“It's a Mindset”: Health Equity at Children's Mercy Kansas City

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Tom Haederle
Every component of the health care organization has a role to play to advance health equity. This essential work should not be relegated to one team or department, but woven into the fabric of the organization. For many hospitals, this will require a culture change. Team members will need to think and act differently, and it will involve engaging people who don't traditionally see health equity as part of their role.

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Tom Haederle
But that is what it will take to truly integrate health equity into an organization.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. AHA's Julia Resnick, director of Strategic Initiatives, spoke with two leaders from Children's Mercy in Kansas City about their health equity integration work and what makes it work. Dr. John Cowden, who goes by J.C., is a general academic pediatrician and directs the Culture and Language Coaching program at Children's Mercy,

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Tom Haederle
also serving as the health equity integration project leader. He's joined today by Jessi Johnson, a health equity specialist in the Office of Equity and Diversity. And now let's go over to Julia.

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Julia Resnick
So before we dive into your equity integration work, can each of you share a little bit about yourselves, your roles and Children's Mercy Kansas City?

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Jessi Johnson
My name is Jessi Johnson. I will be celebrating my eighth year with Children's Mercy just this month. I started originally in the Quality Improvement department for a little over five years, and have now been with the office of Equity Diversity for almost two and a half years.

00:01:38:21 - 00:01:59:22
John Cowden, M.D.
And I'm J.C. Cowden. I'm a general academic pediatrician here at Children's Mercy Hospital. So that means that I am a pediatrician clinically. So I see kids in a primary care clinic, and I serve primarily Spanish speaking families in my practice. I also teach residents and medical students in that setting, which is one of the things that makes us an academic setting.

00:01:59:24 - 00:02:18:09
John Cowden, M.D.
I've been at the hospital about 18 years now. I've always had half my time focused on health equity and diversity, equity and inclusion in a variety of different ways and different roles. And so you also asked about our hospital, Children's Mercy Hospital. So it's an academic hospital as I've mentioned. Very large, tertiary care hospital system

00:02:18:09 - 00:02:37:23
John Cowden, M.D.
really. We have our main hospital in Kansas City, but we have a number of different campuses and sites throughout the Kansas City metropolitan area and throughout the region, sort of out into both Kansas and Missouri. And we have about 8500 employees roughly across all those campuses, most of them concentrated in in our main hospitals in Kansas City.

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Julia Resnick
Can you tell me a little bit more about the community that Children's Mercy serves, and some of the equity challenges that you see in Kansas City?

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Jessi Johnson
I think Kansas City is not unlike many other metropolitan communities in that, as far as like specific to some of the equity challenges, there's a long history of racist housing practices. It was in Kansas City that one of the first property developers used deed restrictions and other tools to exclude people of color from purchasing homes or properties in certain neighborhoods.

00:03:07:24 - 00:03:38:19
Jessi Johnson
We'll still see some of evidence of that today. And this racial segregation can be observed using current demographics census data, much like other communities. If you overlay demographic maps, you can see where the history lies. We know that this history leads to a significant and measurable wealth gap, with the median net worth of white families in Kansas City as of 2002, being $285,000, compared to $44,900 for black families.

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Jessi Johnson
Just kind of - we know that that much of this is due to redlining and the opportunity of generational wealth being passed down. And that's something that we see in a lot of comparable sized communities and even larger communities. Also, I think unlike other areas, Kansas City has food deserts in the urban core, and there's also limited access to care in rural areas.

00:04:01:13 - 00:04:26:00
Jessi Johnson
That isn't special. Or, you know, unique. But I think one equity gap that is special to Kansas City is how we straddle two different states. Both states are conservative politically but have different leaders and different legislation being proposed or passed that does affect the care that we can provide. This also includes even Medicaid expansion and states interest or lack thereof

00:04:26:03 - 00:04:43:12
Jessi Johnson
to do so. There may be specific programs that come out of the state of Missouri that would exclude Kansas residents, even if they're just one mile over the state line. That's definitely something you see and don't see is the longer you live here, it just becomes part of the norm.

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Jessi Johnson
But when it comes down to, I think specifically legislation, access and the care that's available, there are differences for the fact that we are really smack dab in the middle of both Kansas and Missouri and how that affects as we travel across state lines.

