From the earliest days of the patient safety and quality movement, here in the U.S. and abroad, healthcare providers, administrators and researchers have taken it upon themselves to define "quality.” Metrics based on clinical endpoints such as blood pressure, hemoglobin A1c level, weight and others have been used to measure "quality" and "improvement.” With increased awareness on the part of this same group recognizing that social factors – the social determinants of health – are directly responsible for as much as 70% of a person's clinical outcomes, the need to redefine "quality" in health and healthcare is upon us. We will explore how social context may shape the patient's, family’s and, indeed, the whole community's definition of "quality.”
Community engagement video featuring local work by:
• Lisa Meadows, MSN, RN, PPCNP-BC, on St. Louis Children’s Hospital Community Health Advocacy & Outreach programs: Healthy Kids Express, Head to Toe, Teen Outreach program & Safety Street
• Kaytlin Reedy-Rogier, MSW, on Pipeline to Compassionate Care Project
Speakers explain how multiple community programs meet patients in their own community to provide healthcare and build trust. The second portion outlines a program that trains medical school trainees to better understand social determinants of health and how life experiences can impact patient behaviors when interacting with healthcare.
thomas said, my my talk is title of the future is now the intersection between patient defined and that's an important part of this health care quality and the social determinants of health. And with your indulgence, I'm going to refer to the social elements of health as the sdo h from here on out. It's just a ton easier to say. And so please bear with me as I use that license of the podium. If you will, I have nothing to disclose. And I had a long time goal earlier in my career to have something to disclose, but the kind of work that I do seems not to attract funding um, so I have nothing to disclose and will continue to aspire to do. So at some point, what I hope we can do today and as much as virtual and pandemic living allows us is to have a conversation um together, I hope we can together understand and discuss the current state of public health, public hospital quality measures as they exist in the in the moment. Um further I hope that we will be able to collectively identify a variety of those sort of commercial rating systems that I think many of us um and our institutions certainly aspired to be successful in and to understand some of their nuances. Third, I'm hopeful that we will be able to collectively understand some of the domains and I don't I don't claim that I want to make any all of you experts in the S. T. O. H. But begin to understand some of those factors that go into patient care and clinical outcomes. But certainly in this question of quality I think what what contextual ISes them um and finally to really get a beginning sense if not an expert level understanding of the interplay between the social terms of health and what we define and what patients more importantly defined as quality and health care. Mm slide here we go. So I want to start off with the question to the audience that I'm not actually asking you to answer. It's not at the Q and a part of the talk yet, but the question is are we asking the right questions when we start trying to define quality, when it comes to the community in particular? Are we asking ourselves the right questions and maybe we're asking the right people the right questions. So to do that, I want to sort of frame how we in health care and I think most of you are probably providers of healthcare at one level or another. What what is it that we see when we start talking about quality? And I would posit that what we actually see um and seek to measure is actually value. Um and it's a it's a very commodity driven approach because in America is I think most of you know, and understand some of the audience members are not from or in this country, health care is a big business. Um and I would say if not first and foremost, it's pretty darn close to the thing that drives health care is it's it's a question of business principles and success in that domain. Um and so we really do look to achieve value, and how do we define value? Is is one of those important pieces of our conversation today, and I think most of you, if not all of you will have seen some version of this equation or this this graphic at some point in your life and your career in health care and that that's pretty simply stated, that value is defined in its most rudimentary forum as the quality of the good or service over how much it costs. Um and to, to sort of break that down a little bit. Um the value for an individual who is buying a thoroughbred racehorse um is interpret herbal, in part by how much it costs that racehorse, and then in some, to some degree how much that racehorses able to to win in earnings if it's in fact racing. Um And so the value point is really a very cut and dried proposition of how much money is on the bottom and the denominator. This equation versus um how, how quote unquote good. In other words, winnings, how many races does the horse win? But in health care we have to have a different approach to this in my view, because despite our very commoditized approach to health care in this country, I didn't go into that into health care for that reason. I think most of you probably didn't. I hope most of you probably didn't. And so others have broken that quality over cost equation out into something that's a bit more healthcare specific and that is as you see on the screen outcomes, um clinical outcomes, and we'll get into that in a little bit more on the talk future, but also the patient experience of those outcomes. Um As the definitions, if you will that this this particular presenter used to define quality over cost and they've broken it out further into direct and indirect costs and that's important as well, as if you're talking about a business outcome of you know, how much does this cost? And the question is to whom the individual patient to the health care system that's providing a service to the pharmacy that's purchasing the medication from a distributor. Um So those are the kinds of questions about costs that are pretty important um when this value proposition is framed within health care, um but I I also found that to be too rudimentary. Um and we start talking about quality and again this value question that we're talking about now, you have to understand what quality is right to be able to define. And I use the example of the racehorse, it's how many races as the horse wind, that's not the the numerator here for health care. And so I think we've begun to dig deeper in this quality space as to what does that mean? And so another author. Um and this is actually from a chief resident in at the University of Michigan gave grand rounds a few years ago, dr Hugh, telling whose name I probably butchered. So, if you're in the audience forgive me Um added um this very, very important piece in my mind that's appropriateness to this equation. So you have value equals quality plus service over cost. And I think that was a really important addition to this because the metrics they use are the ones that showed in the previous slide which is the outcomes, the hard outcomes of mortality and infection rates and copies and those kinds of things, but also the experience. What what did the patient go through to achieve those outcomes? But I I very much like this edition of the word appropriateness um to this particular graphic because I'm going to go back and take the highlight off if the care is provided in the wrong place at the wrong time um for that patient and not in context. And I really want to emphasize this piece of context because we're gonna talk about that in some detail later on. Um and then also breaking out the direct and indirect cost component of it. But if you look at this appropriateness um modifier, if you will um at the right place and right time is something that triple aim that we've I think many if not all of us are familiar with but this idea of of the patients context and I think it's really the patient's context, they work that they're talking about because certainly that's what I believe to be. The most important part of this