Using the Lens of Health Systems Science to Achieve Health Equity

Good afternoon everyone thank you so much for joining us today we really appreciate your time i'm going to introduce our guest speaker for today's dean's forum session um with us today we have dr roslyn native beester she is an assistant professor of obstetrics and gynecology she's the associate director of the women's health division and the director of health system science medical education at the university of michigan she's a michigan native who earned her undergraduate degree at the university of michigan she pursued a dual degree in medicine and public health at the university of michigan medical school and school of public health she completed her residency training in obstetrics and gynecology at the university of michigan as well she then worked as a general obstetrician gynecologist in the metro detroit area prior to returning to the university of michigan to join the women's health division in 2015. she's an active member of the american college of obstetricians and gynecologists advocating for her patients and fellow ob gyn providers she's also a board member of the michigan council for maternal child health and serves as the director of ob gyn resident quality improvement education at the university of michigan her practice encompasses general obstetrics and gynecology her special clinical interests include family planning abnormal uterine bleeding lower genital tract dysplasia health education and health policy join me in welcoming dr maven bister thank you so much for that kind introduction and uh thank you all so much for having me here today um the topic of my talk for today will be about using the lens of health system science to achieve health equity in terms of objectives for today's talk we will be defining health equity and making the case for addressing health inequities in the context of improving the overall health system explain how societal and system 11 level trends impact the evolution of the field of health system science review the definition of health system science and its domains describe how competency and health system science equips health care professionals to address societal or systems level concerns such as health inequity and then finally comparing different frameworks that have been described to achieve health equity as well and thinking about them through an hss lens so before we discuss how application of hss can help us to achieve equity we must review what led to the development of the field of hss to begin with and what it is and how this field of study plays a role in teaching future healthcare professionals how to work towards improving health and health care as you are all aware the flexner report which was published in 1910 resulted in significant improvements in medical education it helped to define the competencies that we still are based on today to help teach our students about basic science and clinical science but it was limited in terms of thinking about the other factors that we must consider if we're trying to help our patients achieve health and move away from more of an acute model of care towards chronic management of care as well and population health for a variety of reasons we have needed to look at kind of a different way of approaching all of those factors and health system science is one way to kind of bring all of that together so to think a little bit more about just what is the reasons for thinking about all of these factors i think many of you have probably seen this graphic here but it indicates the total national health expenditures in the united states and billions of dollars between 1970 and 2019 as you can see there's a clear uptick in what we're spending with us reaching about 3.8 trillion dollars in 2019. this correlates with um approximately 18 of our gross domestic product and it also is reflective of the trends that we've seen for patients as well in terms of the amount of outpatient costs that they are seeing as well despite the hefty price tag that we have on health here in the united states we are not ranking well compared to other systems in terms of the overall quality of our system this uh graphic here shows how much money we're sending spending per capita so around 8 500 per capita and then despite that we're ranking 11th out of the oecd nations that are mentioned here however this should not be a surprise to us based on how we're spending our money so when we think about the factors that make us healthy about 10 percent of that is related to access to care 20 related to genetics 20 related to the environment and about 50 percent related to healthy behaviors in contrast though when we think about that 3.8 trillion dollars that we're spending 88 of that is going towards medical services with only 4 towards healthy behaviors and another 8 towards other things and so it makes it clear that we're not really spending our money in the way that we need to to help our patients truly achieve health we also have limitations with regards to who was able to achieve that health we are not performing well with regards to health equity as well and i'll go on to define that a little bit later so other things that are contributing to those differential levels of health are a variety of different social determinants some of which related to where you live so this is coming from a interactive program that is available on the robert wood johnson foundation website that lets you enter the zip code that you're in and then look at what your overall life expectancy would be you can see here that you know both of the zip codes that are entered here in places where there is an academic medical center but the life expectancy is different it differs for both places with ann arbor or washington county having 81 years and roanoke city having 74 years and then they also both differ with regards to comparison to their states and specific and then also to the overall average life expectancy for the united states as well aside from thinking about the actual zip code the type of area in which you live also can impact your outcomes so this is a uh graphic that comes from a paper in which one of my partners was actually a senior author um where they were looking at the predicted uh probabilities of severe maternal morbidity and mortality amongst rural and urban u.s residents between 2007 and 2021. so one thing that is very notable when