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Julia Resnick
Yeah, that certainly is a unique situation. J.C., anything you want to add?

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John Cowden, M.D.
Yeah, I'll just add again, like many, many, many cities maybe all cities in the United States, we have lots of newcomers who come to our community from other places in the United States or from outside the United States. So we have immigrant populations that are of many different generations. So we would have our immigrant communities that might have been here since the late 1800s

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John Cowden, M.D.
and then also newer immigrant communities that are being established throughout the metro all the time and again across the state line. And in both states, we have different policies and, different almost culture of welcoming around immigrant populations. So we keep a close eye on that and work a lot with community to understand how that's impacting families and children in the city and what we can do as a hospital to, to support.

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Julia Resnick
That's really wonderful. And it sounds like there are a lot of opportunities to, expand the work you're doing around health equity. So can you talk a little bit about what you mean by health equity integration?

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John Cowden, M.D.
Yeah, sure. health equity integration is a term that we use at Children's Mercy to describe a mindset when we're talking about an individual or, culture, when we're talking about a group, or an organization where the need for health equity perspectives to be part of the root of your work, the foundation of your work is needed for us to actually achieve health equity.

00:06:20:26 - 00:06:38:24
John Cowden, M.D.
And that that's needed in addition to special projects we might do. And there's been a history of special efforts, both at Children's Mercy in it, at many of the hospitals where our listeners might be in another parts of our society where, you know, let's do a special side project that's going to focus on an inequity that we've found

00:06:38:26 - 00:06:57:20
John Cowden, M.D.
in addition to our regular work. Or let's do some extra education about, you know, how we work as humans together and how that can lead to problems in equity. Let's do that as a special educational effort. Those are great. But we have found over more than almost 20 years now doing this formal work at Children's Mercy

00:06:57:22 - 00:07:19:09
John Cowden, M.D.
that doesn't get us very far to do special efforts only. We have to get down into the roots of what we do. And so health equity integration is about bringing perspectives around health equity into the everyday work of all people who are working in a hospital in our case. Every single person in the hospital. And so you'll hear phrases like baking it in instead of putting it on top or weaving it in.

00:07:19:11 - 00:07:41:01
John Cowden, M.D.
There are different analogies or phrases people use to describe this. We're not the first ones to ever think of it, but we did want to try to operationalize it so that we could talk about it and move forward to action so that we actually make that a reality and can start to see health equity out in the future, rather than kind of going in circles and feeling like we're not going very far with, with just doing special efforts.

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John Cowden, M.D.
That's what we what we mean. Jesse, I don't know if you want to add anything to that about how we talk about health equity integration.

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Jessi Johnson
I mean, I think just even the origin of it, I have a lot of respect for the history of the Office of Equity, Diversity and J.C.'s part in that. And understanding as I came to the project, much more novice on the subject, that there was many years of, you know, I guess unsuccessful efforts of really helping the organization see their role that they play in this and how important it is that they acknowledge and accept the role that they play in this.

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Jessi Johnson
Also, that when I first really became passionate about health care disparities, I was really sort of kind of focusing on I think a lot of us think of the how we're measuring this. What is the gap, what, you know, the statistical significance. And J.C's just been a wonderful mentor in leading this effort in how we make this a qualitative kind of journey with our colleagues and coworkers in an organization that was founded in health equity.

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Jessi Johnson
we have a really special legacy specific to the women that created this institution and that we can stand on, and help kind of be a part of the ongoing story and ongoing journey with health equity that Children's Mercy will always have a legacy with.

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Julia Resnick
So you have that legacy and you have the ways to talk about health equity. But I think and I know a lot of our listeners in their hospitals, like equity is a separate department and they do equity. So how do you how do you get people that don't traditionally consider equity to be their job, to integrate it into their mindset and their day-to-day work?

00:09:20:00 - 00:09:36:15
John Cowden, M.D.
There's one piece of health equity integration in the way we talk about it and think about it that we found can be helpful is that we start, first of all, with the assumption that everyone wants to be great at their work. I want to be the best pediatrician I can be, period. That someone in finance in our hospital wants to be the best person in finance

00:09:36:15 - 00:09:52:00
John Cowden, M.D.
they can be in their work so we give that benefit of the doubt. We all want to be great. And then we also assume that the way humans work with each other can cause inequities. It causes differences in the way we think about each other, in the way we act around each other. And that can have real impact on people's lives.

