Taking Healthcare by Storm: Industry Insights with Dr. Rich Greenhill

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Rich Greenhill, DHA, FACHE, Chief Transformation Officer at Quality Insights.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website. 

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-ARPA-112924-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the Medical Director of Quality Insights, and today I am pleased to have a repeat guest come on the program. Today we are talking with Dr. Rich Greenhill, Chief Transformation Officer at Quality Insights and Editor in Chief of the International Journal for Quality and Healthcare Communications.

With over 30 years of experience in healthcare, Rich is an expert in AI, quality improvement, and patient safety. And he is a sought after international speaker and consultant for organizations like the World Health Organization and the National Association for Healthcare Quality. He's also a member of the prestigious International Academy for Quality and Healthcare.

He holds multiple advanced degrees, including a doctorate in health administration and a master's in data science. And he is a recognized leader in healthcare transformation. Quality and safety rich. I am so glad that you are here today for us to have this conversation. Welcome. 

Yeah, it's good to be back.

Dr. storm, it's it's great. And I'm looking forward to the  topic today. 

Yes. So today we are talking about bias in healthcare and we're going to be touching a little bit on riches recent experience, direct experience in healthcare. And I will say, I've been a.

patient as well. And I will say it's really one of the best ways to really experience what is going on in health care. So rich, can you share what happened to you during a recent visit to the emergency department maybe briefly and how did that bring bias into the forefront of your thinking? 

Thank you.

And again, it's good to be here and always good to talk to Eugene. And, recently I was feeling bad and I, went to the emergency room in the local area where I am. And while I was in that setting, I walked in and checked in, as normal. I wasn't feeling well.

I, had a fever and some other things going on. And so one of the nurses came and did their initial checks after they put me in the room. And then I had a mid level provider come in the room. This provider, was there to do the screening, right? For the, the attending, whomever.

And this person asked me what was going on. I'm not a regular patient because I have a base knowledge of the work in healthcare, right? So after I explained. what I've been experiencing, I keep notes and stuff. I'm one of those patients. This person said, and I quote, Mr.

Greenhill, I know that you say you're not feeling well, but you just don't look sick to me. In that moment, I was, besides feeling awful, I was beside myself. And I thought, what does sick look like? And I, at that moment, I was thinking, or wondering are they not taking me seriously?

And do they really think I would be here at 2 30 in the morning on a weeknight because I wanted to avoid work or something? It just was very awkward. And, it made me think what do you see when I walk in to the room? And what have you seen before that made you ask me that or say that to me that I don't look sick?

Is there a way that people are supposed to look when they're sick? Those are the things that were going through my mind. And I'm thinking what's the reason that someone would think I'm not sick? And that's the, that's when the word, the idea that this person probably has experienced someone before.

I don't know what, maybe a drug seeking person or another person that looks like me that came in or something that, I don't know, it was just very awkward. And I thought, this seems like a situation where this person has some kind of bias, either through ignorance or intentionally. So it was just a weird experience.

Yeah, most definitely. And you wonder how many patients almost have to prove that they have to prove that they're sick, which is crazy. So how did that experience affect your perception of the healthcare system as both a patient and a healthcare quality improvement professional? 

In that moment after this person left the room, I felt really disgusted and minimalized and, I felt super charged as well because, I'm in the patient safety space and this is a patient safety issue, I think.

And in fact, I was so upset that I almost got up and left and I wasn't feeling well, and really in those moments, in most emergency rooms, they have that pain chart and they'll ask you what your pain tolerance is on a scale of one level is from a scale of one to 10. And I thought, who the heck created that chart?

It has a smiley faces on it. And who was it based on? And it was almost in a moment where I thought Does the patient have to be a great actor and mimic the chart to be taken seriously? And then I thought, I'm pretty well traveled internationally. And I thought what happens to someone from another culture?

And I've seen many different cultures in my life who may come in, who may not show their pain on their face, the way that chart outlines it. And this really, sets up the whole experience for a negative outcome. I guess unless patients are willing to be great actors, and it took me to wondering, like, how are these people trained?