looking at this is that it's been increasing for all groups across this time period which is really unacceptable we should not be having rising severe maternal mortality and morbidity in the context of all of the advances that we've made with healthcare but it also demonstrated that there was about a nine percent higher likelihood of rural residents having severe maternal mortality and morbidity controlling for socioeconomic factors as well which is pretty disconcerting in addition to uh thinking about where we live the kinds of jobs that we have and our social economic status have an impact on our health as well so this graphic is uh actually an old one from a paper that was published by marmot at all about the white hall studies and so this was a longitudinal epidemiologic study where they were looking at the health of british civil servants that began in the 1950s and then went on for many years after that and the data that was collected showed that there was a clear relationship between the employment class of the people working for the british government compared to their health in specific it was a linear stepwise correlation so the um higher someone was up in that ladder the more likely they were to have better health and on the opposite side the lower they were on that employment ladder the less likely they would have good health as well there's also differences related to education level and so this chart is showing the remaining years of life for us adults at age 25 based on educational attainment so you can see here that as someone becomes more educated their years of life are increasing and that is true irrespective of gender this doesn't break out for racial and ethnic uh differences as well but there are some that exist there too and this is significant when we think about like what is the typical education level for you know someone who lives here in the us the people with graduate degrees is only about 12 percent uh college graduates about 20 percent some college 29 high school graduate 27 and then 12 with less than a high school graduation and so these really play a role in terms of like how long that person can live and how what their health looks like over the course of that time period as well aside from changes related to where you live education status and financial status there are also differences which i alluded to with regards to race and ethnicity as well this chart from uh peterson and the kaiser family foundation shows that mortality rates are higher than average among infants born to mothers who are black american indian and alaskan natives and pacific islanders which is unacceptable i should be unmuted now um so in terms of other things around racial and ethnic disparities the kobit 19 pandemic really shined a light on um just how big a deal these things really are uh this graphic here shows that the risk of infection hospitalization and death uh related to coven 19 was higher in those who were american indian alaskan natives black or hispanics compared to whites even adjusted for age and so all of these things together really push us to think about are we satisfied with the type of system that we have are we satisfied with the the way that things are going for our patients the differences we see for our patients depending on where they live where they work um you know what their their financial status is and i think that the the answer is no we're not satisfied with this um when we think about what we really need to achieve to ensure that we can say that overall health is doing well i think that's where the term of health equity comes into play there's a number of different definitions that you can see if you look in the literature but i selected this one because i thought it was short and sweet and straight to the point it comes from the office of disease prevention and health promotion and simply states it's the attainment of the highest level of health for all people this graphic underneath it is from the robert wood johnson foundation and is another way of just visually showing what we're trying to get to so you'll notice that everyone is riding on some sort of wheeled device whether it's a bicycle or a tricycle to all get them to the place where we need them to be but what each person needs is not the same i'm pretty short so i would not do well to be on one of those larger bikes and similarly for the person who is on the probably your right hand side my left hand side a tricycle is something that better fit their needs as well and so kind of in thinking about that and thinking about trying to get to better health for all i think we really need to tie that in together with the triple aim which is about improving population health reducing the per capita cost of care and then improving the patient experience of care and it's really hard to envision a world in which we would do any of these things without thinking about how to make this a possibility for every person um it at first glance seems like this is something that maybe is beyond the scope of what we as healthcare professionals should be thinking about um but really if we want to make things better if we want to really get to health which is the reason that we go into this then we have to think about these things and so i think that i've kind of went towards uh establishing the moral case for why we should think about addressing health equity um i think that you know this quote from donald berwick from the uh the let's see journal of the american medical association excuse me on the moral determinants of health really encapsulates where we need to be moving in terms of how we think about ourselves and our role so i'm going to read it to you now healers are called to heal when the fabric of communities upon which health depends is torn then healers are called to mend it the moral law within insists so improving the social determinants of health will be brought at last to boil only by the heat of the moral determinants of health so aside from the moral case to consider for why we should be thinking about addressing health disparities and in turn working towards health equity there's also a financial or a business case for it as well so this table comes from a paper by levis gaskin and richard in which they estimated that eliminating health eliminating health care disparities or health disparities would lead to a savings about 230 billion dollars which is not