really is a multiplier when you start talking about value. And again you can't really get to quality because none of the equations of value um particularly in in America, which as I said, is a very commoditized approach to health care. You can't get the quality or value without actually factoring in the multiple, multiple active multiplication factor of quality. And so they did a really good job I thought. And we're going to now focus on this quality question a bit more. Um and so what we measure in terms of quality and I think those of you who are process improvement improvement experts will will recognize the adage that we measure, we improve what we measure, right? If we don't measure something, if we don't pay enough attention to see how well we're doing at it, then the chances are that we're improving it continuously are are less and if not less, are absent. And so when we start talking about quality measurement, let alone the definition of quality. Um I think there are there are at least 22 definitions and two perspectives that we um need to be cognizant of as as part of our conversation today. And the first is what we in health care and the we I'm referring to here is in healthcare, just half a disclaimer that eventually we're all patients in all likelihood one way or the other, we all become patients and hopefully we're all connected to primary care already. And so to some degree were already patients. But I'm specifically speaking of those of us who are health care providers, health services providers, health services researchers. And we start talking about measuring quality. We have things like this. Um and I'm gonna bore the heck out of you to read this paragraph to kind of give you a flavor of why this is the what we see version versus what the patients not ourselves see. To utilize the NQ. F. National Quality Quality Form. Endorse composite, users must use these NQ F nanometer weights when using the ark Q. I. Trademarked piece of software to compute compute the composite measure using their own data. These weights are included in the I. Q. I. Hospital composite. Wait Virgin 2020 point SAS macro wow, tables two and three provide that the N. Qf weights for the composite measure and the some of the weights for the indicators included in the same comment that always equals one, which is really an elegant way to describe a computational program that was designed and essentially being sold by the National Quality Form. And I'm okay with that. And these are things that are important to us. Um, but I would deposit that maybe not as important to individual patients communities, family members. Very few of them are going to access the NQ F. Website and find the weight of uh, pancreatic resection, mortality um, rates for their surgeon because they can't first and foremost. But these are the kinds of things. And if you look at the very bottom of it, the slide, it says that the source of this is our agency, healthcare related research and quality health care costs and realization, project state impact databases. And so the Q. And artist quality. So by definition literally literally by definition the term art. The the acronym ends in the word quality. Um and they are using these measures among many others to begin to define quality along these various domains. But I hope I have convinced you by reading that paragraph to you and I apologize for that in retrospect that these are not patient facing. I don't think there was a panel of patients who were who were invited to art or to the C. D. C. Or to pick your acronym um To sit down and say what we really need to have a weight of .0071 for sexual resection mortality rate as part of a quality indicator for us as individuals. Again very scientifically elegant. Important because if we don't measure anything we don't measure these things. The chances that we are going to continuously improve them are diminished but probably not patient and community oriented. Like I think they probably should be in a hook convention that they should be. Here's another good example um from the core quality measures collaborative which also works in conjunction with um the N. Q. F. And you can see here there's again a variety of of uh uh measures and conditions. And there's a steward. And you'll note in that column of stewards there's CMS, there's a million cardinal Colonna cardiology, american College of Cardiology. There's a heart association boston Children's um There's no patients right? There's no Stuart who are who are individual groups of patients for community members who are in this steward category in column. Um And I think that's that's one of the flaws that we we have to overcome. Um you know, we have these additional things and again, I think most of you are probably familiar with the the heat is measures or the healthcare effectiveness data and information set, which is a rich data set by the way for research purposes. If you can access it, it's it's really worth the time if you are into a health service research mode and you're institution. Um It's a it's an important piece and it again falls into this um grab bag of things that are used to measure quality from the perspective again, of the providers of service and services. And so here you can see that the the N. C. Q. A. Another another agency that's entity that's interested in discussing and publishing quality information for consumers that's their target audience um uses heaters measures um to benchmark institutions like my own at the University of Virginia and certainly Barnes jewish and washoe. Um All the places that we most of us work in are benchmarked using among other things things like these measures. And again I think that's value adding um when you're when you have conversations amongst peers but it's hard to really connect that. And then one of my favorite slides in my talk is this one which is this sort of the rainbow wheel of of factors that go into what is described as patient and family centric primary care. And you'll see on there that there are various aspects of this that include things like um quality measurements. You can see continuous improvement driven by data which is in that sort of burgundy um uh pi piece um optimal use of health care I. T. And that all sounds great. Um But it's it's a busy thing and it's not something that the average individual community member would be looking to look access to on the web or even in a public library because it's pretty complicated and it's almost impossible to interpret if you're that patient remember the family in the center of that graphic. So I asked this question earlier and I said you know what are we are we asking the right questions? And I think maybe as I look at it the better question are we asking the right people the right questions? And so as I've kind of gone through that that litany of of here's all the various alphabet soup that we all see um in our daily work of quality improvement and process improvement in our various institutions and our practices and our settings, patients see a very very different uh Rainbow Right? Very very and through a very very different lens. And so there's some screenshots here from just the web. And I think all of us um and certainly any of us to working in the health system um have been told about our U. S. News and World Report um rankings right? And we've been told to fill out the survey when the time comes so that we can we can talk about ourselves in the most favorable light. And we've been asked by our cmos and are ceos to make sure that we do the survey so that we can get our our our name out there if you will and climb these rankings so patients have the ability to access this. They can if they can afford to buy the U. S. News print edition but also um if they can access through the through the web so if they have access to the web then they will do things like look up to the U. S. News and world report ranking of an individual hospital or health system and they can stratify it by a variety of conditions and you'll see on the on the slide here. The Burbage talks about being time before covid. So this is a pretty fresh screenshot as you can imagine. Um The methodology changes that are on this slide here and they talk about tavern cohorts and struck measures and the outpatient volume. These are things that that the public can access um fairly readily if