Agendas

Topics & Objectives: Introduction to Health Equity and Quality Improvement

•  Define health equity.
•  Describe the difference between equity and equality.
• Describe how quality improvement will be integrated into the curriculum for this program.
• Characterize the historical origins of quality improvement in healthcare and other industries.
  

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Key Takeaways:

• Health equity means that everyone has a fair and just opportunity to be as healthy as possible.
• Health disparity is a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.
• Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvements.
• We will apply QI tools using case-based, interactive sessions as part of this program.

Topics & Objectives

1. Cultural Sensitivity – Foundational Awareness
2. Understanding the basics of Infection Control infrastructure
   • Describe the cultural sensitivity spectrum.
   • Define cultural sensitivity.
   • Describe the ways in which facility-level policies and procedures can support COVID-19 infection prevention and control.
   • Identify changes to facility-level policies and procedures which can improve COVID-19 infection prevention and control for patients who are at higher risk and historically underserved.
     

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Key Takeaways:

• Cultural sensitivity is being aware that cultural differences and similarities between people exist without assigning them a value – positive or negative – and knowing that they influence values, learning, and behavior.
• Cultural sensitivity is also a set of skills that allows you to understand and learn about people whose cultural background is not the same as your own.
• An effective infection prevention and control (IPC) program aims to reduce healthcare associated infections (HAI), address emerging infections and pathogens, and improve patient safety.
• IPC programs require infrastructure, including policies and procedures, annual risk assessment, prioritized interventions, surveillance, trained staff, and committed leadership.
• Health equity and cultural sensitivity principles are critical considerations in the development of IPC policies and activities.

Topics & Objectives

1. Promoting COVID-19 Vaccination: Strategies and Communication
2. Understanding Cultural Values and Attitudes
   • Recognize the barriers to vaccine access and confidence that are most likely to impact patients who are at higher risk and historically underserved, including racial and ethnic minority populations and people living in rural communities.
   • Integrate knowledge of these barriers into conversations with staff regarding vaccine hesitancy.
   • Define cultural values, beliefs, and practices.

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Key Takeaways:

• We were able to develop three safe and effective vaccines in record time because we built on existing methods and used parallel processes to speed development.
• COVID-19 vaccines greatly reduce the likelihood and severity of infection, and these benefits can persist over time with the aid of boosters.
• An optimal communication plan on vaccination includes multiple methods to surface barriers to and communicate information, as some are more effective in reaching specific populations than others.
• There is a continuum of intercultural sensitivity development that spans from missing differences in cultures to bridging across differences in culture.
• Culturally sensitive approaches to care, particularly COVID-19 prevention and control, ensure communities receive important information in a way that resonates with them and their cultural values, beliefs, and practices.

Topics & Objectives

1. Health Equity Historical Context
2. Quality Improvement Human Factors and Systems Thinking
   1. Recognize and explain the role of human factors in work processes and error analysis in healthcare
   2. Describe systems thinking and how this relates to the Swiss Cheese Model
   3. Give a historical example of medical racism.
   4. Recognize the present-day impact of historical medical experimentation.

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Key Takeaways:

• Systems thinking is the study of complexity and the relationships and interactions among components of a system.
• Human factors is the study of how humans interact with a system, given that all errors have a human component and a system component.
• Systems thinking and human factors are tools that can be applied to help us better understand and address health inequities.
• Health inequities exist today because of historical events that disadvantaged and harmed certain communities.
• Structural factors such as housing, education, and income contribute to and perpetuate health inequities.

Topics & Objectives

1. Long-term complications of COVID-19 (part 1)
2. Cultural attitudes (part 2)
   1. Identify the long-term complications associated with COVID-19 infection.
   2. Apply best practices in the management of long-term complications associated with COVID-19 infection to tests of change in your facility.
   3. Reflect on how their own cultural values and beliefs impact their engagement with COVID-19 prevention and control efforts.

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Key Takeaways:

• Omicron variant has become the predominant COVID-19 in the US and the state of Nebraska
• Long COVID refers post-COVID conditions, a wide range of new or persistent symptoms four or more weeks after first being infected with the virus that causes COVID-19.
• Post-COVID conditions can affect one or more organ systems regardless of the severity of the acute COVID-19 infection.
• Culturally sensitive approaches to care, particularly COVID-19 prevention and control, ensure communities receive important information in a way that resonates with them and their cultural values, beliefs, and practices.