insignificant when you think about that 3.8 trillion dollars that we spent in 2019 um part of the reason that we see this is because um disparities in health uh result in changes in how people utilize care so for example there are higher rates of complex medical conditions and minorities and those with lower socioeconomic status which results in a higher utilization of care there are also studies that have shown that racial and ethnic minorities as well as those with limited english proficiency are more likely to have an adverse event an inappropriate or expensive test order that's not needed a longer length of stay in the hospital higher rates of readmission and higher rates of admissions for conditions that could be managed outpatient these just encompass some of those but there are others that contribute as well aside from the direct costs of health care disparities or health disparities um there are also some indirect costs as well and so uh this graphic comes actually from the harvard business review and shows that presenteeism so going to work while you're feeling ill and then also absenteeism which is missing work because you're not feeling well all contribute to about 340 million dollars so it's not insignificant when we think about how not feeling well can impact your productivity at work or your ability to even attend work and so taken together there's both the moral and financial imperative that demand that we as medical professionals do something to eliminate these disparities and to achieve health equity and incorporating education and things like health system science and the application of its competencies are one way to go about doing this so in terms of health system science this field has really emerged um as the third pillar of medical education and in response to all of those things i was presenting before high cost cost diminish quality difficulties with coordination of care health disparities all of these things bring us to this point health system science is defined as the principles methods and practice of improving quality outcomes and costs of healthcare delivery for patients and populations within systems of medical care and so by helping to teach our future workforce about this we can help ensure that people will be better equipped to address these concerns when they get out into practice i think there's also importance that comes from educating ourselves about these competencies as well and also our graduate medical education trainees too and so in terms of this framework i think it would be very easy to just say well we're going to teach everybody about health policy so we can do things there or we'll just teach everyone about social determinants of health on its own or just about qi but really when we think about what it takes to actually make a grand sweeping change to what our system looks like you really have to bring together uh different domains in order to do that and so the framework that has been proposed by the ama through their health system science textbook really helps to do that it helps to unify a number of important domains that we need it also ensures that certain areas don't get marginalized so it's not just ui or like i mentioned not just policy it helps establish a foundation for how we think about how we teach this material facilitates a shift towards a shared mental model and national standards so it gives us a way to think about what is competency and all of these things what does it take for us to say a healthcare provider has learned what they needed to learn in order to really be able to apply things and then it also is catalyzing the creation of a new professional identity for uh healthcare providers as system citizens as well so in terms of the content domains i think it's hard to talk about having competency and hss without actually talking about what the different domains are within that the ama textbook most recently showed this updated graphic which includes the core functional domains foundational domains and then linking domains as well and so in terms of the core functional domains at the center we have the patient family and community so really thinking about the people that we're here to help right like thinking about the patients and the context in which they are seeking care and trying to live healthy lives um it's surrounded by things like our health care structures and processes so the way we actually go about delivering that care and the systems we create to do that uh healthcare policy and economics so thinking beyond uh you know just the advocacy we do locally for our patients in our office but like what is happening at a policy level both at our hospitals and our practices and nationally within our states and then also the economics behind how people utilize care you know supply and demand and what that means for people moral hazard and how that impacts how people seek care and how insurance is designed thinking about clinical informatics and health technology so these are the things that help to support our connections with patients so things like telehealth but also help us to collect the data and understand better like what our population is looking like in terms of their health outcomes population public and social determinants of health which we've talked a little bit about throughout this talk thus far really hard to improve health without making sure we're addressing all those contributors value in health care where we're looking at the quality of that care over the cost of care and so that's not just meaning that we're trying to provide the cheapest possible care because sometimes that's not what is the appropriate thing to do from a value standpoint it's about analyzing the data that we have available and using that to figure out what the best course of care for our patients would be and then finally health system improvement so really identifying those problems and going through in a scientific way to understand them better and then also implement countermeasures to address gaps that you identify the next are the foundational domains so this leads to change agency management and advocacy ethics and legal which is something that we've kind of always talked about but is very foundational to what we do leadership so thinking about how we all work together to move towards a common goal the vision and the skills that it takes to do that um and then also teaming so thinking about