Are you trained to believe that chart, one through 10, and then maybe that's a question for you being a physician is that the chart that's okay, this person looks like they're in pain Am I supposed to grimace? I, have a beard, so maybe they couldn't see my grimace, but I don't know.

It's just, it was just very weird. Would you say that providers are, is that the primary chart that you're trying to use that one with the smiley face thing? 

I will say it's interesting. And I think in just the medical training usually as a medical student, you're like scared of everything.

And so you get put in charge of these patients and you think, Oh my God. Like this patient is so sick. And then, you tell your higher ups residents, attending physicians, and then they'll go in and they'll say, if this patient's fine, there's nothing wrong with them. And you get made to feel like an idiot.

So I wonder if that maybe is leading to this, but we know that. There's a ton of diagnostic errors that are made, people are dying because of these diagnostic errors, because, probably as your case illustrates that people are not believed, what, I love that line that you said, what does sick look like?

I think we really need to ask ourselves that as a health care community. 

And it goes to, if you look out there, you know this, that maternal outcomes, for example, black women are really horrible. And some of that I believe, and I've heard and read in some papers that there's this perception that the pain tolerance is for black people.

Black women is different than other groups. It's I don't believe that's true because of course I'm a, a black male and you've been around different groups of, black people, but I think that the way we all express it is different. And that doesn't mean that we're not in pain. It just means that it's different.

And so if those differences like you're alluding to are not Okay. Considered then it sets up for very negative outcomes because especially during childbirth if someone, maybe everybody doesn't, I've never had a baby of course, but some people may scream like in the movies, right? And some people just may breathe like Lamaze or who knows, but it's it just makes me wonder is bias really the reason that we see some of the things we see around pain tolerance or people with negative outcomes that, around pain.

Yes. Have you, in your experience in different healthcare settings as a professional, have you seen any strategies implemented in healthcare settings to address and reduce bias? Okay. in patient care? 

I know that there are some tools out there. If you look in the literature there was some papers that I looked at there's one that was published, I think, in 2022 from the annual review of public health, where they looked at, the vicious cycle.

They looked at a conceptual model of the vicious cycle of how care diminishes when there's confirmation bias and then a virtual cycle of and basically what I've seen conceptual models. I haven't seen anything just, out there that people could replicate and use. And unfortunately, I think with some of the collapse of, the diversity, equity, inclusion, mindset, I think it's led people to go back to their norm and, and not really think about, other people, but this conceptual model in this article that Vela produced talked about a virtual cycle that improves care where practices are de racialized, the learning environment is unbiased, and it really focuses on mindfulness of providers.

And I think while there are not a lot of things that I've seen, and it could just be because of my limited sort of knowledge on it, I think people being mindful that, bias doesn't mean that a person's bad. It's the truth is that we're all biased about a host of things in life. And it, and what that means is it just depends on where we have been, what we've been exposed to and whatever our experiences are.

And I think that for those who aren't thinking about bias or they think they're not biased, it's really naive of anyone to think that our personal biases, we don't bring them to work because we do. And that's not a bad thing. But bias is about your limits or whatever around your experiences. And I don't think our humanity is siloed.

So we can't assume that we're not going to extend our personal biases to other things. There's some implicit bias tools out there. I think I don't know if you've ever seen any in your practice, but there are tools out there. But Really, unless there's some type of structure built around it, where providers and nurses and doctors are trained and forced to use it.

In the rush, people will just move on and do what they do. And not really think about it because some of the bias is implicit where you don't even really know that you're being biased. And again, it doesn't mean that we're bad because we're biased. It just means that it's something we have to pay attention to.

And. Both those things can be true at the same time. I can be a good person and have implicit bias, I believe. 

Yeah, I think the recognition of it is one thing getting individuals to recognize that they have bias is probably a huge hurdle. And then once you get individuals to recognize the bias, what then? I haven't seen anything quite honestly around what to do then once you get people to even recognize they have bias. So I think there's a huge need for that kind of training, but honestly, 

I almost wish, Gene, that in, and obviously I haven't been to medical school, I almost wished that it was a part of medical school where, and we know, I was speaking to someone a while ago about some of the, things that, ways y'all are trained around, for example, kidney function and other things around different races.