they have access to the web or fairly readily if they can access live television and they watch the right news program in the evening. Um Again very different than the metrics that I showed earlier. Um No mention of national Quality Forum to mention and no mention of NC. QA on this on this slide because U. S. News has its own tool um in its own measure measuring stick if you will. Um and there's some assumptions that are built into this as you can see. So if you don't know what a tavern is, you can easily be be forgiven. They do Write the words out trans Catheter about replacement, which you have to be sophisticated enough really to understand what that means. Um and is that a surgery that a procedure I don't really know is at high risk. So is a is a rate of 15 um Good, better and different. Um And below average is what and what does that mean? It's hard for a person who is not facile in this space, which is the vast majority of americans and if you no fault of their own, it's just, it's complicated stuff. Um and then they go on to talk about stroke measure within 30 days of a tavern. So you get this layering effect of things that are just dead are described and defined as quality, but it's not just US news. Right? So there's that one source, I just talked about US news, but there's also a joint commission and for those of you who are our Joint Commission uh employees, I'll apologize. Joint Commission is probably my least favorite because I have had the hardest time as a leader in my health system as a physician practicing for 25 plus years to connect all of the measures that Joint commission studies and analyzes with improving the lives of my patients and or my team members because I think that's also an important thing to point out that Joint commission. I think more than many is also focused on the work environment for employees of health systems and so that's important. But a lot of the things in the survey writing is that we do that end up ends up costing lots and lots of money for eventually indirectly are indirect costs. Go back to that value equation. Um Is for the patients who pay for these things. Ultimately it's harder for me to connect a lot of the things that the commission has done historically with improving the lived experience of individuals in their health. Um But don't despair beyond us. News beyond Joint Commission is also leapfrog. Right? And so you you begin to understand that the things that a patient can readily access that are readily available out there in the real world are things like like leapfrog in the U. S. News reports. Joint commission is not as easy but certainly leapfrog scores get put up on billboards as you drive by highways in Virginia here you can see that we're a leapfrog. A and uh we're the only you know we're one of five leapfrog hospitals in the whole state of blah blah blah. These are the kinds of things that health systems used to leverage these publicly available rating systems about and in theory can sexually about quality of our institutions. Um but if you look into this this is the 2020 version of the Leapfrog Hospital survey scoring algorithm. Um These are the major categories that they looked at sections two through 10 um inpatient surgery, maternity care and you can read the rest. If you click on one of these on the website you then get a breakdown of how they go about developing these scoring systems and that X number of C sections versus Y. C. Sections at another institution puts one higher or lower on in that particular algorithm and then they add all that up to give you a literally letter grade of a B. C. D. Or F. Um and I can tell you that having been an institution that when I first got here in 2012 was a leapfrog d um that was all hands on deck for our institution. That was a major game changer for us. And you know, we've we've pat ourselves on the back to the point that now we're because we're now leapfrog at least I think we're last we were leapfrog a we're very proud of ourselves. Um Again it's a little hard to understand how that necessarily translates to patients understanding quality. Um and I think you'll see there's a gap that I've hopefully identified for you so far. And this next slide is one of my absolute favorites about this whole mishmash of measuring quality. And this is the best doctors. And I think every institution that has um some number of doctors who are given these awards of being the best doctor America's best doctor. And there's a whole bunch of these things that are out there and I think you probably know I'm talking about there's plaques in the clinics on the wall. You can't possibly miss those. If you go to someone's office, if they would be given the best artery award, I promise you it's pasted somewhere prominently in the clinic so that you can see that they are in fact the best doctor. But here's my, my favorite part of the story. And this is a journalist who publishes in a propublica and I'm sorry that the pro part of public account didn't make the slide. But if you just take a second to to read through this, I'm a journalist. Apparently. I'm also one of America's quote unquote top doctors. Um, so Marshall Allen is the author of this journal article and I'm sure many of you have seen this. Um, he got a phone call from a voicemail from America's top doctors calling to let notify him about his top doctor award. And they need to make sure that everything was accurate in his profile before they sent his plaque. And so the irony of it all is that he's a journalist and not a physician as you see in the rest of the paper and the rest of the article there. Um, and the last paragraph that I have on the slide, it says, I asked how have inflicted and the answer he was given was my peers had not made it me, she said defiantly and my patients had reviewed me. I must be quote a leading physicians, she said, except that he's not okay, it's not a physician. And so you see my point that it's almost impossible for patients to really truly understand quality. And I think that's on us as healthcare virus because we haven't done a great job of defining it and we certainly haven't done a good job of asking them despite what top doctors claims to have done what they think good quality is. And I think we have to get there um because I think we can all probably agree and this is this is actually from Kaiser building foundations website but characteristics of quality health care, I think we would all agree that safe, effective, patient centered, timely, efficient and equitable are foundational in that conversation. Right? These are all things that have to be part and parcel of high quality health care. Um and timely is one of those things that I think our friends in Canada would would argue is not as important because what's timely to an american is different than what's timely to a german than is different than what is timely to uh look etcetera etcetera. Often the case that our lack of patience with things does not translate to worst health care. Um it could be that the the wait for an imaging study is is totally acceptable and appropriate clinically but is distasteful to the person doing the waiting. So I put a little asterix by timely um but see I'm doing on time. All right. So, but I think safe, effective, patient centered and efficient and equitable are absolutely part and parcel of what we would define as that. And I think going further from this, the stink stock snippet, why patient reported outcomes is key to health care quality. I couldn't agree more. It's patient reported, but I would take it one level below that to say that like politics, healthcare quality is local. Health care quality is personal. In other words, healthcare quality should be contextual, it should be based on the circumstances of the individual. For example, When we start talking about measuring human a one C as a measure of diabetic control, I think that as a as a data point is value added in almost all circumstances, but if we don't contextualized the A one C of the person who is homeless, who is living off of whatever foods they can eat because that's what they have access to versus the person who lives in my home and this and you can see my size. But I'm in my home right now where I have access to high speed wifi and enough space and quiet that I can get this talk. My context is entirely different than the