Topics & Objectives

1. Infection Prevention and Control Risk Assessment
2. Different Forms of Racism
   1. Characterize the principles of effective risk assessment for CoVID-19.
   2. Apply these principles to risk assessment in your facility to identify areas for intervention and improvement.
   3. Demonstrate how structural racism impacts health care.
   4. Differentiate between the different forms of racism (i.e., structural; systemic; interpersonal; etc.).
      

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Key Takeaways:

• A facility risk assessment is conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to the environment of care in a specific healthcare setting.
• Organization-specific and community-level data inform a list of risk factors which are generally scored based on the probability of the event, its impact, and the organization’s preparedness for it.
• Risk assessment should inform development of Infection surveillance, prevention and control plan.
• Risk assessment should be conducted annually or more frequently if significant changes occur.
• Systemic racism exists at the level of institutions (harmful policies and practices) and across structures (education, health, transportation, economy, etc.) that are interconnected and reinforcing over time.
• When dealing with risk, race is not a risk, racism is.
• Systemic oppression is systemic and has historical pasts. It is the intentional disadvantaging of groups of people based on their identity while advantaging members of the dominant group (gender, race, class, sexual orientation, language, etc.)
• Systemic oppression and its effects can be undone through recognition of inequitable patterns and intentional action to interrupt inequality and create more democratic processes and systems supported by multi-ethnic, multi-cultural, multi-lingual alliances and partnerships.

Topics & Objectives

1. Cultural Practices (part 3/3) (behaviors)
2. QI Root Causes 1/6: What is the problem you are trying to solve?
   1. Describe three examples of cultural practices.
   2. Identify the characteristics of effective problem statements and their role in supporting quality improvement.
   3. Demonstrate the ability to develop effective problem statements for quality improvement projects in your facility.

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Key Takeaways:

• Clearly defining the problem to be solved is a critical first step in any quality improvement project. This often entails choosing from among multiple problems that could be addressed.
• A good problem statement describes the issue that needs to be addressed without offering theories on potential causes or solutions.
• The narrower the scope and more specific the description, the easier it will be to identify root cause(s) and to solve the problem deemed most important.
• Religion, culture, beliefs, and ethnic customs can influence how patients understand health concepts, how they take care of their health, and how they make decisions related to their health.
• Asking about patients' religions, cultures, and ethnic customs can help clinicians engage patients so that, together, they can devise treatment plans that are consistent with the patients' values.

Topics & Objectives 

1. Social Determinants of Health 1/6: overview; socioecological model
2. QI Root Causes 2/6: What is your process?
   1. Recognize the impact that social and structural factors have on health outcomes.
   2. Recognize the importance of process mapping as a foundational step in quality improvement projects.
   3. Apply process mapping to quality improvement projects in your facility.

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Key Takeaways:

• Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
• SDOH can be grouped into 5 domains: economic stability; education access and quality; health care access and quality; neighborhood and built environment; and social and community context.
• The socioecological model (SEM) conceptualizes health broadly and focuses on multiple factors that might affect health.
• The SEM approach focuses on integrating approaches to change the physical and social environments rather than modifying only individual health behaviors.
• Process mapping is a technique for visually representing the steps involved in a workflow.
• Process mapping relies on a strong problem statement—a concise and focused description of the issue that needs to be addressed.
• When mapping a process, it is always advisable to start simply by outlining the 4 to 7 high-level steps in a process.
• Once a high-level process is refined, a more complex process map can be generated which outlines all the steps and decision points in a process.

Topics & Objectives

1. Social Determinants of Health 2/6: economic stability.
2. QI Root Causes 3/6: Where are the known or potential points of failure?
   1. Explain how inequities in housing, employment, food security, and income affect health outcomes.
   2. Recognize effective methods for identifying potential points of failure or human error in a process.
   3. Illustrate how these methods can be applied to improve the reliability of processes in your facility.

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Key Takeaways:

• In the United States, 1 in 10 people live in poverty, and many people can’t afford things like healthy foods, health care, and housing; this impacts their health outcomes.
• Key to families and individuals achieving economic stability is helping people earn steady incomes that allow them to meet their health needs.
• Human factors is the study of how humans interact with a system.
• The techniques that help teams identify and manage human factors can also be deployed to identify and manage the integration of social determinants of health (SDOH) into patient care.
• Using the fishbone diagramming technique (also known as cause-and-effect diagramming, or Ishikawa diagramming) can help you develop a broad list of causes for your problem statement.