Race is a social construct. When you look at humanity, there are differences in regions of around right around people, for example, if you himatic, it's a different on different sides of the world, right in different parts of the country, whether your elevation, but that's not linked to race.

So the fact that we have injected the notion of because I'm black and Hispanic or whatever, the breakdown is into this, I think that has really made this difficult because race is a social construct. It's not. I don't believe a medical sort of thing. Yeah. Yeah. Your hermeticate is different.

Maybe if you're from sub Saharan Africa, your red blood cells are different because you have evolved to deal with plasmodium species, and, and then you don't have G6PD and, whereas we don't have that protection because we're it's not endemic here. So the physiological differences because of evolution around disease is different than race.

And I don't think There's the delineation of that. So we just attributed all, okay, these people are different because of their race versus where they are, their geography, their evolution to deal with disease and, those kinds of things. So that's just a thought. 

Yeah. Holistic approach.

I would agree. So I know you recently did some training and I'm going to pull your recent training into this conversation about bias. You did some recent training with. Pro side. I think I'm saying that correctly, right? And you are very excited about the ad car model. I read a little bit about it and I am excited just about what I've read.

So do you feel this model, first of all, maybe tell us a little bit about what the ad car model is just briefly, and then do you feel this model could be used? Help drive change in the area of bias and healthcare. 

Definitely. I was as part of my annual training, I decided to go to pro side training and become, certified change practitioner really the knowledge, to help our organization with some of the things we're doing.

And I was just blown away. Like I've been in. What was the improvement for years? And I'm just. It's a scientific, process to help with change right in the outcome model. You look up online is really You know, focused on individual change, of course, and so I'm not a spokesperson for pro side and I'm a practitioner, but that car stands for awareness, desire, knowledge, ability and reinforcement.

And what this model does is it really points people to first acknowledge that there needs to be change, right? And there's a whole bunch of things under this. This is just the acronym that anybody can find online, but there's a lot under it. And then there's desire, by the person to really be part of that change and go through that.

There's new knowledge, which is what you're mentioning that there's really not a lot out there about bias on how to change. So once you tell somebody, for example, people, someone recognizes, Oh, wow, I have implicit bias around certain things. How do you change? And I think that's what's missing right now.

And then ability and reinforcement. So that's really about, getting those skills and then implementing them and sustaining them. I think ADCAR is wonderful because it's a framework and I'm a framework type person. It's really useful just to get people to first recognize that there's a need for change and then go through a very methodical process to make that change.

Again, I'm not a spokesperson or I don't have any conflicts with ProSci, but I think What I learned is that it's just a very powerful tool and set of tools to really focus on how to change and to help people through that process. Because change is hard, as and I've been reading a few books about change and, change is like death, because people feel lost inevitably.

So if you're having to change part of who you are or see yourself differently, because I'm biased about something, you It can make you feel like you've been a bad person, right? And so there's a whole bunch of things that go with that. I think the bias discussion is this is a start, but there would have to be a lot of scaffolding around this to really help people transit that process.

Because we don't want people to think, wow, I've been a terrible person my whole life because I've thought this way. It's, that's not true. It's more about now your experiences have expanded. Around what you understand about yourself. So how do you take that and make it better for your patients and for your own self growth, Adcarb and the other tools in ProSci, hands down are just really powerful if you're trying to make change.

And again, I'm not advocating for anyone to do that. But it just really changed my life to go through that experience of that training. 

Yeah, it sounds very exciting. I am a big fan of looking at things from different perspectives. And so your recent experience, right? You were a patient rather than, like a healthcare professional.

So as a patient, what advice would you give others on advocating for themselves or loved ones that they sense bias? we know it's there. And a would that advice change? 

And Gina, I thi that first of all, the pa consider that when they a state, they might be treat in different ways and sometimes put in someone else's head.

And again, you know the person's head is that doesn't mean the person's bad. It's just, when somebody is sick, seeking care and vulnerable. The last thing they probably want to think about is bias. But your question is a great one. And I think the thing that patients can do is in advance of being sick and in their families is to be informed about what should happen when a person's enters the care environment, whether it's the emergency room or clinic or somewhere else.