person who was living in homelessness who's a one c is potentially quote unquote out of control if we don't contextualize these things and I think we fail entirely at actually measuring quality because the quality, as I said at the very beginning of this is very personal for each individual. So how do we get to us to the to them from us? And by that again, I'm going back to us and might equip my slide here is physicians, healthcare providers, pharmacists, nurses technicians. How do we get from us in the business and the practice of healthcare and medicine and nursing and pharmacy to them to patients to live experiences? How do we connect those two? As I hope I've convinced you disparate perspectives on what is quality and therefore what is value and the lingua franca that we have in this country. Certainly I think in most of the developed world of how healthcare interacts with individuals, it starts off with that time honored good old fashioned history and physical or H. And P. And you'll you'll see here, I've got a few templates from various institutions around the around the country. This one is from Southwestern University College of Medicine as you can see at the bottom and it's a it's a it's a pretty good template for an H. M. P. You've got your date, you've got your historian who is writing the information down, you got your chief complaint, your HP. I all the components of a very billable um comprehensive visit H. And P. There's another example here different formatting but same basic idea. Um And you'll see the same things and the C. C. Is chief complaint for those who didn't know and then you have allergies and medications in one column and a very tiny social history and cultural history. And all of this is very standard stuff. Right? The galway HMP. And lastly here's one from our friends to the north and Dartmouth. Same thing. You've got the HMP completed by so who's the documentary if you complain or diagnosis planned procedure, all of these things should look very familiar to most of us. And it is how particularly physicians but other license independent practitioners of healthcare interact with their patients on a daily basis. Right? We document all these things and also this is how we get paid. This is how we document how much we did, how much work we did for our billing. Um but I have a problem with this and this is why this this bridge metaphor is is a challenge we have to overcome and it's the chief complaint business, right? That's the C. C. There. You can see chief complaint and go back to chief complaint, chief complaint, chief complaint. And thomas has heard me say this at the double AMC, it's always giving me chest pain. One of the very first things we do is capture someone's quote unquote complaint when they come to us for health care or advice or guidance or conversation. Um and so I I very much am hoping that we can do away with chief complaint as a concept, right? I would take it out of all the ancient ancient P templates entirely and I would replace it with chief context. And again, pour thomas has heard this more times than he probably cares too. But I would take that same acronym with the CC, which is chief complaint now make a chief context. And at that phase of the H and P, I would say that the bridge then becomes questioning and serving in the individual for their social determines of health or the sdo H. It is my concerted view and in my research supports this. That if we don't understand this aspect of an individual's lived experience in the moment and going forward and certainly in the past, then we will be almost completely impossible. Uh, it will be impossible for us, forgive me for to meaningfully impact someone's health and wellness, no matter how much insulin we prescribe now, how much of a weight loss program we uh, we write down for an individual or in any number of other things if we don't understand these things and I'll kind of go into a little bit more detail in a second and I think it's it's impossible for us to define the context that was mentioned in that what I thought was the best version of the value equation and therefore to define quality. Um and in this graphic and this one I think is from the C. D. C. S. Current iteration of this representation of the sdo H. U. C. Education access and quality. You see health care and health care itself and quality. You see neighborhood in both environments, social community context, economic stability, all of these things I think makes sense to any of us who have spent some time thinking about this as social or societal determinants of health. And I think our colleagues who are in europe probably are aware of these things, but they may roll their eyes because they tend to invest much more heavily in these aspects of society as a construct than we do in this in this country, tend to invest more heavily in the health care part of this, but depending on who you ask and depending on which research you look at, No less than 40 50 of a person's individual over a lifetime. Um, and in the moment healthcare outcomes are driven by these factors and a few others that aren't on on there, but the sub factors of things like social and community context include things like um are you downstream of pollutants in your environment? Are you living in urban heat sink? Are you living in a desperate, all in a rural area? Do you have access to drinking water that's safe? Are your public schools, places of violence. Are the school shootings that take place in your school? So all these things that are sort of subcategories if you will of the S. D. O. H. Um play into this notion of of value and quality for health care in a way that I don't think we've yet really bridged to break these down further. And again you'll see this is from the Kaiser Family Foundation. It's a wonderful website that's got a wealth of information available for general consumption. Um If you look at these economic stability in the major categories, I went through earlier, you can break them down into sub categories. And I love things like walk, ability and and zip code and geography as examples. Um Community and social context again near and dear to my heart because of the term context. But social integration, isolation is something we really seem to become a real problem, particularly for the elderly during the pandemic, but also before the pandemic. But you begin to understand that if we don't really understand that the individuals context along these major categories and maybe one or two others depending on your view of this, then it's gonna be really hard for us to actually contextualized and therefore understand quality in their individual lived experience. So I want to take you on a journey to go back to some slides but with a different perspective. And that is looking at something like acute mortality. I'm sorry, I keep myocardial infarction or am I mortality rates who dies after having a heart attack and this is from the N. Q. F. Um I want to dig a little bit deeper into why that measure is not sufficient in my view. That am I mortality is an important thing to know and to manage and mitigate of course. But if you look a little bit more deeply into the N. Q. S. Or this actually NHL B. I believe the risk factors that go into having an acute heart attack and cute and am I our age, environment occupation. If you think back to environment, that was one of the major categories um in the S. T. O. H. Traffic, I showed you family history, well, your family history is also comprised of the exposure to your family, of interpersonal violence, environmental um risk factors like air pollution um and groundwater that's not potable lifestyle habits include things like exercise. Well, if you don't live in a community that has sidewalks or if you live in a community that has only high speed roads near near where you live, exercise is hard to do, particularly you can't afford to go to a gym like most of us. Um, and I want to take a serious pause here and look at this last one for this, this notion of race and ethnicity as a risk factor for coronary heart disease and therefore eventually am I? Which again is one of those NQ F metrics we talked about as a measure of quality. First of all, I think most of you know, but I'll say it bluntly race is made up construct. There's no such thing as race. And so race or ethnicity being a risk