Topics & Objectives

1. Social Determinants of Health 3/6: education access and quality.
2. QI Root Causes 4/6: How will you know your process is reliable?
   1. Describe how inequities in early childhood education and development, higher education, and language and literacy affect health outcomes.
   2. Identify the key characteristics of a reliable process.
   3. Relate these characteristics to both existing and new processes in your facility to understand whether they are likely to be reliably implemented.

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Key Takeaways:

• People with higher levels of education are more likely to be healthier and live longer.
• Interventions to help children and adolescents do well in school and help families pay for college can have long-term health benefits.
• A reliable process requires a common understanding of the problem it aims to solve, the high-level steps that need to happen, and the places where errors are most likely to arise.
• If our aim is to deeply understand the sources of error, then a root cause analysis can provide a systematic perspective on the sources of error.
• If our aim is to learn more about the sources of error quickly, then observation and/or assessment can be used to quickly inform decisions.

Topics & Objectives

1. Social Determinants of Health 4/6:  neighborhood and built environment. 
2. QI Root Causes 5/6: Why are these parts of the process unreliable?
   1. Discuss the impact that crime, violence, and environmental conditions have on a person's health outcomes
   2. Recognize effective methods for identifying the root cause of potential points of failure or human error in a process.
   3. Apply these methods to learn about the root causes of unreliability in processes in your facility.

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Key Takeaways:

• The neighborhoods people live in have a major impact on their health and well-being. Many people in the U.S. live in neighborhoods with high rates of violence, unsafe air or water, and other health and safety risks.
• Interventions and policy changes at the local, state, and federal level can help reduce these health and safety risks and promote health. For example, providing patients with transportation to their doctor’s appointments.
• Root Cause Analysis (RCA) and the Plan-Do-Study-Act (PDSA) technique are two methods for identifying the root cause of potential points of failure or human error in a process.
• RCA is most effective for bigger problems where the risk of failure is higher and it is necessary to deeply understand the causes of error. The most common tool used for an RCA is the “5 Whys” technique.
• PDSA is most effective for smaller problems that only require a quick assessment of the potential causes.

Topics & Objectives

1. Social Determinants of Health 5/6: health care access and quality.
2. QI Root Causes 6/6: What would success look like? (Aim Statements)
   1. Identify the impact that access to health care and health literacy have on a person's health outcomes.
   2. Identify the characteristics of effective aim statements and their role in framing quality improvement projects.
   3. Demonstrate the ability to develop effective aim statements for quality improvement projects in your facility.
      

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Key Takeaways:

• As of 2018, 9% of Nebraskans under age 65 were without health insurance. People without insurance are less likely to have a primary care provider, and they may not be able to afford the health care services and medications they need.
• Interventions to increase access to health care professionals and improve communication — in person or remotely — can help more people get the care they need.
• The Hierarchy of Actions is a framework that can help you identify solutions that are most likely to eliminate or reduce the probability of an adverse event.
• The Impact/Effort Matrix is a tool that can help you assess how the potential impact of a solution and the effort it will require fit with your needs.
• An Aim Statement is a written, measurable, time sensitive statement of the expected results of a system redesign/quality improvement project.

Topics & Objectives

1. SDOH 6/6: social and community context
2. IPC: COVID-19 Management and Treatment Updates
   1. Apply a determinants of health approach to providing patient care.
   2. Describe changes to guidance on COVID-19 management and treatment over the course of the pandemic.
   3. Articulate the research basis for recent changes in COVID-19 management and treatment.

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Key Takeaways:

• Several treatment options for COVID-19 management in the outpatient setting have become available in the past 4 to 5 months.
• Our recommendations for therapeutics in order of preference: Paxlovid, Remdesivir, mAb, and Molnupiravir.
• The supply of therapeutics is increasing. There are online tools to assist with locators of treatments and drug interactions. (Example: COVID Therapeutics Locator website)

Topics & Objectives

1. CS: Communications across cultures
2. IPC: Long-term Complications of COVID-19 Infection (part 2)
   1. CS: Explain differences in communication styles across cultures.
   2. IPC-1. Characterize the ways in which our understanding of the long-term complications associated with COVID-19 infection has evolved in the last six months.
   3. IPC-2. Identify resources in your facility or community that can be leveraged to address these complications.