how we work with the other profession health professionals within our space how we partner with our patients how we partner with our community to be able to improve health and then lastly systems thinking which is a linking domain and really serves to bring together both that core foundational domain and also excuse me core functional domain and also foundational domains it also helps us to think about how do we link together the basic science and clinical science of what we're doing so really allows us to give a holistic approach at things and so in short health system science brings together so many different domains and helps us to evolve to the needs of our society and what that society needs to be healthy or to achieve health and health for all um i think that one thing that's important to consider about that evolution component though is that there are often going to be trends or um events that occur that cause us to need to evolve in the way in which we provide that care and competencies and this help to do that i also anticipate if we were to look at this five or ten years down the road that there would probably be new things that would be included within this wheel so things like the business of medicine and also would love to see uh equity be something that is more prominently displayed here because it's really hard to say we're reaching our goals without having done that so now i'm going to move on to talking about how we can go about achieving health equity and doing that through applying hss knowledge skills and behaviors we'll be reviewing three different frameworks during this time period the first one starts at kind of like a broader systems level and this comes from the robert wood johnson foundation and the university of california san francisco it has four steps but really focus on the goal of achieving equity and health but then also achieving equity and the factors that determine health so in those determinants so the first step is to identify important health disparities that are of concern to key stakeholders so really thinking about that center of the circle about the patients the families the communities that we care for um especially those who are affected by those disparities and identifying social inequities and access to the resources and opportunities that are needed to be healthier that are likely contributing so this means beyond just looking at oh like is there a grocery store in that area or you know have we made parking affordable for our patients but it's really thinking about the structures that are in place that are setting us up to have some of these uh disparities as well the second step is looking at change of policies laws systems environments and practices to eliminate inequities and the opportunities and resources needed to be as healthy as possible so that's really a mouthful it talks about a lot of different things um and i i think that it can sometimes be challenging to think about what role we can play as healthcare providers and impacting these things however you know without our input without us coming to the table providing expertise doing the research that uh proves like kind of what the best course of action is it's really difficult to help educate the people who are helping to write these policies our legislators both locally and federally and so that's really a place where we can uh provide our expertise and be helpful um i think that you know sometimes people also envision um the idea of going and like testifying as part of that which is certainly a component of it too but i think there are multiple ways to go about impacting policies and laws um in terms of our systems so that's like giving feedback to the people where you're working about things that you notice that are potentially making it harder for people to seek care we at our institution have recently been undergoing a transformation with regards to how we can provide prenatal care where we're offering people options to kind of customize their path and do some things virtually and some things in person and you know one of the questions that was asked as we were doing that is with regards to the virtual visits you know what about people who don't have access to be able to do like a video call and how can they be able to um you know participate in this model and we you know made it clear that although virtual for most people in our institution think about video calls um it also includes phone calls too and there's still quite a bit that can be done through that um that doesn't diminish the quality of the care that our patients are receiving but may make it more accessible for them to do that i think the other thing of consideration too about the advantages of doing some of the visits virtually is that it also helps decrease the amount of time that people need to take away from work it addresses issues around transportation as well and so kind of gives us an opportunity to set up a structure or an environment that will help improve our patients health and health increase their likelihood of being able to participate in the care that they need to the third is about evaluating and monitoring efforts using short-term and long-term measures so this is really like quality improvement 101. so we evaluate what's going on we want to monitor and see what the impact is of whatever things that we're in we're using as interventions and look at them both in the long and the short term short term um we're thinking about measures really considering structural process balancing all of those things in addition to outcomes as well and then finally after getting that information reassessing deciding if there is some adjustment that needs to be made so kind of thinking about continuous quality improvement and then moving forward to plan your next steps so the second framework that i'm going to talk to you all about today comes from the institute for healthcare improvement and this one is more focused on what health care organizations can do to help achieve health equity um this uh was something that was informed by uh projects that were undertaken in 2015 so they did four 90-day innovation projects to explore how health systems can impact health equity in their communities with a purpose to design and test a framework for health systems to impact multiple determinants of health and to make significant improvements in health equity in the communities that they