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John Cowden, M.D.
And in the hospital, of course, there are many obvious examples of that, and we talk about those examples. So we take those two assumptions as given when we start our work and start talking about it. And then we will talk with folks about saying, you know, what are you already doing? Or what are you already worried about in your own work that might cause different impact in the way things happen around you, the processes you use.

00:10:10:22 - 00:10:27:09
John Cowden, M.D.
You know how you think about people that people think about you. And we kind of invite people to explore, where are they already concerned about differences or inequities? Where are they curious? What kind of celebration should we have for the things they already do? They might tell us, hey, I already have change this thing or our team has done this.

00:10:27:09 - 00:10:46:01
John Cowden, M.D.
We say, yeah, great, that's so amazing. So we start from a place of what I like to think of as, respect, for people in who they are and what they do, and assume that this is something that matters to them. It might not, but for many people it does. And then start to build on that. And then we can then say, let's explore.

00:10:46:01 - 00:11:01:21
John Cowden, M.D.
What have you thought of doing even more of or better than before to do even better at your work? You cannot be the best version of the thing you do if you don't take into account the way we are different from each other and the way we treat each other differently based on those differences. So let's explore that together.

00:11:01:24 - 00:11:20:03
John Cowden, M.D.
That, I think, then allows people to teach us about their work and what it is that's going on for them, rather than us coming and saying, we're going to teach you how to be better people. People don't like that, we found in general. And they don't respond to it. But when we really get curious about them and what they want to be and how they want to be great, we can start to then find roads of opportunity towards equity in their work.

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Julia Resnick
I love that, so talk me through your DEI checklist and the universal questions. What are they and how do you use them?

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Jessi Johnson
These tools, I think, came about by, you know, even a matter of necessity. We wanted to provide something to our problem solvers at Children's Mercy. Those that are doing quality improvement work, process improvement work, they're already using a tool that they were you called the framework for problem solving. And it had a lot of opportunity to integrate with the concepts that we were wanting to teach

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Jessi Johnson
and so we actually created the original DEI checklist to pair with the framework for, for problem solving, so that those that were out through our institution, really addressing some of the really important gaps in care that we're wanting to create solutions for. They were able to have something that they could keep and carry with them that really fit specifically into the design of that tool.

00:12:15:08 - 00:12:38:28
Jessi Johnson
And from there, it's really organically been adapted numerous times for different users and for different reasons. And we welcome anyone to consider adaptation for their own use. Our spiritual services team has actually been a surprising adaptation in how they've decided to use the health equity integration checklist that wasn't specific to clinical care or even hospital specific.

00:12:39:00 - 00:12:56:23
Jessi Johnson
And so there's users of this - or fans of the checklist that can really see even just taking a piece of that and how that might apply into our way, that they could live in their daily work. But the universal questions is also something that was designed to fit into any bottleneck processes, the way that we refer to it.

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Jessi Johnson
So we consider portal requests for support. Portal requests for education. Those are spaces that those would fit naturally to just add one simple prompt, one simple pause. The questions are crafted or created by the teams that will be using them. We support them in that. but it's really important, really, really foundationally important that they're the owners of that process

00:13:22:12 - 00:13:47:27
Jessi Johnson
and of that question. So the question that has been in use the longest is with our clinical safety team. They use a universal question in every apparent cause analysis for a safety event that occurs, to see what may have contributed to that event and what we may consider changing to prevent that event from happening. That specific question went through several iterations over several years, and they added a preamble.

00:13:48:00 - 00:14:06:23
Jessi Johnson
And so it was just a great way of showing how they chose to own the question and apply it to their work. And they use the answers that are received from that question in their work. It's not a question they're asking for us. So universal questions, just a way to refer to something that can be very, very broad and can be changed and adapted as many times.

00:14:06:26 - 00:14:22:15
Jessi Johnson
But it has a very specific purpose in creating a opportunity to stop and consider how might our differences play a role in the project or problem, or the solution that we're looking for?