Also, arm yourselves and your family to have those questions ready, plan ahead about what's happening in a care episode. If it's an emergency episode, it may be different, right? But, oh, what should be happening? And that really, in my mind, Is an informed patient and family and it lays a groundwork for the safer care experience.

And it doesn't not mean being hostile toward caregivers, because God forbid, you're already stressed out and all that, but it does mean in my mind, being an active patient in the care process. And as a patient focusing on an approach of co development of the encounter with your doctor, your providers.

For me, and I think my physicians know this. It should never be that a care team is doing something to you, but they're partnering with you. And so sometimes the care that the patient has to really remind the care team of this. And because in those situations, especially emergency situations, they're trying to get you in and take care of you.

They may have 10 patients and the alarms are going off everywhere. But maybe it's up to the patient of family to really try to slow that thing down a little bit. To make sure that we don't lose the humanity of the person sitting in front of us, or them rather, while they're going through their, trying to get intervention on whatever's going on.

So yeah, 

I such an important guidance. So you are a data scientist. That's great. important big thing in your life. So do you think data collection analysis can play a role in identifying and addressing biases within the health care system? 

Absolutely. I was just at the District of Columbia Hospital Association annual summit in Washington D.

C. About a week or two ago, and There was a real intense discussion, a panel at the end about maternal outcomes. I was surprised to learn, Jean, that DC is actually making, they're a leader in the country around making strides for reducing negative outcomes around, death, of black women and babies there.

So they had several people on the panel and the chair of the obstetrics and gynecology department, talked about using data. around the encounter to really coach providers on how they close the gap around biases. And so it was interesting, and I'd never thought of this before, but what she and the others said was what they do is they have been looking at data around how much time is spent with different patients based on their race.

There's, how much, their insurability and all these different things, these different data points. And they found that patients that have negative outcomes tend to have less time spent with them. So what they do is that's a flag for their first level of screening to go into those notes and see what questions did you ask?

What labs did you order? And they've been able to use that as a means to make sure that to start a discussion. So absolutely. I think because the word bias, in other words are so incendiary to some people, you almost have to go to data to do this. And that's an, physicians are scientists, right?

So it's a a more objective way to look at, okay, why did you do two different things to these three different people? And let's explore that. And back into the conversation that way. I thought it was genius. I think one of the young ladies on the panel was a politician or maybe a public health person.

And this is working for them, which I thought I never thought of that. before, to use data around measuring the things that happen in the care episode to make sure not just that they line up for medical necessity, but also why is there a difference in how much time you spent with these two people who should have probably had Some type of similar timeframe that, it took for you to get through the encounter.

So it was a very interesting thing, but yes, I think data is the way to go. Absolutely. 

Yeah, that's so fascinating. I think it's so interesting if you look at the amount of time. I recently looked at a study when I was doing a presentation around patient centered care, I looked at a study that compared time that a physician spent with a caregiver conversation, if they had a loved one who was in the ICU.

So obviously very tense and they compared conversations with black caregivers to the conversation with white caregivers and the conversations with black caregivers were markedly shorter. They got less information, that they had less correspondence overall. So it just, We need data to really get at the bottom of what's happening to show clinicians what they're doing and solve the problem most definitely.

And I think too, Jean, since we have had what I call a recoil in the equity and inclusion space, because again, these words, unfortunately, are politically charged when for us in healthcare, we're just trying to take care of people and, be fair. I think data is really the only way to go because it removes the, we don't maybe have to say the word, but focus on what the data is telling us and focus on the, this, social economic factors.

Those are indisputable but we can, we all can, we can argue whether we think someone is biased or whatever, but you can't argue with the data, right? So I think that's good to go 

Yeah, that's what I feel like data is not blaming anybody. It's just giving you information. So it's yes, so I've been thinking about you know as we move into the respiratory season i've been thinking about vaccinations and particularly covet vaccinations because the rate is very low and they've You Studies have shown, CDC actually reported, that if individuals experience bias or discrimination in healthcare, they're more likely to be unvaccinated, and it probably has to do with trust among other things.