serve to help develop this framework they obviously use the information from those innovation projects as well as health equity literature reviews expert interviews site visits and then learning from exemplary health systems on the cutting edge of this work there are five steps to their framework and so the first is making equity a strategic priority the second is developing structures and processes to support health equity work the third is deploying specific strategies to address the multiple determinants of health on which healthcare organizations can have a direct impact decreasing institutional racism within the organization and lastly developing partnerships with community organizations as well and so we're going to take each of these on their own so for the first one for health equity as a strategic priority this really lines up with what we think about when we think about leadership competencies so really helping to set a strategic direction for your organization and then also putting in place things to help reinforce that so one example of that commitment or reinforcement comes from the robert wood johnson university hospital where they actually provide 15 of executive compensation based on metrics related to achieving health equity goals the other is looking at how we do our reimbursement how we do our funding fee for service is something that has been around for a very long time but it doesn't really reinforce the principles that are necessary to achieve improve population health and achieve health equity we really need payment models that are looking more so at how can we um reward people for improving that health and so that would be things like accountable care organizations which i know that you all have here and then also capitation models too that really reward you for interventions that prevent diseases as opposed to just doing more volume of things like a fee-for-service model would the next is developing structures and processes to support health equity work so some of that comes from having a governance committee so when you think about trying to lead a change you really need to think about what is that coalition that comes together to help support and to help lend more credibility to the work that is being done and make sure that we stay accountable to that leadership vision that has been established however it's not just enough to have the coalition and that vision you also have to have the resources so we often you know focus on the things that we have the funding for or that we are getting some sort of reward or incentive to do and so it's really difficult to think about how we can achieve um health equity without actually dedicating resources to work on that and so you know another example coming from robert wood johnson is that they have seven business resource groups where they um support equity work across different divisions and provide funding to be able to impact those things so things that creating activities that impact workforce patients and the community with a large number of their employees participating in these as well third is deploying strategies to address multiple determinants of health on which the healthcare organization can directly impact so i think the one that's the easiest to think about is with regards to health care services so thinking about what we know about our processes and structures within our own health system and how that can impact the health of our patients um this is you know collecting data to kind of have a better understanding about what our disparities are and then what areas we need to target and then creating projects and incentives that help to target those areas that we need to improve i think one thing that's important to think about though as you think about creating initiatives to work on improving things it's important to look at more than just um a change from baseline so just seeing does this one particular group improve you also need comparison data as well because you can very easily put forth an intervention that results in everyone having an improvement in their health status but doesn't actually close that gap with regards to disparities um and so really like people talk about that is the idea of focusing in on the margins to make sure that those changes actually are closing that gap the other aspect is with regard to socio economic status so at first glance that seems like something that doesn't make a lot of sense for an institution to be thinking about but going a little bit deeper when you think about all of the people that are working at a health center there are many different roles that are involved in that you know we have our environmental services we have clerical staff we have medical assistants nurses advanced practice providers clinicians a number of other allied health professionals as well that are all working within our centers and a lot of times these people come from where we're located right like from the community in which we live and so by making sure that we have things in place to help prepare people to be able to come and work for such a large employer like a health care system or a healthcare organization and then also finding the ways to develop those people so that they could move up throughout the organization it's a way of supporting the socio-economic status of the community in which you're located similarly for physical environment so the having a medical center in your area can have some negative impacts in terms of the waste and the pollution that comes as part of that and so taking efforts to look at how you know what the carbon footprint is of the place where you're working and what things can we do to kind of reduce that are very important um they can also undertake different initiatives to kind of help beautify the area as well so walkways and parks as part of like the the campus um as ways to try and help improve the environment for the people that we serve and then lastly is around healthy behaviors which really this is um we can obviously counsel like individual patients about healthy just behaviors and kind of help connect them with resources but this is really focusing more so at the level of the employees so how can we help to keep our employees healthy and encourage healthy behaviors through like incentive programs etc um because one like i said people who work here often live in the nearby community as well but then additionally