Category Archives: Musings

Ferguson

The following post was written by Ken Haller, MD a pediatrician in St. Louis MO.  It is  used here with permission.

Follow Ken’s blog at http://drkenhaller.blogspot.com/ 

#ferguson

In the coming days no one knows what exactly is going to happen when the Grand Jury in the Darren Wilson case hands down its recommendation regarding whether he should be indicted for the killing of Mike Brown. I daresay we all hope for peace and justice, and we all hope that everyone will remain safe.

I have been a pediatrician for just over thirty years now. I moved to Missouri in 1986 and practiced in East St. Louis for ten years. For the past eighteen years I have practiced in St. Louis at SSM Cardinal Glennon Children’s Medical Center. I have always worked in what are euphemistically called “underserved communities.” This usually means people who are poor. This usually means people who are black. This usually means people who are both. I have seen parents endure terrible hardships to keep their families together. I have seen grandparents heroically taking on the care of children years after they thought they were done with childrearing. I have been humbled by seeing kids who have done remarkable things under circumstances that, as a kid, would have sunk me.

Sadly, I have also seen families who have not been able to withstand the pressure of being poor, overworked, and marginalized. I have seen families fall apart. I have seen kids who have developed behavior problems because their brains have to be on high alert because of various ongoing threats in their environments. I have seen parents unable to continue to be parents because of the constant strain of wondering how they can feed their kids and keep a roof over their heads while working two or three minimum wage jobs that do not make ends meet.
I have also read posts on Timelines all over Facebook saying that these people just need to “get a job,” “calm down and go home,” “pull their pants up.” These commentators have all been white. They do not understand, and do not wish to understand, what it is like to live another reality, one where you are always, automatically suspect, one where you will not be shown houses in certain neighborhoods, one where your family had no alternative but to send you to a crappy public school. They know that they are doing better than the African-Americans who live a few miles away, and they actually believe they deserve it. They believe that their relative success is all due simply to their work ethic and their good choices. They do not believe in White Privilege, i.e., that being white in America confers certain advantages over non-white persons, because, when you have it, it is nearly invisible, and if you know you have it, your first reaction is to feel really guilty about it. So they deny it because it’s initially too painful to accept it.
But it’s true, and I know how I benefitted from it. I grew up in a safe, white, middle class suburb on Long Island, with excellent schools (our high school had a full time Russian language teacher), lovely parks and beaches, dependable pubic services, where my dad had a good-paying job as an aerospace engineer that he got as a result of a college education on the GI Bill. All that prepared me to go to an excellent college where I got scholarships and to medical school to do the work I am privileged to do today.

I could tick off, one by one, how many of those advantages are withheld from the kids who come to my office, as well as from their parents and families. The strange thing is not that Ferguson is happening; it’s that it’s taken this long to happen.

As I said above, I am a pediatrician. And in that role, I just want to make one plea to anyone who reads this about what may happen in the coming days: I would ask everyone who may be involved in public displays over the next few days to be aware of how this will affect the children in your lives.

Children are not just small adults. As we learn more about child development, we know this to be true on every level: physical, psychological, cognitive, emotional. What children need – and the younger they are the more they need this – is stability, predictability, and a feeling of safety. As a species, humans are altricial, that is, we are born more immature than just about any other mammalian species our size. That means that babies need nurturing, caring, feeding, swaddling longer than do infants of other species. The payoff, of course, is enormous in terms of intelligence, creativity, and the ability to love. Part of that process, though, requires that children know who will be tucking them in, who will feed them, who will bathe and dress them, when that will all happen, and who will love them. They need this to be the same from day to day, as much as possible. They need all this because they are trying to figure out how the world works. As infants mature from beings who, at about two months, smile at everybody, to babies who, at around six to eight months, begin to know who loves them and to choose them over strangers, to toddlers who will run off and jump and climb and fall at the slightest provocation, children have unique needs are various stages of life. What does not change is that they always need to be supervised, and they always, always need to feel safe.