So in your opinion, what lessons about bias in healthcare do you think have emerged from the COVID 19 pandemic? And how can we apply these insights to improve quality and equity? Inpatient care moving forward. 

It's a good question. There were a lot of examples of bias during COVID. Some reported some I know of just because, the communities I was in.

And I think as everybody knows, COVID 19 really magnified disparities for underrepresented groups and particularly around general socioeconomic factors personal factors, healthcare factors, and, When I say general socioeconomic factors, people's employment or increased exposure, the, what do they call them, essential workers.

Those were things, health factors are really people that didn't have insurance or were underinsured, personal factors were around, just some genetic determinants or disease determinants, for example, There's a belief that blacks died because they had less vitamin D and they had more diabetes, right?

So it just exposed all that. So I think that's what we learned is that in the evidence showed. And if you look at the literature that we need to really address. Disparities, right? And it's right, like thinking about those populations at risk and really being more intentional about how we engage them and focusing on making sure that the information that we give is vetted and culturally appropriate it's maybe incentivizing vaccinations in neighborhoods and thinking about that and really being culturally responsible, responsive rather to race sensitive interventions.

It's almost we want to think that everybody is the same. Our country is very diverse, and we really can't think that way. And we have to look at all of these different layers of how people, live and move. And so I think the lessons are to really Focus on investing in programs that facilitate or close the gaps for inequity in communities that have been marginalized or disadvantaged.

And that goes beyond just the care encounter. But looking at, how do they get to their appointments? Do we need to have bands to go to people's houses to vaccinate them? I think we have to think out of the box. for people because or people are working in jobs where they can't take off. How do we bring the vaccines to them?

Could we have a vaccine ban, for example, that rose the community and goes to the community and shows up at fast food restaurants or walmart or, different places that will encourage people to be vaccinated. I just think we have to think outside the box and meet people at the point of where their need is and not think, okay, everybody has to come to our clinic.

That would be great if everybody had the same equal playing field, but I think it just showed us that we have to be more targeted in I don't know, understanding and how we deliver here, especially vaccines. That's full of the charge. I'm going to tell you that, but 

yeah, 

It's focusing on the information and making sure it's vetted and the people understand it's just going to be tough gene because social media, any old dog or cat can put anything they want on social media.

We're, we as an industry are battling against that and what that brings. So 

yeah, I would agree. I could talk about this all day, but I have one last question because yeah, I don't think we can talk for hours and hours here, but what can healthcare quality improvement professionals and organizations do to actively combat bias?

in their organizations and communities and, individuals they work with? 

It's a good question. I would say really focus on data, right? Collection of data that is comprehensive about the communities that we are in and serve, because I think the more that we understand about our communities, the better we can craft those programs to take care of those people.

And also really taking that data on demographics about those people and entities in our community and going deep on understanding the cultural differences and nuances and customs of our patients. An example from a few years ago, when I was in the safety net is, we would have male Muslim patients come in to our clinic and they were not comfortable with females examining them.

And so I think at the moment we didn't think about that because maybe we didn't know our community well enough, right? But that would have been an important thing for the care team to think about, to plan for, to ensure that those patients had a male, right? And if there are certain sort of parameters around, what that physician can do or care provider can do to them because of their religion, to plan and prepare for that, right?

And so I think being deliberate in how we evaluate needs and not just assuming or really allowing one or two demographics. in the country to drive the assumptions about everybody, right? We are diverse, so I think in the data we collect in healthcare entities, really understanding, not just male, female, insured, uninsured, but really understanding deeply, if we have these different groups of people, what are their cultural norms that they honor that might enhance, enable, or prohibit them from wanting care or seeking care?

And I don't think we go that deep because we don't have time or we think we don't have time. But if we're really trying to make a dent in this, I think we have to go deeper than the superficial data that we're collecting now about our communities. 

I agree 100 percent and I really appreciate this conversation.

It's a big, huge interest of mine. And I learned a lot today. Rich, thank you so much for joining us today. I think this is going to be maybe one of, at least maybe one more conversation in this space. Yes, but I really appreciate you joining us today. 

Yeah. Thank you, Jean. And and I'll be talking with you soon. 

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.