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John Cowden, M.D.
Would it be useful for me to walk through the checklist itself very briefly, to kind of like what's in it?

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Julia Resnick
Yeah, I think that would be really helpful.

00:14:29:03 - 00:14:55:07
John Cowden, M.D.
So the DEI checklist as Jesse described, originally paired with an existing tool for problem solving, but then it took on a life of its own as we adapted it for other people to use. But all of the checklists have a certain structure in common. So whether it's for a clinician to use in thinking about their clinical practice, or a researcher or research team to use, or a board of directors to use and thinking about their own work or strategic planning team.

00:14:55:15 - 00:15:15:17
John Cowden, M.D.
And there are many others. What happens with the checklist is there are four simple steps. Step one is for everyone to get into a health equity frame of mind. There's a list of vocabulary words of phenomena, concepts that happen when humans work together. So things like equity and disparities and racism and anti-racism and social determinants of health.

00:15:15:17 - 00:15:31:18
John Cowden, M.D.
And you know, there are about 10 or 12 of these terms with very brief definitions and a little table to have the individual or the team just read through to remember this stuff happens in life when we work together as people, we need to be aware of that. Step two prompts the user to think broadly about the word diversity.

00:15:31:20 - 00:15:50:11
John Cowden, M.D.
And so when they think about, you know, what does it mean to have a diverse patient population or diverse team? Whatever it is, we have to make sure we get beyond the first two things we think of, which is usually race and gender. When we say is a board of directors diverse and go beyond that, it has a list of lots of other characteristics that come into play when we work together, or how we hope to serve others.

00:15:50:13 - 00:16:06:01
John Cowden, M.D.
So it's to broaden the mind about diversity is step two. Step three is to make sure that at every step of what you do, you're actually taking into account these phenomena and whether or not they might play a role. So not just one time, but to repeatedly return. And then step four is to use a worksheet on the back to keep track of your thoughts.

00:16:06:01 - 00:16:16:24
John Cowden, M.D.
And so some further questions to prompt. So those questions will differ on the back depending on who the user is or what version of the checklist we're talking about. But that's the basic format of the checklist.

00:16:16:26 - 00:16:31:16
Julia Resnick
That's great. And I love how each team that you work with can customize it so it feels relevant to their work. And it's not it's more organic and I guess baked in that way. So can you tell me what DEI integration looks like in action at Children's Mercy?

00:16:31:18 - 00:16:52:27
John Cowden, M.D.
You know, it's interesting if you came to our hospital and you said, hey, Jesse and J.C., can you just show us, you know, health equity integration, like, as it's happening, you know, where will we see it? There are a couple ways that we would show you health equity integration happening. The first would be in what Jesse and I do and other teammates who work with us in the health equity integration project, what we call the project.

00:16:52:27 - 00:17:18:05
John Cowden, M.D.
It has certain activities, so we give workshops, for example, to teams within our hospital about these tools and about this idea, and then help support them in creating action plans for themselves. Again, based on what it is that matters to them, where they want to go with this work. We also do one on one coaching sessions or consultation sessions with either individuals or teams who have this interest as well, and we can help them craft their own integration activities and their own measures of that.

00:17:18:08 - 00:17:41:01
John Cowden, M.D.
And then you would see us also doing different promotion activities where we just start talking to folks about this and trying to inspire them. So you'd see that as one kind of integration and then the results from each team. But also we would start pointing to all kinds of things that aren't under the project we're talking about. There's so many examples of integration happening throughout the hospital that folks wouldn't necessarily call health equity integration if you ask them what they're doing.

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John Cowden, M.D.
But Jesse and I can point out and say, that's health equity integration right there. Look at that team. How amazing it is that they in their huddle before every clinic session. They've now integrated this opportunities for equity question.

00:17:51:15 - 00:18:16:07
Julia Resnick
Yes, that's really more culture change than it is a specific project, which I think is so important. So I know some of our listeners will be from children's hospitals, but a lot of them will be from not children's hospitals and I think this is incredibly relevant to both types of care. But can you talk about why it's particularly important to integrate equity into pediatric care and what makes this setting a little bit unique?