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Key Takeaways:

• Long-term symptoms associated with COVID-19, or post-acute sequelae of SARS-CoV-2, can present anywhere from 4 weeks to more than 12 weeks following infection.
• The risk of long-term symptoms is higher for females, patients who are obese, patients with co-morbid conditions, and patients whose COVID-19 infections were severe.
• While treatment guidelines exist, there remains a general lack of high-quality evidence for treatment.
• All international communication is influenced by cultural differences. Even the choice of communication medium can have cultural overtones.
• Context, defined as the way messages are conveyed using either single or multiple layers of clarity, is key to communicating across cultures.

Topics & Objectives

1. CS: Explicit bias.
2. QI: Change management (part 1/2): Strategies for Managing through Failure
   1. CS: Reflect on an explicit bias they hold.
   2. QI-1. Describe the constructive role that failure plays in the quality improvement process.
   3. QI-2. Discuss strategies for preserving motivation and morale in health care teams working through failure.

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Key Takeaways:

• Failure is a constructive part of the quality improvement (QI) process. The goal of QI is to design rapidly without planning for every possible situation, learn from the results, and adapt with intention.
• Failure contributes to change when individuals choose to learn from it.
• Presenting failure as a natural part of QI helps to preserve motivation and morale among staff. 
• Explicit bias are attitudes and beliefs we have about a person or group on a conscious level. Expressions of explicit bias (discrimination, hate speech, etc.) occur as the result of deliberate thought.
• Take the following steps to address bias: 1. Acknowledge the bias in the interaction, 2. Make a conscious decision to address the bias, 3. Strategies to counter the bias (humor; reject the stereotype outright; ask questions; and, acknowledge discomfort), and 4. Continue the conversation beyond the
  interaction.

Topics & Objectives

1. CS: Implicit bias.
2. QI: Change management (part 2/2): Securing Buy-in and “Selling” Your Improvements
   1. CS-1: Describe an example of implicit bias.
   2. CS-2: Differentiate between explicit and implicit bias.
   3. QI-1. Articulate effective strategies for securing buy-in from leadership and key stakeholders.
   4. QI-2. Discuss strategies for aligning your QI project with institutional priorities.

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Key Takeaways:

• Effective change in leadership requires a balance of structure and flexibility. John Kotter’s eight-step framework, outlined in his article “Why Transformation Efforts Fail,” is a highly adaptable and effective guide to this process.
• Kotter’s “See-Feel-Change" approach tells us that behavior fueled by emotion is more likely to last than behavior fueled by analysis because it will be resistant to negative emotions.
• To maximize the likelihood of successfully implementing a change, start by identifying the needs of core audiences and where/how these are aligned or misaligned.
• Implicit bias is when we have attitudes towards people or associate stereotypes with them without our conscious knowledge.
• Implicit bias is indirect whereas explicit bias is expressed directly. Implicit bias can interfere with clinical assessment, decision-making, and provider-patient relationships such that the health goals that the provider and patient are seeking are compromised.

Topics & Objectives

1. IPC Outbreak Identification & Response
2. QI: Applying QI tools to root cause identification and management 
   1. IPC-1. Describe the critical elements of an effective approach to COVID-19 surveillance.
   2. IPC-2. Articulate the principles of an effective outbreak response strategy for COVID-19.
   3. QI-1. Apply QI tools to the identification of the root causes of error in improvement projects relevant to COVID-19.

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Key Takeaways:

• Surveillance is a process of systematic collection, collation and analysis of data with prompt dissemination to those who need to know for relevant action to be taken.
• An outbreak occurs when more cases of a disease than expected in a specific location over a specific time period.
• The Quality Improvement Knowledge Application Tool Revised (QIKAT-R) is a validated tool for assessing the quality of QI project’s scope which focuses on the ways in which a project’s aim, measures, and changes build on one another.
• We have shared more than a dozen QI tools in previous sessions that can be helpful when applied to an appropriately scoped QI project.

Topics & Objectives

1. HE: Communicating health equity; emotional intelligence.
2. IPC: Antibiotic Stewardship
   1. HE-1: Define emotional intelligence.
   2. HE-2: Name one health equity guiding principle for inclusive communication.
   3. IPC-1: Define and characterize antimicrobial stewardship in the context of COVID-19 pandemic.
   4. IPC-2: Discuss strategies for improving antimicrobial stewardship during and after a pandemic.

