supremacist work cultures, right? We get quality and safety, we understand it. It's legible to our institutions and it's workable to talk about racism and the kinds of things that we've also been talking about in this conversation is far more threatening and you might be regarded as impolitic or impolite and might disable the dialogue. And yet we also have admitted in this conversation that doing so is important and we need to be able to do so if we're ever gonna get through this. So how do we navigate this? I mean, this is the question that I also am up against. I believe that quality and safety methods and approaches is really important to how we tackle these trauma, but I also believe it might change the message. You might sanitize it, make it easier for people to tolerate. How do we manage that in our dialogue? Yeah, I think exactly. I think it's a moving target because when we first hit that realization, like let's see what we could do with the concept of safety and quality improvement as something that already exists. This was back in two years ago. And it was interesting how the clinicians because of their experience of learning collaboratives, obviously of the IHI approach said, well, we recognize that these are valued by our organizations. They're valued by leadership. Leadership has to take part. So it won't just be me burning myself out on my little project and not getting any credit, not being able to collect any data. So they were thinking very strategically and they were saying, you get kudos if you're a leader on this or that. So that may be a way to involve people and especially to get leadership interested in something because they knew from their own experience what had failed. I mean, these were very savvy clinicians who said, I know exactly how far I can get with my own email list to solve a patient care problem. And it's like this far. And these were people who were in places like Massachusetts and New York but that in other states, there was even less ability to do anything. So people resorted to workarounds. So in order to get things on a more recognized basis, rather than this kind of secret status of working on issues having to do with undocumented immigrants, you had to acknowledge that your system cared for undocumented immigrants. You had to engage with the data, Lea Zalman's work, that these immigrants were not a drain on the system. In fact, they contributed to Medicare and Social Security disproportionately because they were not going to be able to take these funds out. But now, of course, you do have to situate this in terms of talking about social inequality. You have to, as David was saying, you have to be able to name the problem and saying that this is part of this without putting one group against one another to say we have stratified systems. White privilege means that means there are subordinate groups. And we often treat immigrants as an exploitable worker class. The philosopher Michael Walzer has said, democracy shouldn't want live-in servants. We shouldn't just say there's this group of people who won't have rights, but we expect them to be there to do the dirty jobs. We totally want them to be there. So how do we talk about that while not tripping over the third rail of amnesty or something that is going to freak people out? Because that becomes a problem. That becomes a problem to talking about this with donors. That becomes a problem with talking about this in the larger community. We don't want to mush everything together. And it's easier to talk about this in Massachusetts or New York than it is in some other places. But it is part of our conversation. We can put it in public health and talk about problems of othering, problems of us and them. And that has a very long history in this country. But to get it back to, I do think that thinking about this in terms of improvement and innovation is important because I think the idea of doing a good job in caring for immigrant patients is important to people who do that every day. They don't want to have to do a substandard job or a work-around job. They want their work to be as good as any other area in healthcare, whether they're generalists or whether they're specialists. So I think that's important. And I think I would imagine that's the same for people who care for people with dementia, for people to name another marginalized population, to care for particular geographic communities that have large housing project populations where there are all sorts of barriers. You want to do a good job caring for this community and you want this community to experience social justice. But so I really like what David was saying is you want to give clinicians who have a lot of things to do opportunities to be involved in social change and not feel they have to do it as their own special project. Nancy, thank you for that and all of the panel. This has been a really stimulating round from you. As co-chairs, we've decided that given the time, we'd like to take a question from the audience before we go to our own. And Kelsey, would you like to see what you're seeing in the Q&A? Sure, this is a question for all three of the panelists. That's quite summative. So from Dr. Lachlan Faro, asking whether each of you could name up to three, although you can name fewer, concrete things that should be true by one year from today that would be convincing proof that a health system is taking health equity, including racism as seriously as they should. Or if they are not taking health equity seriously enough that would be evidence in that regard. And I should probably jump in as moderator to say we have six minutes together and I probably have 30 seconds right at the end. I can tell you what we're doing. So that might be, and you tell me if it's enough. So we've named racism, that's the easy part. Many places have it named in, we actually made it a strategy, equity, which I don't like the word equity, it's too vague four years ago. So that wasn't new. But what we're done now is we have a racial justice action committee with a series of recommendations with measurement at the board level, at the leadership level, at the people level within our organization, things like wealth and opportunity to, at our student level, at our patient level and our community level. And we've created a scorecard, which I think we're trying to socialize, Kader and I've talked about that scorecard that actually measures just like the human rights campaign measures health systems on LGBTQX health, one that measures systems on that. For example, does your senior leadership get measured on anti-racism? So a series of very, very specific measures and then commit to improving. So that would be my answer. What we tolerate, what we promote and what we don't measure, we can never improve. Yeah, I'll build on David's points and just say, you can, Lachlan's question, you can interpret in two ways. What can an individual health system, a service delivery or service operator do or what can the health system do kind of writ large across our whole country, perhaps? So I'll answer them in turn, building off of David's point about what Rush is doing and how it's done at a health system, at a service level. I think what you say is exactly right, making health equity into a strategic priority, making it, ensuring that equity attainment is a key part of the strategy. And I'd go perhaps a level further than you're saying, even which would be the tie executive compensation to the reductions in equities. It's actually by and large, we just advocated this for a large biopharma company that's part of the larger health ecosystem. I think if biopharma can do this, I don't know why healthcare delivery organizations can't. So I think the notion that we would have some kind of equity being part of the strategy, measurables being set and then tying compensation to it makes a lot of sense to me. At a macro level, at a whole country level, I'd say that all policies, especially health, and I mean this in the broadest possible consideration, all policies and especially healthcare policies ought to be put through an equity test about whether they would exacerbate or remediate inequities. What's the likely trajectory? What's our prediction about X policy? And just like OMB rates a policy for its economic impact on the overall US economy, I think there's a possible step that could be placed into the process in which a policy is evaluated around its equity impact and its economic impact going forward. Nancy, in one minute. Oh, sure. I think looking, something you could do within a year are opportunities for advancement and mentoring of minority professionals at all levels, including both the professional, the clinical workforce, leadership and also paraprofessionals is important to make sure that people who are working in healthcare, a major employer are experiencing the fruits of anti-racism work. Fantastic. So, Jim Saban, would you like to make a comment? It may not be a, there really isn't time for a question but we haven't had a chance to hear from you and wonder if you would like to say something before we wipe out right now. I'd make a comment based on the question I was going to ask, especially of KDAR. If I understood what you said KDAR, you were proposing or you were suggesting that the obverse of trickle down economics may act within healthcare. I believe you said that when disadvantaged populations and areas of inequity are focused on, there may be universal benefit that we could think of as trickle up benefit. And given the extraordinary explosiveness we've seen around affirmative action which is a social policy designed to attempt to address inequity in so far as there's truth in the trickle up concept. It seems to me that that could be a very valuable tool for us to use. But the overall comment we could make from the perspective of what the organizational ethics consortium has committed itself to is really to thank the three speakers for the way you focused on marrying institutional function, system function, organizational function and crucial goals. The goals aren't left to be out on the street with the protesters. They're brought into the organizations and you've been working on and thinking about how can the goals be built into the fabric of what organizations and systems do. So you're really doing something extremely important and that is not simply preaching or wringing your hands about distress but waiting in with colleagues to do the necessary work. So thank you so much for being with us and this terrific opportunity you've given us. Thank you, Jim. Thank all the panelists and to those of you who attended in the audience. Our website will show future programming and there will be a recording of this session available posted in the next couple of weeks on the YouTube channel for the Harvard Center of BioEffects. Thanks everyone. Good night.