factor has struck me as a, as a problematic way to frame these things. And this is a very common thing. You'll see. Um, if you look at quality data that they use race, particularly people of color um, described as black or african, american Latina, latino as a risk factor for diseases. And I'm here to tell you that's just not biologically true. Um it is true that the exposure is that that people of color are exposed to our lead more often than not too poor outcomes for a variety of illnesses that lead to poor outcomes and things like acute myocardial infarction or stroke type two diabetes. But raised by itself as it's currently defined, is not a risk factor for anything that's from Heart Institute actually. So I'm going back to this graphic to show you that some of those same words that I talked about um in that last slide. So we talked about likeability are on this graphic as S. T. O. H. But I'm not used as risk factor modifiers in the heart lung NHL. B. I. Data. I just showed you so, digging a little further into a different disease to kind of make this case that that we can work our way from what the health system and the measures of the health systems in the world, So, CMS and qf. Arc et cetera. What they look at in terms of um measures of success or quality. Including I used example here of COPD um and I dig into this risk factor connecting the the quality metric with the risk factors that might lead to experiencing the disease that is measured. And if you look at this one a little more closely you see that um people who have COPD um most of them smoke and I think you know that are used to smoke. People who have COPD have a family history of COPD particularly they smoke long term exposure to other lung irritants. Also as a risk factor. Keep that one on the top of your mind for a second. Air pollution, chemical fumes and dust from the environment or workplace. Ah environment, workplace though should sound familiar. We'll take it even further. Um this is from the american lung association. You look at these established risk factors in the last we talked about those already and again, these are for COPD and too many other degrees asthma as well. Um you'll see on the right air pollution computed asthma's which has got to do more with access to healthcare, poor nutrition. So food insecurity. Um Male gender holder conversation, low socioeconomic status. Look at that when we're at the bottom that list of probable risk factors of COPD and as a physician, it's hard for me to connect being of low income with a disease. Right? But it's easy to connect. If you look at the sdo asian, see what that's probably what connects these these dots here. So if you look at these several things right here, these are sdo. H. Right. And so we're talking about quality measures in terms of COPD, which is an outcome that CMS, as I just showed you, wants to keep an eye on. Well, yeah, we need to look closely at these social determinants of health because if we don't understand these and don't help our patients mitigate these as health systems, as universities, as institutes of higher learning, then our chances of impacting COPD on a massive scale. Pretty loop. And that was data from an indian group that published and this is the reference there for for the attribution. Um Dr Gupta at all. Um and this is another graphic from a group in china g and it just shows you how universal these things are. They're talking about asthma in this particular case. But look at the very top of this which is um exposure and you'll see it says air pollution, traffic, pollen, um airborne microbes, um indoor air pollutants like nitrous oxide, which is a byproduct of air conditioning in some environments. They built this model here for looking at asthma which again is pretty highly correlated with what happens in COPD. A lot of these things are based on, as you see in their graphic living in urban and rural environments, but they all end up in the same place of COPD and or asthma. And so the environment, the lives environment, the lived experience the context of patients is incredibly important because if the cost of your COPD outbreak in your community or or a or a large number of individuals having COPD is that they live downstream of a pollutant. If CMS wants to measure that as a qualify that as a quality metric, we have to actually get rid of the pollution right? We have to change the home environment. We have to understand the socio demographic characteristics and either mitigate the environment or move the individuals or the community away from the pollutant or the irritant. Much different problem than prescribing inhalers and steroids. Right? Much of a problem than provide prescribing antibiotics for flare ups. We can get down to the root of these things. We get down to the social tunes of health than the quality measure is much easier to achieve and frankly, much more sustainable. So our current state as I've described is that we often conflate quality and value. I truly think that we are really truly measuring value most often in this country rather than true quality. Again, because we really haven't asked are individuals are patients, I should say our community members what they think is important as a measure of quality for health care. We just made some assumptions. We've asked insurance agencies and the American Hospital Association and big interest groups like that, what they think are quality measures. But we really haven't done a good job of talking to our patients within the context of their lived experience of what health care quality actually looks like. And so I think value is actually more accurately described as an economic or business principle And that most current quality ministries and I have convinced you this in the last 40 minutes or so are often aimed at us as providers and looking at what we think. We can measure what we think is important and what we think we can do something about and therefore what we want to be measured on. I would submit to you that patients who's lived experiences are governed by the Sdo H I've talked about and many others um probably value different things than we do and would define quality from the patient's perspective differently if we give them the chance to, particularly if we give them a chance to do within the context of their own lived experiences. And with that I will end my remarks and I think oh sorry one more slide. Um as I said patients probably value different things and I think it's better defined by patients contextualized to understand that context. We actually have to, in my my mind in my view universally and ubiquitously ask patients about there S. D. O. H. We have to understand them because they often change, right if you're employed for a long time and the pandemic hits and now you're unemployed, you now have a very different social dynamic and that's the thing that's playing out all of the country as we all know right now. So economic instability is a new phenomenon for people whose S. D. O. H. May have been different two years ago than it is now and and in a much more fraught state than they were. And so my recipe for this is understanding the patient's context and the S. Two H. That that governs it for individuals will enable novel and personalized, truly personalized definitions, value and quality. And with that I will show you a picture of why I do what I do every day. My my wife and kids there we are at the outer banks of north Carolina. For those of, you know that area. That's the pier on the sound side in duck north Carolina where we're headed in a few weeks for another escape from Covid in a nice social distance way. And at that point I will take any and all questions and I will see. I'll stop sharing my slide. Here we go. Thank you, mike for that wonderful talk. I will help facilitate some of the questions. So the first one, um, it seems this will require public private sector partnerships. How do we incentivize private health care to engage with the public sector? Yeah, well, I I totally agree that there is no chance, um, that either any single component of our society and it's it's a societal problem that we're talking about. And so the answers have to be also at the societal level. I think incentivizing their private sector has begun to a small degree. And that is if you look at the fact that Z codes exist and for