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Key Takeaways:

• Antimicrobial stewardship is a vital function in all healthcare settings, improving patient outcomes and preventing the threat of increased antimicrobial resistance.
• The COVID-19 pandemic has presented numerous challenges to antimicrobial stewardship, chiefly redirecting staffing resources elsewhere.
• Addressing health disparities and educating patients, providers, and staff are key to ensuring equitable therapeutic access and improving antimicrobial prescribing.
• Facilities should familiarize themselves with new regulatory requirements as well as CDC Core Elements to optimize ASP.
• Nebraska ASAP is available for guidance and one-on-one support for any ASP questions.
• Emotional intelligence is the ability to identify and manage one’s own emotions, as well as other people’s emotions.
• Language in communication products should reflect and speak to the needs of people in the audience of focus, using non-stigmatizing language.

Topics & Objectives

1. CS-1: Enhancing sensitivity to cultural similarities and differences
2. CS-2: Fostering a culturally responsive health care setting
   1. CS-1: Define cultural sensitivity and its application.
   2. CS-2: Demonstrate behaviors and language that create a culturally responsive health care setting.
   3. CS-3: Describe examples of cultural sensitivity in health care settings with an emphasis on Native Americans.

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Key Takeaways:

• Cultural sensitivity is being aware that cultural differences and similarities between people without assigning them a value – positive or negative, better or worse, right or wrong, impact on values, learning, and behavior.
• Consider the use of spiritual leaders when providing care to Indigenous communities.
• Incorporate flexibility into hospital visitation policies.
• Questions to ask Indigenous patients if there are special considerations in their culture need to be aware of.

Topics & Objectives

1. HE: Organizational considerations to advance health equity
2. IPC: Setting Up an Employee Health Program
   1. HE-1: Describe one organizational policy to advance health equity.
   2. HE-2: Discuss interpersonal, interpersonal, and institutional factors that contribute to advancing health equity.
   3. IPC-1: Discuss components of Infection Prevention Program for Healthcare Providers.
   4. IPC-2: Explain how to establish pre-employment assessments for Healthcare Providers.
   5. IPC-3: Discuss how to manage exposures and illness in Healthcare Providers.

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Key Takeaways:

• Equity requires a deeper understanding of diversity.
• Equity-mindedness requires an understanding of personal context, and it applies to patients and colleagues.
• Initial considerations when beginning DEI efforts:
  • Understanding the “WHY” – individual, departmental, organizational, and community
  • Advocating for resources - defined needs lead to a more refined budget
  • Data should drive decisions and inform practices
  • Connection to Mission, Vision and Values is key
• A basic infection prevention program for healthcare providers should include: Pre-employment health assessment in relation to work risks, vaccination and immunity, fit testing, protocols for sickness, protocols for return to work, protocols for potential exposure and known exposure, specific guidance on colleague health conditions, and guidance on managing emerging risks
• All medical facilities that provide direct patient care should have a comprehensive immunization policy which describes the exposure risk for vaccine preventable diseases by job description, provides recommendations for immunization based upon exposure risk, and ensures a prompt review of immunization status prior to caring for patients.

Topics & Objectives 

1. HE: Utilizing data to assess health disparities (part 1/2)
2. QI: Formulation of solutions (part 1/2): Are there particular groups who are impacted? (Segmentation)
   1. HE: Assess data to better understand health disparities.
   2. QI-1: Name the audiences who are most likely to be impacted by your improvements.
   3. QI-2: Identify early adopters to maximize success.

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Key Takeaways:

• Applying segmentation means trying a change on a portion of the population where you are most likely to succeed in order to test the idea without dealing with all the obstacles.
• Stakeholder mapping and communication planning help identify all of the audiences who are impacted (positively and/or negatively) by a change and strategies for reaching them.
• Stakeholder engagement strategies may change at different points in the adoption process as adopters can be included in outreach and communication processes.
• Health disparities are the preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.
• Assessing data for health disparities is important because without data-driven decision making, assumptions are made.