it is much harder to care for people if we're not taking very good care of ourselves as well and so that could potentially impact our ability to provide high quality care to our patients too the next is to decrease institutional racism within the organization and so when we talk about institutional racism again just to reiterate this is not about individuals but this is about a system in which there is differential access to goods services and opportunities of society based on race so trying to address those structural components that are causing that it really takes uh and it really takes a deep dive into thinking about what are the structures norms rules regulations um and policies that we have um within our institutions that can potentially um impact uh disparities and kind of compound those structural uh barriers that exist um some of it is thinking about just the physical space in which we um provide that care to how our building's designed how easy is it to actually get into the health center um what is parking uh like for patients is it easy to access is there enough of it how much does it cost them you know is that something that's going to be prohibitive i know at my institution our parking is is a limited fee but it's still not free and so for someone who is having difficulty with financial items that can be a challenge as well it also means looking at health insurance plans too so um and this means thinking about the types of insurances that are actually accepted so um most people are aware that with regards to insurers medicaid is one that does not tend to reimburse quite as well as the private payers and then also not as well as medicare and so really it requires some insight into what can we do to help advocate for better reimbursement for the services that we provide so that there's not this uh disincentive with regards to providing care to patients of lower socioeconomic status and so really thinking about what things we can do to impact that and then also thinking about what community organizations we can partner with to make sure that those who are uninsured and underinsured can actually access the insurance options that they would qualify for but may not have been able to access on their own and then finally it talks about reducing implicit bias which i think is important and sometimes gets emphasized maybe more in the context of thinking about racism than maybe what it should but i think that it's still an important thing for us all to consider and this is just the unconscious bias that we kind of all live with on a day-to-day basis and thinking about how that implicit bias is impacting the care that we provide and the structures that we have and so again another important thing to think about as we're looking towards achieving health equity and then lastly which i think this part is one of the most important is thinking about the partnerships that we develop with community organizations to work together on community issues related to improving health and health equity this could be something that's a formal relationship so we have this at my institution where we have essentially service agreements with different areas one of them is a clinic that i go to in flint we also work with an adolescent payer clinic as well that's in the community and then partner with a number of the free clinics in our area too to actually provide providers there to help provide care for these patient populations but also to allow us to uh better interact and work with the safety net providers that are present and also with community-based organizations that are in our area as well it also means thinking about what we do with our money right like there's should be some level of community benefit that is coming from your healthcare organization for those that are non-profits that's a requirement in order to be able to be a non-profit and so so thinking about the financial and in-kind contributions that we can provide to different partnerships in the community to work on improving health for our patients one example that ihi provided was the health improvement partnership of santa cruz county california that has 26 different organizations that are dedicated to increasing access in health care and building strong health care systems one of the projects that they undertook that was successful was working on reducing emergency room use for infants with medicaid insurance so really thinking about how do we work that with that community to be able to implement different programs to improve things and then the last framework that i'll discuss today is looking more at a smaller practice level and so this is the racial and health equity concrete steps for smaller practices that comes from the ama steps forward program and also done in collaboration with health begins so this is a toolkit from the ama where they adapted a practice transformation framework uh to offer these steps to help move practices uh forward with um regards to working towards achieving racial and health equity so they indicate five steps as well so the first is committing to do the work so this means that you need to have leadership so when we're thinking about the health system science domains thinking about how leadership is involved in this what types of change management advocacy is going to be necessary to make this commitment and then thinking about the team itself and the dynamics there and how that impacts how well we can do that work it'll really require a lot of courage from individuals to be able to do this because often in order to approach this kind of work it really it requires us to take a deep dive and learn about things that we need to improve and a lot of times we don't want to think about those things it also may result in us having to have some difficult uh conversations about why we do the things that we do speaking of which uh the next step is thinking about how we can start shifting group norms by learning about what we we do know and then also what we don't know about our outcomes for our patients um it can sometimes be challenging to get that uh information but it is really important that we start thinking about how do we go about asking those questions and learning more about the barriers that prevent people from being able to achieve their goals of having good health it requires getting a handle on your data so we have to commit to collecting real data so that's race