those of you who don't know what the code is, essentially. It is the uh, the, the diagnostic codes and for those of you don't know, we All right doctors and nurses and pharmacists and etcetera write in code when we're doing our billing primarily. And so we have to assign a specific diagnosis or code eventually to anything we want to get paid for it. And I'll put it that way bluntly. Um, Z codes are relatively new in the last few years. Category of codes that actually look at our our specifically about the S. D. O. H. And it looks like CMS will probably use them as modifiers to get to this notion of a new definition of quality and value going forward, you know, with the Change administration, who knows? But it may well be that we will be incentivized to document these things. But the other incentive for the private sector is really this question of value. It's hard to get much, much work product of a person who works for you who's who's out sick, right, low back pain, injuries are a huge cost of time and waste and turnover. For almost every industry in America, there are very few that don't face this issue of workdays lost. And so the incentive is actually already baked in a healthier, um workforce, a healthier, um, student body mrs, less class, mrs, fewer days of work is more productive and frankly, is happier and therefore more productive. And so if you if you embed this notion of, of capitalism as a foundational way to do business, including in health care, it's actually the most obvious synergistic relationship in my mind, where I I think it's really fallen down is, um in academics where academic health systems don't always see the value of this more and more of us are. And I'm pleased to say that, that, you know, Eva is beginning to understand that our job as an anchor institution includes understanding these factors about our patients, um and investing in things like housing in the community, and investing in our public schools directly and indirectly so that they are better functioning and therefore the individual societies in the hole in the main healthier three um two um sort of piggyback off of that question is health care is being measured for the outcomes, but the outcomes are influenced by the social determinants of health. How does health care help impact those to get a different outcome? Well, so I did look into that a little bit, but I'll elaborate a bit further. So, an example, a very good example, and I use the term the example of the homeless individuals and their A one C and the talk if you Have a population of individuals who seek care and your health system or frankly if they just live anywhere near you and they could potentially access you access your system. Few 911 services. Um The root cause of their illness. Well no matter what it is can't be solved if they remain homeless. It turns out that that human mammals need shelter um to live their safest and healthiest lives. And so things that are going on around the country as examples of how health systems can particular. Integrated health systems can really mitigate these things is investing in public housing. Um The other other major thing that's happening in the housing space, that's a very exciting development um is that health insurance companies have also figured this out. And so there are lots of environments in which I know United Healthcare has got this and some Medicaid offices around the country have begun to do this where physicians and mps, anybody who can, who can prescribe something can prescribe housing or can prescribe food. And there's a public benefit that's available to them with that prescription in hand will be electronically these days um that that we can continue to lobby for to advocate for if you are are partnerships and our payer sources to provide the resources because Aetna certainly figured it out if if they've got people who are marginally housed, if they got people who are really food insecure or eating the worst of the food they can afford because it's what's cheapest their costs as an insurer are going to continue to rise. And so they figured that out. And what we can do, I think is as healthcare providers, whether it's in the big system or a small one is to continue to advocate for the ability to prescribe food and shelter, because those are the two biggest things that I've seen that lead to a whole host of all the bad outcomes that we get measured on currently. Oh, another question here. How do you suggest that physician groups engage patients to find out what their goals of quality are? Yeah, So I think that the first step is to use any any one of the readily available sdo a screening tools are out there. There's the health leads tool which they've offered to the world for free. Um There's they're prepared tool CMS frankly actually convened a working group from 234 years ago now um to develop and for those of you are conduct you hcs you've seen it because you have to um as part of your funding um a screening tool that's intended to document that Health care service providers have asked and captured Sdo data around 20 different domains. Um So there are there are tools that are already out there. You don't have to invent a new one yourself. In fact I would urge you not to um They ask different questions. They have different domains but then ask them of everybody that that will answer the questions. Not everyone answer questions. But I think you know having a community based conversation with your patient base um that we're going to begin to ask you some really odd sounding questions that may not sound to have anything to do with your health care but turns out they're pretty important for us both to know. Um If you're living in your car, what I prescribe for you to manage your blood pressure might be different than if you're living in a mansion. Right? And so these are the kinds of things that we can do as health care providers and there are tools that are already out there, they're free. Um you know, I think I will put my twitter handle in there. I I designed one here that emerges is preparing health claims tool. I'm happy to give it to you. You know, the more people who use this, the happier I am. So there's no proprietary feel about this for me. But they're definitely out there for you to use a question sort of related to our current state of the pandemic, but certainly tell health continues to expand. But do you see telehealth as a possible move towards overcoming some of the social determinants of health challenges? Or is it something that's more isolating and impersonal? So I think it's it's it's primarily going to be a real win for us in this business with the caveat, there is a bit of a double edged sword in terms of access questions that also, you know, the people that are most likely to be negatively impacted by um sdo H domains are also going to be the ones who are at least I could have access to broadband and wifi and those kinds of things that said there is a, you know, the pandemic has has forced the hand of primarily CMS and therefore many other other other payers that telephone based encounters also qualify for frankly for payment for reimbursement and to be blunt if we don't get paid for it, a few of us can afford to do anything very long in health care. And so the the game changing piece of telehealth and I'm a giant fan telemedicine, let's just be clear. I think that's one of the most important things we can do is that we have to have the parallel policy change that allows telephone encounters to be part of that rubric as well. But also the the push that I think President biden and his administration are really trying to do in terms of infrastructure includes broadband access, two parts of the country that have little access to cell phone towers that alone broadband, you have to have both. But there's no question that for the moment and I've seen this in Haiti the cell phone is an important and powerful tool for telehealth, right? The the idea that you can do an encounter particularly behavioral health care encounters without being face to face doesn't feel best to us. But absolutely its value adding for patients who can't get to or don't want to leave their other otherwise their place of safety or their place of shelter. So I'm a huge fan and I think it's going to be a game changer, as long as we don't go backward in time with the