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Jessi Johnson
One of the ways that it's unique in a pediatric setting, I think specifically to even with DEI concepts is a particular challenge for pediatric hospitals is how we understand our patients and families identities and their language needs. Not all families speak the same language. Not all family members share the same racial identity. And in a pediatric hospital, it's a much larger group of people that we are caring for, even in the way that we provide care or an indirect way that we may provide care.

00:18:46:23 - 00:18:53:00
Jessi Johnson
And that is a unique responsibility for all institutions that provide pediatric care.

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Julia Resnick
So you already do so much fantastic work in this space. But as you look towards the future, what's next for you?

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John Cowden, M.D.
Well, a lot, there's always more to do, of course. We're just scratching the surface. We've been excited about the momentum that we see in this area, not only where we might be working and connect with people, but others in other hospitals, other parts of United States where we can network together and say, hey, you all are doing something similar over there.

00:19:18:20 - 00:19:35:10
John Cowden, M.D.
So we see a lot of momentum coming. We do a lot of internal growth and spreading through our workshops and consultations and coaching, where there'll be more of that. But also we do a lot of work outside the hospital where we will consult with or do workshops for or connect with folks at other hospitals, around the U.S. and in other countries.

00:19:35:12 - 00:19:50:03
John Cowden, M.D.
We've done that over the last five years, and we want to keep doing that because that's how we inspire each other to share our stories, to share ideas, and to agitate our minds and say, what else can we do? We got to go farther. We're not even close to health equity now. We can't even see it yet in the future.

00:19:50:03 - 00:20:06:14
John Cowden, M.D.
But we know we've got to keep getting deeper in our work to make the work we do different for everyone we see in a way that's supportive to them. This may be is a good moment to just say that we love sharing all of this stuff we're talking about and anyone who wants to who's listening, who wants to see more about these checklists

00:20:06:14 - 00:20:23:10
John Cowden, M.D.
we're talking about universal questions. They're all freely available on our public website. You just have to look for health equity integration, Children's Mercy, you'll find it. And they're just downloadable. You can use them. You can modify them any way you want. There's a copyright statement that says you can't sell them. So we don't want you going off and making lots of money off of these.

00:20:23:16 - 00:20:37:26
John Cowden, M.D.
These are for sharing. These are for helping, helping hospitals do better, not for making money off of. So you'll see that copyright statement. But please feel free to go access this stuff and be in touch with us, because we are really excited to keep conversations, going and growing in this area.

00:20:37:28 - 00:20:40:20
Julia Resnick
Jesse, anything you want to add before we wrap?

00:20:40:23 - 00:21:09:23
Jessi Johnson
I think one thing that is special about all of this and just lessons learned or key takeaways in our experience with this is this is very uncomfortable for a lot of people, unlike how we may create a culture of safety or how we may want to create a culture of quality improvement or be a lean institution. This is a topic that makes folks extremely uncomfortable, and that discomfort can push them away from receiving it.

00:21:09:26 - 00:21:33:14
Jessi Johnson
So there is a different way that we would consider, and a delicate way that we would consider approaching folks as we're wanting to spread this work. We don't expect everyone to enthusiastically adopt everything that we're teaching and we are very aware and understand that, the sensitivity of this does affect how folks may receive or react to the consultation or the workshop.

00:21:33:17 - 00:21:54:28
Jessi Johnson
And we're really open to understanding how in everyone's individualized identity plays a role and how they may be able to apply this in their institution and/or agree with our teachings. So we're open to that. And we know that we're not going to reach everyone, but we're still believing that the snowball of progress that we've created will just continue to grow.

00:21:55:00 - 00:22:01:26
Jessi Johnson
And we really do look to partner and pair with those that are interested and enthusiastic in embracing this methodology.

00:22:01:28 - 00:22:19:24
Julia Resnick
Well, I look forward to seeing how your work continues to grow. I hope you keep agitating minds. I hope that this podcast helps agitate some people's minds, and maybe think differently about how they're integrating equity into their day-to-day work. So J.C., Jesse, thank you so much for the work that you do for your communities, for sharing with us.

00:22:19:26 - 00:22:21:25
Julia Resnick
Really appreciate you being here.

00:22:21:27 - 00:22:30:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.