ethnicity and language which i think that you know many of us can admit that we don't always do a great job of collecting this information collecting information on disabilities that may be affecting patients too um all of these things really help us to better understand who is being adversely affected and then help us to be able to do that focus in the margin that we talked about with a first model as well the next is to develop a sheer shared clear compelling vision and goals and so really thinking about how do we bring all of the people together to think about where we ultimately want to be making sure that those goals that we set are smart goals so specific measurable achievable relevant and time bound so that we actually have some accountability to the work that we're doing as well and the last is launching targeted improvement efforts to get at trying to achieve those goals and get at trying to improve those measures that are selected so again thinking about the qi process and this is a graphic of the pdca cycle where you actually go through make your plan um kind of move through with the test that you're going to do analyze it assess see what happened and then adjust and do different actions to see what we need to do to think about how to either expand it beyond like our small trial or to change it up because we didn't get the outcome that we anticipated and so this slide here helps to summarize the different frameworks that were presented today i think that one of the things that kind of permeates throughout all of these is that really importance of an understanding of the different health system science competencies um it also talks a lot about you know considering your stakeholders so thinking about the people that you're trying to serve and what their needs are um thinking about the importance of having leadership and vision so all of the the people in the boat can grow the same direction um being able to act on determinants of health so really understanding what are all of those factors that are impacting your specific patient population and then making changes to your structures and processes to address that monitoring the progress because we can identify the problem but if all we do is identify it and don't actually um you know institute an intervention or try a counter measure then we're not really going to be able to make any progress there um we have to make sure that we are targeted when we do those interventions so we can't just try a bunch of like random things we really have to analyze where our problems are coming from and then target our counter measures to those root causes um and then finally it goes without saying we have to address racism and the impact that it has on like what we do on a day-to-day basis as well and so again when thinking about those themes that emerge the hss competencies and systems thinking so that holistic view leadership teaming change agency management advocacy the ethics and legal concerns informatics health technology to help support that work uh thinking about how we can make changes or how we can understand and make changes to health care policy economics looking at our care structures and processes and then utilizing health system improvement techniques to be able to address the things that we identify will really help bring us closer to having care that is of high value for our patients and that on a population level we'll have better health and in turn have health equity by ensuring that that better health is for all of us so i'm going to leave you with a quote from uh sir william osler the good physician treats the disease the great physician treats the patient who has the disease and so to me this is really just the definition of what a system system looks like so it's someone who's really taking that broad view of things pulling in all of the different factors that are impacting a situation to think about how can we improve the health of this individual patient but then also thinking for the population or the community in which we serve as well and so really we have an opportunity with uh health system science education for undergraduate medical education medical education and faculty development like what we're doing here today to really make a difference if we can move forward and make that commitment so with that i will end uh thank you so much for your time here are my references thank you dr maven easter this has been fabulous thank you second iteration because i already saw this this morning i was doing a little bit of um playing around on that zip code um oh yeah um website that shows um the um age of uh the life expectancy for uh zip code and i'm always fascinated by zip codes particularly in this area because of the zip codes that we serve so yeah we serve roanoke city and we serve roanoke county which are two very um different ordering zip codes yeah they're very different they're they're four years apart just yeah right next to each other and i looked up um a lot of the surrounding areas and it's and even i even went to see um the core zip codes in virginia and then plugged those in and we're still really pretty low in the roanoke city area so yeah that's surprising to me you know you look at the codes for a lot of different things like covet infections codex vaccination rates all those types of things but it's still so shocking to me distinctions yeah between that yeah no i think it's pretty incredible i didn't include this slide here but um there's a slide that i've used in the past that uh shows like the difference in um in life expectancy in chicago based on like where exactly you're living and even within like a mile it's a pretty significant change i want to say it was like maybe 10 years different um and so even you could you know hop on the l and end up in a different life expectancy depending on like where you're born um for me i'm from flint michigan so from genesee county and our numbers are not as nice as ann arbor's when you put in the zip code right but um i do think it's interesting but it speaks a lot to um how factors around where you live impact things you know i was talking with sarah earlier today about the flint water crisis and like you know really what that looked like and you know how could we have something like that that happens and you know some of it's just related to like you said really well people making decisions um often guided by money for other people