policy. And I guess a quick follow up to that question is the utilization of tele health hubs and community centers or churches. Do you think that could overcome some of the issues like you were mentioning with broadband access or other issues? Absolutely. One of the things that I've been, I've been pushing in terms of pandemic response, but it's really I'll share some some laundry. My version of the pandemic response is that the pandemic is no different than all the other diseases that we've that we've dealt with in this country. It's just much more rapidly of onset and outcome. Um My answer is I think that we should be leveraging the following places in different ways. Public schools, fire and ems stations, public libraries and health centers, those should all be sources of broadband and many, many of them are publicly available. So if you're enough THC on the call, you should be providing, in my view, should be providing broadband access to anybody that can get to you or can get within striking distance of your wifi network. Ultimately, for me, it's a public utility question and it should be that that's something that no one has to pay for it because it can literally save your life um either acutely or over over a long period of time. And so I think there's no question that there is real value in that. And I think leveraging infrastructure, most public schools in most jurisdictions, not all by any stretch, have wifi in the school. Um one of the things that we've tried to do here during our picnic responses to make university buildings hotspots for the community. So if you live enough close enough that you can walk to a U. B. A building and get close to it, the wifi doesn't stop at the walls. Um, and so making it available and making it not password protected becomes also pretty important. But yes, those are, I think public buildings can be leveraged in ways that we really happened in the past. And I think health centers, whether FQ Hcs or not, FQ Hcs or lookalikes are really good examples of places. And I think that the public school systems, which do so much already as it is between school based health centers and school nurses who do tremendous work being very much the frontline, particularly for kids, but also their families can be leveraged further to become these hubs that we're talking about because even if you live far far from a public school, your church and your public school are probably the clue things that you know where they are, no matter who you are in a community, your kids public school, even if it's far far away from you live in a rural area where the school is really remote, it's a thing, you know, where it is not to get there. Um, one of the ideas you were just speaking about with, you be a providing, you know, wifi that does not have is not password protected for people who are able to get their sort of speaks a little bit to a topic that you briefly mentioned in the anchor institution and the the role that academic medical centers who are taking on that role of the anchor institutions are starting to play. Can you just describe, you know, a little bit more about what you mean by anchor institution and again, maybe just a couple of examples of some of those concrete steps that, you know, you be a or other anchor institutions are taking in their communities. Sure. Uh and I'm I'm happy too, because this is something that's near and dear to my heart as thomas knows he's a plant. Um So the idea of an anchor institution is is not that complicated, um but yet not that common yet. So the idea is pretty simple. It's that in any given community, um the primarily biggest employers um dr the local market of everything, right? They drive the housing market because where they set their their salary scales, drives who can afford housing in that community in that market, where they set their benefits, who they negotiate their benefits package with if it's a, you know, there um enrolling their their employer based insurance program through Kaiser, drives the healthcare market in that in that environment. The idea is that because Institutions like you be a which is the biggest employer for 20,000 square miles or so in Virginia. In terms of the university, the health system, the combination of the two um, as well as all across the state, we've got sites as most places do scattered across the Commonwealth. The idea is that because we can and do drive things like the wave structure in this region. President Ryan Jim Ryan is our university president. One of the first things he did was to to raise the minimum wage of our employees. Well if you via is hiring it $15 an hour and everybody else is paying the federal minimum wage of eight and a quarter or whatever it is in the current state, who's going to work somewhere else. Besides, you can be right if you're gonna keep your employees now, you've got to you've got a bit of a price for going on and the anchor institution piece there was to lift all boats, right? We we say we're going to change our salary structure. It does have a ripple effect beyond what happens to be a that is um in my view sartorius for the community. Another example is um student housing in Charlottesville. For those of you have never been here is um 52,000 or so um permanent residents, another 30,000 of them students during the academic year when you add all the students up across all the different units. Um So student housing um in our case only the first two years of student housing is required to be on campus. So years 23 and four, I'm sorry three and four students are allowed and most mostly due to live off campus. Well we have a you know fairly well heeled um I mean um income if you will for our student bodies and so parents are buying kids houses. Here's the problem with that. She's not fundamentally itself a problem if they live where I came from which is the D. C. R. I. Lived in D. C. Before I moved here to Charlottesville 10 10 years ago or so. Um The housing market there is different than the housing market would be by itself naturally here in Charlottesville. But parents are paying housing market prices in D. C. For houses here. What does that mean if you live here with the lower uh average income than is in the D. C. Area cost of living is lower here but so is lower. So is the income. The housing market is actually affected by the D. C. Suburbs in the district itself. Which has driven a lot of working families out of housing here in Charlottesville. And they have to move further and further away from their place of work. You be a because of student housing. And so the anchor institution aspect of that is that the university is is investing in public housing starts all over Charlottesville. Um That will be and are guaranteed because we have the leverage is the biggest employer as I said to ensure that they are a significant chunk of them are affordable housing units as opposed to market driven housing units. So you be a is gonna sort of cap the amount that they'll that can be spent on mortgages and or rents in these places because well backstop the company's gonna build and buy and sell these things. But the covenant is only up to a certain point of of income where you have to be able to charge you know, your reporting point for your mortgage or your rent. That's anger institution activity. That is driving housing security as opposed to insecurity and driving income, which drives everything else frankly. Right? If you can make twice as much as you appear at a minimum wage internally then you're buying power goes up in, your ability to purchase, health care goes up if you don't have health care, if your employer, all those things ripple effect outward from institutions like that. And we are no by no means that the lead in this we're we're kind of late for the dance and to say U. N. C. Um as an institution as a whole has been a tremendous example of this Rutgers in New Jersey Chicago has done tremendous work on the south side in particular where they've invested very heavily in the community. Not one bit of it as a hospital bed necessarily, or clinic or a doctor or a nurse. Great, thank you so much. We are unfortunately going to have to wrap up thank you for your wonderful presentation today and for joining us virtually for our safety and quality symposium, we have a short video to highlight some local work. Um so it's a 10 minute