So to those who will choose to be part of a demonstration, I respectfully hope that you will choose not to bring your children. While I completely understand the desire that your children should be witnesses to history – and I have no doubt that Ferguson will be part of the litany that now includes Selma and Montgomery – young children will not remember this. Their brains are not wired to retain clear memories during the first few years of life. Everyone in St. Louis and around the world knows that the only thing we can predict about the upcoming days is that they will be unpredictable. And that is not an atmosphere that is healthy for kids. If they see their parents yelling, being yelled at, being assaulted, they will experience only fear and threat, and that is never healthy for a child. I know you love your kids, and you are doing this to make a better world for them. Please leave them with a responsible adult. Please make sure you get home to tuck them in. Please tell them the stories of these days when they are old enough to understand the sacrifices you made for them.

And to those in law enforcement, if you encounter demonstrators with kids, please be aware of how your interactions will affect these children. One thing that has amazed me, both before August 9 and since, is that when I ask African-American kids who come to visit me in my office what they want to be when they grow up, a significant plurality of the boys say, “Police.” So many of these kids already see you as people of power. Please do all you can to make sure that your interactions with them and with their parents leave them with a sense of respect for you and what you do, rather than fear.

I truly believe that both demonstrators and law enforcement want to assure that everyone remains safe in the coming days. I truly believe that both demonstrators and law enforcement are doing what they do to make the world a better place for our children. And I truly hope that everyone will keep their kids at home where they can be safe and be best prepared for this better world to come.

– Ken Haller, MD 11/19/2014

Follow Ken’s blog at http://drkenhaller.blogspot.com/ 

 

Have Soapbox; Will Travel

By Amy Wilson-Stronks

Last month I delivered the keynote address at the American Medical Association’s Fall 2014 Commission to End Health Care Disparities Meeting. I was flattered to be asked to speak to a room of accomplished healthcare professionals who are leading efforts to improve healthcare by addressing healthcare disparities. I envisioned this as an opportunity to share some observations made during the years that I have been working toward the same goal/directing efforts in the same direction.

Specifically, I saw this unassuming audience as an opportunity to get on my soapbox, a position I find myself on with increasing frequency as I continue to work in healthcare. The title of my talk was Putting Patients in Patient Safety: Lessons Learned.

When tasked with delivering the keynote, I was told to “ ‘ignite’ the audience; give them something provocative to consider, something that will keep them awake during this dinner time presentation”. Since the focus of this group is the reduction of health disparities with the ultimate goal of eliminating disparate care, I believed I could deliver.

Why? Because fundamentally, our current systems are so flawed that none of us will EVER be able to eliminate disparities for any vulnerable or underserved group. I envisioned this message: Give up, we are wasting our time!

No, that was not my opening line. But beneath my remarks, that sentiment muttered like a mantra; it was the gist of my talk, whether articulated or not.

Why am I so negative? Several reasons. And, yes, these are points I shared with my esteemed colleagues.

There is no such thing as racism, sexism, (Insert any “ism”) .
“Not in my backyard,” “We treat everybody the same.” It would be short sighted and inaccurate to blame healthcare organizations for racial, ethnic, and other healthcare disparities. However, since health care is received at healthcare organizations, they necessarily are essential to the solution. Yet, many do not believe that they are culpable, nor do they think it is a problem that they need to address as a priority.

If our care organizations are not interested in evaluating the care they provide to various population groups that have been identified at the national level as suffering from health and healthcare disparities, then how will we recognize when we are doing things right? I have found that many healthcare organization leaders are not aware what is happening across their organization during patient-provider interfaces. They may set expectations that all patients are treated with dignity and respect, but they aren’t told, nor do they observe the Emergency Department staff comment, “Oh no! Not another Ebonics. I wish my shift would end already!” They don’t realize how unconscious and conscious bias can create a chasm between providers and patients from different racial and ethnic groups. And the bias isn’t only between providers and patients, but also among employee groups, as one HR professional once confided to me when asked about the lack of racial diversity in his organization,

“You know, the blacks (employees) really need to get over (themselves); Slavery was over a hundred years ago.”

Yeah, I guess we all need to get over it. But that won’t eliminate disparities.

Meaningful Use isn’t Meaningful
Meaningful Use is designed to establish a degree of data accessibility across the healthcare system to support care transitions, improve data access and communication, and improve systems for monitoring and evaluating quality by introducing uniformity and compatibility. This makes sense. And it is necessary for us to really understand how healthcare disparities present, what causes them, what removes/improves them, etc.

Unfortunately, the data necessary for us to address healthcare disparities are rarely captured, and if captured, they are rarely accurate.
“Only Press Ganey Data Matter”
“We have the data field right here.”