where they won't be impacted at all with regards to the consequences um so it's it's a an interesting thing from that perspective for sure absolutely um for those of you who have questions feel free to either unmute yourself take uh you know show your video or just under yourself or type them in the chat we can convey your message if you would like to do it that way um however you'd like lots of great questions this morning i see there's a comment on a forum on black maternal health in in february that was uh held which sounds like it was very good i didn't catch it but i'd be intrigued to see a recording if there's one that exists hit him we can find a question that asks um can you comment on that there but can you comment on other blacks on other strategies to improve black maternal health yeah i mean i think that really the first strategy is better understanding your local data so when i think a lot about the patients that i care for day to day i don't really have like very easily accessible ways to see like what the outcomes are right i'm just seeing like what's happening for my individual patients um and so i think really the first step is just making sure that the data that people need to understand what's happening is in the hands of the people who actually are going to be caring for those patients and thinking about changes in my state we have a perinatal collaborative that has different regions within it where we are doing work looking at how can we address issues around uh health disparities in specific and maternal health as well we're part of region nine which is relatively newer i think it's only been for the last couple years we're really looking at initiatives that can help with that so like you know support for uh doulas as one part of that like what does that look like because it's been shown to help reduce like the likelihood of people getting c-sections which can have morbidity that comes with it as well um i think other things that we've been undergoing just like more locally in my own department are with regards to some of our de and i initiatives i serve on our uh work work group work group um not a task force we're grouped for uh quality improvement and we also have been kind of looking at okay you know these are all of the different indicators we typically monitor let's go through and like actually look at our data you know i look at our data that's stratified by race ethnicity languages spoken so that we can get a better understanding of our interventions and then for resident level they have changed one of their morbidity and mortality conferences to being a health equity rounds so an opportunity for us to actually talk about patients that have been identified to have had an issue related to like bias or to like over racism that impacted their care and kind of think about what are the systems things that helped enable that um additionally we also are working to include kind of people who identify those sorts of things actually allowing it to be filed in our patient safety reporting software as well so that it can be better tagged and monitored as well okay a few more things popping in um can you please elaborate in general on um ways to minimize institutional racism yeah no i think that's a great question so you know i mentioned earlier just based on the ihi uh structure kind of thinking about the ways in which we we provide our health care services an example i provided during the talk earlier today was that with the covid pandemic when it first started in an effort to consolidate staffing we closed some of our our health centers and had people move to do their practice at a different one as a result um and what we realized through that process is that a lot of our patients like based on like the resources they had and where they lived were like taking the bus to get into their clinical centers and we had ended up closing a number of the centers that were actually easily accessible on the bus line and so um we you know it wasn't an intentional thing right when we went through we were just trying to kind of address concerns about uh staff sickness and like you know absenteeism related to covid um but when we actually looked at it from more of an equity lens we realized that we had made a structural change that actually made it harder for our patients from areas that were more underserved to access care so really taking the time like you know to reflect on the changes that are made and talking to that target population about how they're impacted are ways that you can go about trying to address things like institutional racism i think that the you know um other thing is just making us accountable to paying attention to those things paying attention to the factors that are impacting that so we're doing a push now to do a better job with screening for uh social determinants of health and then also um to make sure that all of our employees irrespective of what unit that they work in that they are going through like implicit bias training or bystander training to make sure that when we're seeing things um more locally we can also address them too great thank you so much let's see uh somebody else says it would be a great student project to collect the data regarding caroline health systems collaboration with the local safety net organizations to identify gaps in the system would be a great project that does sound like a good project could it count as a research project for their credit i heard that that's a requirement another comment thank you for everything you're doing to strive for improvement thank you all i think it's really exciting that you all are are making a focus on health system science and thinking about how can we educate the faculty because the learning environment is really where the students are seeing how we model things um and so if we're making sure that everyone is well-versed in these things and we can model it better for them and help reinforce it as opposed to doing a hidden curriculum that gives them a slightly different impression as well that's wonderful thank you so much this is the end of the hour um if anybody has any further questions please filter them through us and we will um get them on to dr baby's easter and i'm sure she will respond with some very thoughtful answers so thank you so much thank you and happy to hear from anyone you all have my contact info have a great day and stay warm thank you.