video featuring Caitlyn reedy Rogerio from pipeline to compassionate care and lisa meadows from ST louis, Children's hospital on the child health advocacy and outreach programs. That video will be played and then there will be a wrap up session that comes on after. Thank you again so much for your presentation today. It was my pleasure. Thank you very much. And if you, I didn't see if you put it up there but please do put my twitter handle up there so people can reach out of one and thank you all for the kind comments and the Q. And A. And the excellent question. I will try and put it in the chat. Thanks. Thank you. So the pipeline to compassionate care program is a program of the ST Louis Integrated Health Network. Um and it's a program that's designed to help bolster curriculum within our medical campuses across the region. Um so I worked both with washoe washoe med school, Slew med School um and the ST Louis College of Pharmacy to help create more cohesiveness around our messaging around health equity, social and structural determinants of health, trauma informed care of all these social medicine concepts to make sure that we've got providers that are matriculating through our medical education programs that are coming out prepared to serve vulnerable and underserved populations. I think it's really important that physicians are able to make connections between what a patient is experiencing in the community, what a patient lives through on a daily basis and then what that means when they show up in a hospital setting or at their doctor's office and their safety and and what that means for them can look very different um as well as the what they perceive as quality of care. Right? And so making sure that those connections are being made by the physicians before the patients ever get to that space so that they're having an overall better experience, I think is is one of the ways that I see this making sort of a market impact on a doctor's ability to be effective, social and structural determinants of health. Are these aspects of the patient's life that impact their health? Um and those are things like the social determinants of health, particularly things like housing, transportation, child care, um the structural determinants of health, are these broader things, Right? These more policy level things? So what does housing policy look like? What's legislation around health care? Um We think about Medicaid expansion, right, That's a structural determinant of health. At least two thirds of the population has experienced some sort of trauma in their life, so it's not a far leap to say that everybody has and how do you alter care or your approach to care with that in mind. Um And so one of the really sort of distilled down ways to think about this is changing the question from what's wrong with you, to what happened to you, right, and that cognitive shift can really impact the way that you have compassion for your patients, You have empathy, you can be nonjudgmental. Um and I think it really sort of opens up opportunities for building a therapeutic relationship. There are things that maybe are out of our control are inevitable in a doctor's visit. That's the nature of health care. And there are ways that we can minimize. There are ways that we can talk through it. There are ways that we can prepare patients so that they're not caught off guard. And I think those are all the things like walking through this with them, because I think so much of that is muscle memory, right? It just is the way that it is and it's always been this way. Does it always have to be this way? Right. And where can we start to make intentional decisions about how that looks? So chau stands for child health advocacy and outreach. It is where all of our community program is housed within Children's hospital healthy kids Express was the first medical mobile unit in our area. It started in 2001. There are currently three mobile units which are all equipped like Doctor's office is the first being dental dental does not only screening but also provides restorative work. The second vehicle is for screenings. These are the screenings that allow preschoolers to enroll in school and make the schools compliant. Various screens consist of hearing, vision, lead anemia and immunizations. The third mobile unit is Asthma Specialty Care. We work in conjunction with Washington University's pulmonary unit And in August of 2021, we will be launching in partnership with endocrinology, a diabetes mobile unit. All of these mobile units travel to schools and provide care or daycare facilities. Top is teen outreach program. It is an evidence evidence based program that's ran um and was devised through women. It promotes the development of adolescence through that very trying time when they're trying to figure out who they are and what they're doing. So it takes a curriculum and then also combines community service Children enrolled are those who are in the 6th through 12th grade and during this time they learn emotional management, problem solving, decision making skills, goal setting, health and wellness. We bring it all together and work in various, like we said, community service learning projects um And that's done throughout the entire school year. Another program we have is weight management and that's called Head to toe. It's a 17 week program that's offered both to parents and their Children in ages 8-17 years of age. There's various locations and we're in partnership with the washoe obesity clinic. We help hold The different sessions at various locations throughout our community, but once we have a 17 week co heart that starts, it does stay in that same um location. This is also offered through your B. J. C. Benefits package so you and your family are also welcome to join. We also have to injury prevention programs. The first is Safety Street Safety Street uses a life size cityscape module that's assembled and Children come and they navigate through potential street hazards in a safe controlled environment. In other words, we're educating Children to safely navigate things that are close to them so it may be um the uh Metrolink or how to get on the bus. The goal for this is to reduce the number of injuries and fatalities. The final program is called Safety Stop. This is the program where we offer help on various safety products such as car seat safety, helmet safety, home safety and sleep safety, you can imagine by the areas of safety that we touch. We have several partnerships both inside the hospital and outside any family is able to access these services and currently they are located in the garage at ST Louis Children's Hospital. They are located at the specialty care center in town and Country Progress West Hospital in O'Fallon and then in the community. It's open at the Magic House in Kirkwood. Community engagement is extremely important and it starts at the beginning of any kind of program. Before we start a program, we do a community needs assessment and that is done every three years. This the results of this community engagement, our community needs assessment dr what programs we deliver. So engaging partners early in the process is very important. And continuing to expand. Our partnerships are networks is equally as important to provide families what they have identified as a need to increase increase community engagement. We also provide wrap around services actively involved in our families, listening to their needs and finding resources to fit these needs. Our community health worker is an example who works with the families and who knows various resources throughout our community. They assist these families in navigating the difficulties of the health care system and they help eliminate any social determinants of health that arise. We use many other agencies and share these agencies with our families. We want families to know that we are listening to those problems that they have identified and we're actively engaged in meeting their needs. What does this do? This helps build trust both inside the schools and in our communities. But this isn't easy. This is hard work and perseverance that allows us to work directly with community partners and families to ensure that we're streamlining care were building their trust and reducing duplications of services and bringing or filling in gaps