Topics & Objectives

1. HE: Utilizing data to assess health disparities (part 2/2)
2. QI: Formulation of solutions (part 2/2): Evaluate likelihood of success of solutions proposed
   1. HE: Analyze data to determine health disparities.
   2. QI-1. Describe the characteristics of effective approaches to measuring the success of improvements.
   3. QI-2. Articulate the difference between outcome and process measures.

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Key Takeaways:

• An effective approach to measuring the success of improvements starts with a problem statement which offers a concise and focused description of the issue that needs to be addressed.
• Outcome metrics detail the results that you are looking to achieve in your organization. Leadership or management should be held accountable for meeting outcomes-level goals.
• Process metrics detail the actions which you believe will lead to your outcomes. The frontline staff making the changes should be held accountable for gathering process data and meeting process-level goals.
• Stratifying quality data by demographic information is an important tool for uncovering and responding to healthcare disparities.
• The execution of any quality improvement project is an iterative process. When addressing health disparities is part of the project’s goal, this often requires revisiting stratified data to reassess what is happening within each group and whether/how it is impacting the quality of care.

Topics & Objectives

1. IPC: Vaccine Access & Vaccination
2. CS-Microaggressions
   1. IPC-1. Characterize how the options for COVID-19 vaccines have changed in the last eight months.
   2. IPC-2. Identify common current concerns regarding vaccination and resources in your facility or community that can be leveraged to address them.
   3. CS-1. Define microaggressions.
   4. CS-2. Demonstrate a call-in response to a microaggressions.

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Key Takeaways:

• COVID-19 vaccines are recommended for everyone 6 months and older. Several COVID-19 vaccines now available: Pfizer, Moderna, Novavax, and J&J.
• Bivalent boosters provide added protection against Omicron variant and are authorized for use for everyone 12 years and older.
• Influenza vaccine is also recommended and can be co-administered with any COVID-19 vaccine.
• Microaggressions are the everyday verbal, nonverbal, and environmental slights or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.
• Microaggressions can and should be addressed by a bystander or the person experiencing them.

Topics & Objectives

1. CS Recap
2. QI: Measurement: How will you know that you have improved your process?
   1. CS-1. Describe key cultural sensitivity concepts covered over the course of this ECHO program.
   2. QI-1. Differentiate between process and outcome measures.
   3. QI-2. Apply process and outcome measures to example quality improvement projects relevant to COVID-19 and health equity.

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Key Takeaways:

• Outcome metrics detail the results that you are looking to achieve in your organization.
• Process metrics detail the actions which you believe will lead to your outcomes.
• Balancing measures tell you whether changes to one part of a system have an undesirable outcome on another part of that system.
• An Aim Statement is a written, measurable, time sensitive statement of the expected results of a system redesign/quality improvement project.
• Cultural sensitivity is being aware that cultural differences and similarities between people exist without assigning them a value – positive or negative, better or worse, right or wrong.
• Cultural sensitivity can also be a set of skills that allows you to understand and learn about people whose cultural background is not the same as your own.

Topics & Objectives

1. HE: Recap
2. IPC: COVID-19 Updates for Healthcare Personnel
   1. HE-1: Describe key health equity concepts covered over the course of this ECHO Program.
   2. IPC-1: Discuss how COVID-19 vaccination status impacts employee health in healthcare settings
   3. IPC-2: Identify how best practices for isolation and precaution have evolved since the onset of COVID-19
   4. IPC-3: Describe how best practices in COVID-19 safety and prevention can mitigate the risk of transmission among healthcare employees

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Key Takeaways:

• Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” - CDC
• SARS CoV-2 is not gone. Organizations need to have policies in place to protect health care professionals from COVID-19. These policies should follow a strategy around COVID-19 for health care professionals that is grounded in science and data.
• Organizations should strongly encourage vaccination as the best means to protect their work force from COVID-19 infection and complications.
• COVID shedding can persist for days, even after clinical improvement. Given that changes in transmission over time are unclear, it is safest to assume that transmission is still possible.

