Creating a more equitable health system for patients, physicians, staff and community is everyone’s job, say leaders at Virginia Mason Franciscan Health. Continuous quality- and patient safety-improvement has been a longstanding part of the health system’s organizational culture, and that includes their dedicated focus on advancing health equity, as well.
Building on the pioneering Virginia Mason Production System that takes input from front-line physicians and staff to improve quality and safety while cutting waste, Virginia Mason Franciscan Health has developed tools to systemically address health equity throughout the organization and drive lasting behavioral and cultural change.
The tools, methodology and philosophy behind this work were explained in a recent AMA Insight Network webinar. The webinar is available on-demand (registration required).
Virginia Mason Franciscan Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Members of the AMA Health System Program have access to the AMA Insight Network’s Quality, Safety and Equity community. This virtual forum provides an opportunity for like-minded leaders from across the country to hear more examples of how leading health systems are finding innovative ways to address health care inequities in their communities.
Grassroots effort drives equity
In the webinar, Dane Fukumoto, EdD, education program director at Virginia Mason Franciscan Health in Seattle, explained how the system’s effort to “systematize” health equity in its operations was a grassroots initiative that was strengthened by the support of executive leadership.
The effort began about five years ago and gained further momentum in 2020, said Brandee Grooms, MD, director of the Virginia Mason Medical Center internal medicine residency program.
Dr. Grooms took the post in 2019 and said that the first task residents had for her was to “make a commitment as a program to taking a leadership role in health equity.”
“My biggest fear about saying ‘yes’ was that we would do this work in a silo,” she said. “We're a small program of 30 residents, but I knew that there must be other folks across the organization who were either already engaged or primed and ready to be engaged in this work.”
Indeed, prior to her involvement, Amish J. Dave, MD, MPH, Virginia Mason Franciscan Health’s director of continuing medical education, had organized Proudly VM, an employee resource group formed in 2017 to elevate the care of LGBTQ+ patients. The group identified that access to pre-exposure prophylaxis (PrEP) was not being fully met in the community.
“There were a lot of concerns about whether we were providing the adequate services, especially for our transgender population, but also questions about whether we were providing adequate access to PrEP to prevent HIV,” said Dr. Dave, a rheumatologist.
Proudly VM focused on access to services and also created a sexual history training task force that developed a guide for primary care physicians to help appropriately screen patients to identify those for whom PrEP was recommended.
“We moved on from there to other community engagements and other services that we could provide,” Dr. Dave said.
Developing equity tools
Fukumoto described how their initial health equity strategic initiative focused on three areas:
- Developing new standards for collecting patient demographic information to better understand who their patients were and to learn about the communities that supported them.
- Reviewing language services to determine if they were meeting needs or creating barriers to equity.
- Examining organizational leadership, physician and staff recruitment efforts to ensure they reflected the community.
The next initiative focused on equity, diversity and inclusion training, Fukumoto said, adding that a patient-and-family program helped “us really design the work, so they're an integral part of the voice and the participation of building this initiative.”
This includes the two main tools used in this initiative: the equity pause and the inequity waste wheel.
The equity pause can be either spontaneous or planned.
“The spontaneous equity pause calls out behavior in the moment,” Fukumoto said. “If we see a barrier to equity with patients, with team members, all staff have the responsibility and the safety to do that.”
He shared a slide that noted “Spontaneous equity pauses take the form of: ‘Let’s pause and reflect on how equity may be involved in this process/program/policy/practice/etc. What can we do to increase equity?’”
The planned equity pause is a scheduled discussion on a particular subject.
“So if we have a topic that we want to talk about—inclusion, for example—we provide staff members with an activity, a set of tools that they can use in their team huddles or staff meetings to really go deep into that topic,” Fukumoto explained.
“In the clinical setting, these equity pauses are really useful for allowing multidisciplinary teams that are thinking about things like disposition and discharge planning and readmissions, and some of the stumbling blocks that we're trying to better understand for a patient,” Dr. Grooms said.
Leadership teams are also asked to review evidence that the pauses are being consistently used, how they’re being used, and whether they are making an impact with team members and patients.
Identifying drivers of inequity
The inequity waste wheel builds on the Virginia Mason Production System concept that anything that doesn’t add value for the patient is considered “waste.”
The wheel identifies different types of inequities in an effort to prevent them and the harm they cause. They include:
- Silencing, which covers behaviors such as not inviting or hearing all voices or excluding data.
- Underrepresentation, which hides the contributions or information about populations.
- Assumptions, which includes not asking or not knowing about some populations and accepting that they get less than others.
“We have a process called ‘assumption-busting,’ where we look at all the behaviors that telegraph assumptions about things, and then looks at how can we use the tools that we have to either validate those assumptions or to bust them,” Fukumoto said.
“This is part of our culture,” he added. “All our people are tasked to be what we call 'waste-ologists,’ and they’re tasked to look for waste and to think about how they can eliminate waste in the work that they do.”
Dr. Grooms noted that residents are taught the Virginia Mason Production System and many lead quality improvement or patient-safety projects at Virginia Mason Medical Center and at the King County public health clinic where equity is highlighted.
“The tools get used so that we can avoid baking in new inequities as we recreate the system by which we're delivering care,” she said. “By utilizing these tools, the goal is for us to see it [inequity] before it gets created so that we don't replicate unwanted outcomes.”
The webinar’s moderator, Emily Cleveland Manchanda, MD, MPH, said a critical “frame shift” that must happen more widely within health care is to ask the question: “What are we failing to bring to support this patient?”
That marks a change toward a more patient-focused mindset that asks, “What happens to you and what do you need from us?” explained Dr. Cleveland Manchanda, director of social justice education and implementation at the AMA Center for Health Equity.
“It's not just ‘Do what I say,’ but ‘How can I support you to take this action that will improve your health?’” she said.
Explore further with the “Advancing Equity through Quality and Safety Peer Network Series,” an AMA Ed Hub™ Health Equity Education Center resource that offers 11.75 CME credits in all.
AMA Ed Hub is an online learning platform that brings together high-quality CME, maintenance of certification, and educational content from trusted sources all in one place—with automated credit tracking and reporting for some states and specialty boards.
Learn about AMA CME accreditation.