We need to incite collective action to incentivize the vendors of Electronic Health/Medical Record (EH/MR) systems to create adaptable programs for the collection of data on patient race, ethnicity, and preferred language. To the AMA, NMA, NHMA, AHA, and all others working to improve healthcare and advance equity– please join us on our soapbox.

If we still can’t get this right after more than 10 years, how are we ever going to effectively collect data on sexual orientation and gender identity?

Our Systems of Care Aren’t Designed by Patients
“If you listen to your patients CAREFULLY they will give you the diagnosis; if you listen a bit longer they will give you the treatment”

“Only physicians are capable of judging what is or is not good medical practice. Patients and hospital personnel may learn to recognize good practice but only the physician can accurately evaluate its quality.”-Explanatory Supplement to the 1965 Joint Commission Hospital Standards.

“Well, when I am in their room and they are all talking in another language I feel uncomfortable. I feel as if they are talking about me. I don’t like that.”

“Although my doctor knew all about me, each encounter with new people—with blood draws, ultrasound, breast x-ray, etc.—had the basic anxiety of the procedure and layered on to that, the possibility of homophobia and having to watch out for myself” ¹

If patients cannot communicate with their caregivers, then caregivers can’t do their job.

Unfortunately, many things complicate communication, such as trust, fear of hospitals, cultural beliefs and practices, conscious and unconscious bias as well as basic human assumptions. Healthcare professionals must involve the patient in every aspect of their care and not make any assumptions.

This drives the work we do at Wilson-Stronks. We want to Improve Healthcare. And we know that the only way to do so is to work collaboratively and act collectively. This collaboration and collective action must involve our patients. We were honored to be asked to share some of our experiences “in the world” with the AMA Commission to End Health Care Disparities.

¹ Margolies L, Scout NFN. LGBT Patient-Centered Outcomes: Cancer Survivors Teach Us How To Improve Care for All. April 2013.

Note: All other quotes are reflections of my thoughts from information that others have shared with me.

Language Access News

Posted by Amy Wilson-Stronks

It has been several years now since new and more specific accreditation standards were implemented by The Joint Commission to support the provision of interpreters, translated written materials, and other communication supports for people who have limited English proficiency (LEP) or are Deaf/Hard of Hearing (DHH). In that time, we have been keeping our eyes, ears, and fingers open for trends in language access. Recently, we learned of a voluntary resolution agreement between Mee Memorial Hospital in California and the Office for Civil Rights that resulted from three complaints “filed on behalf of three Mexican national origin individuals whose primary language is Triqui-Bajo. The complaints contend that MMH failed to provide the affected parties, who are limited English Proficient (LEP), with effective interpreter services and thereby discriminated against them on the basis of national origin, in violation of Title VI of the Civil Rights Act of 1964.”

Citation: http://www.hhs.gov/ocr/civilrights/activities/agreements/mee.html

Through the compliance resolution, Mee Memorial agrees to a number of provisions including establishing a Title VI Coordinator and Coordinating Office, providing a “sufficient number of dedicated staff,” and creating systems that ensure, “that the primary language of each LEP patient is clearly identified in the patient’s medical record” and assuring that language access resources are available and accessed in a timely fashion. The provisions continue, but what is of most valuable note is that these provisions mirror those of a comprehensive Language Access Plan. It is unlikely that Mee had a Language Access Plan in place. If they had, they would have purposefully planned resources and designed policies and procedures based on meaningful data explaining community and patient language needs. Unfortunately, most hospitals and healthcare organizations have a “policy driven approach” that leaves out thoughtful planning for needs, resources, and processes for monitoring for improvement.

If your organization needs assistance with Language Access Planning, please contact us. We would love to help you proactively improve healthcare for LEP patients served at your institution! Contact info@wilson-stronks.com.

Population Health and Culturally and Linguistically Responsive Healthcare

Posted by Deborah Caputo Rosen

We have been thinking about population health at Wilson-Stronks LLC. Soto notes, “(M)any see attention to population health as a potent opportunity for health care delivery systems, public health agencies, community-based organizations and many other entities to work together to improve health outcomes in the communities they serve.” (1)

Although there are a variety of definitions of population health they share some common themes. Population health has a wider scope than traditional public health because it explicitly includes the health care delivery system itself, and its accountabilities. Not only are health outcomes measured but also the factors that influence them—social determinants of health and disease prevention efforts. A population health management focus includes the active reduction of health disparities and the pursuit of health equity.

Health care administrators have taken a renewed interest in health promotion and disease prevention. One of the drivers for this has been the Patient Protection and Affordable Care Act (ACA). Regardless of your political opinion of “Obamacare”, the law creates structure that motivates healthcare organizations and realigns their interests. Increasing insurance coverage increases access; especially for populations traditionally disadvantaged from preventative services, screening and the resultant early case-finding and improved outcomes (with associated lower healthcare and societal costs).

CMS and the Patient-Centered Outcomes Research Institute, among others, plan to track and study patient results as a research-based means to improve quality. The ACA includes a variety of approaches to increase both the quantity and quality of primary and preventive care, including the development and funding structures of Accountable Care Organizations (ACOs).

A new IRS requirement under the ACA mandates health care organizations and public health systems to engage in community health needs assessment every three years. Communities, including their health needs and health resources, must be described along with a prioritized implementation strategy to meet those needs. Both health outcomes and accountability measures are required.

One size does not fit all” is the lens through which Wilson-Stronks always has advocated and offered services. The new reality of the world of health care provision requires that the population eligible to be served must be identified, its needs and current resources characterized, and the interventions individualized to meet those needs. This offers renewed opportunity to consider culturally-responsive and linguistically effective communication in the design and delivery of care.

Finally, target outcomes must be identified, risk-adjusted metrics developed and mutually accepted and information must be sharable to promote evidence-based promising practices. In the highly competitive and diminishing margins of health care provision, patients and providers alike will benefit when, to quote Thomas Friedman’s book, The World is Flat.

1. Soto MA, “Population Health in the Affordable Care Era”. Academy Health, 2013, pp.2-6

The Plight of Limited English Speakers: Role Reversal

Fluency, Inc., the sister company of Language World Services, Inc. recently released one of the most hard-hitting, powerful short films Wilson-Stronks has seen demonstrating what it is like for limited English speakers to try to receive health care in the United States.

Please watch this and share it with others you know working in the health care field.

http://www.youtube.com/watch?v=uEfrsSqZ-9s&feature=plcp&context=C466ed30VDvjVQa1PpcFPQXFVh0qAqT6EZ845_XnkTbzvgO6V4Pps

NQF Endorses Measures of Health Disparities and Cultural Competency

The National Quality Forum (NQF) has endorsed 12 measures of health disparities and cultural competency, seven of which are contained in the American Medical Association’s Communication Climate Assessment Toolkit (C-CAT)!
This is great news! The C-CAT is an excellent tool for healthcare organizations to measure how they inhibit or enhance the flow of crucial information. It is one of the tools mentioned by The Joint Commission as a way to improve patient-centered communication. More information about the C-CAT can be found at www.ama-assn.org/go/ccat.
To share this good news, the AMA has put together a press release that can be found at the following link: http://www.ama-assn.org/ama/pub/news/news/2012-08-13-nqf-endorses-ama-measures.page.
The press release developed by NQF to communicate the endorsement decision can be found at the following link:http://www.qualityforum.org/News_And_Resources/Press_Releases/2012/NQF_Endorses_Healthcare_Disparities_and_Cultural_Competency_Measures.aspx

HHS announces refined survey standards to examine and help eliminate differences in care based on race, ethnicity, sex, primary language, or disability

Today, the US Department of Health and Human Services announced final survey standards for the collection of race, ethnicity, sex, primary language, and disability status for surveys administered by the department. This is a great advance in efforts to better discern health and health care disparities in different populations. Read more at

http://www.hhs.gov/news/press/2011pres/10/20111031b.html

LGBT Webinar Archive Available https://www2.gotomeeting.com/register/728441986

In partnership with the Human Rights Campaign Foundation and Wilson-Stronks, LLC the Hopkins Center for Health Disparities Solutions offered a free webinar tilted, Advancing LGBT Patient-Centered Care: Strategies to Create an Inclusive Environment on October 11, 2011. The archived webinar presents the business case for building an inclusive environment for LGBT patients and families, shares strategies and a framework for action, and provides an overview of the Health Care Equality Index as a useful tool to begin creating an inclusive environment.

To view, please visit

https://www2.gotomeeting.com/register/728441986