Topics & Objectives 

1. CS: Sexual Orientation
2. QI: How Can you Facilitate Discussion about Change?
   1. C/S-1: Recognize that sexuality is a spectrum.
   2. C/S-2: Demonstrate ways to affirm a patient's sexuality in a healthcare context.
   3. C/S-3: Identify barriers to healthcare that not straight-oriented individuals face.
   4. C/S-4: Express ways to make your space a welcoming environment for not straight-oriented individuals.
   5. QI-1. Discuss strategies for generating ideas for changes
   6. QI-2. Utilize quality improvement tools to identify changes that are most likely to be successful

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Key Takeaways:

• A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for improvement. Change concepts can be helpful when revisiting your process map does not generate new ideas.
• Affinity diagramming or fishbone diagramming (also known as cause-and-effect diagramming, or Ishikawa diagramming) can help you organize your ideas around potential cases of error.
• Utilize quality improvement tools to identify changes which are most likely to be successful
• The hierarchy of actions and impact/effort matrix can help you to assess the potential impact of a change idea and the practicality of implementing it.
• Sexual orientation is how a person describes their emotional and physical attraction to others. A person’s sexual orientation can change over time.
• Sexual orientation is about the genders of your romantic and sexual partners. We cannot assume a person’s sexual orientation based on their sexual behavior.

Topics & Objectives

1. HE: Leveraging Clinical/Public Health Data to Eliminate Health Disparities (part 1/2)
2. QI: How to be Successful at Change
   1. HE-1: Formulate or adapt an intervention to mitigate or eliminate an identified health disparity.
   2. QI-1. Identify strategies for structuring quality improvement projects to accelerate learning
   3. QI-2. Describe how to communicate short- and long-term impact

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Key Takeaways:

• Understanding motivation is critical to accelerating learning through quality improvement projects. This requires understanding both an individual’s attitude toward change as well as their beliefs about the specific change you are trying to make.
• All individuals are ambivalent about change. The sooner we identify their reasons to change and their reasons not to change, the better equipped we are to help them through the change process.
• Stakeholder mapping can help us to identify where individuals’ motivations to change and not change are aligned or misaligned so that we can maximize the likelihood of successful implementation.
• Deep health equity attends to the historical hurt and harms that created health inequities by accurately diagnosing core problems, naming historical context, and offering vast solutions.
• It is important to identify and limit communications of data by asking questions like: Who is represented in the data? Who might be missing? Who determined the methods? Who summarized the data?
• Resources such as those available on the County Health Rankings and Roadmaps website can help you leverage public health data to create actionable strategies to address health disparities.

Topics & Objectives

1. HE: Leveraging Clinical/Public Health Data to Eliminate Health Disparities (part 2/2)
2. QI Recap: Q&A from Participants

   1. HE-1: Identify strategies to eliminate health disparities                                                                                          

   2. HE-2: Outline the implementation steps for one strategy to eliminate health disparities
   3. QI-1.  Discuss how to apply the content from QI sessions to project implementation   

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Key Takeaways:

• Establish a community-wide behavioral change to prevent increased disparities by leveraging culturally informed data.
• Use culturally-driven ways of distributing information to educate and promote healthy behaviors.
• Establishing trust, and acquiring mass participation are necessary ingredients to long-term behavioral change.
• Art is a viable resource to distribute scientific information. Consider other non-traditional sources of distributing scientific information.
• Clearly defining the problem to be solved is a critical first step in any quality improvement project. This often entails choosing from among multiple problems that could be addressed.
• Process mapping is a technique for visually representing the steps involved in a workflow.
• Using the fishbone diagramming technique (also known as cause-and-effect diagramming, or Ishikawa diagramming) can help you develop a broad list of causes for your problem statement
• Root Cause Analysis (RCA) is a technique for identifying the root cause of potential points of failure or human error in a process. The most common tool used for an RCA is the “5 Whys” technique.
• The Hierarchy of Actions and Impact/Effort Matrix are tools that can help you identify solutions that are most likely to be implemented to eliminate or reduce the probability of an adverse event.
• An Aim Statement is a written, measurable, time sensitive statement of the expected results of a system redesign/quality improvement project

Topics & Objectives

1. CS: Gender Expression and Identity  
   1. CS-1: Identify barriers to healthcare that transgender/gender non-conforming patients experience                                                                                                     
   2. CS-2: Describe at least three ways that a healthcare facility can be more inclusive of patients across the gender identity/expression spectrum.
   3. CS-3: Examine the gender binary  

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Key Takeaways:

• The Gender Binary (The classification of gender into two distinct, opposite forms of masculine and feminine, whether by social system, cultural belief, or both simultaneously) is flawed.
• Gender identity/expression are separate concepts from sexual orientation.
• Anti-Transphobia is strategies, theories, actions, and practices that challenge and counter transphobia, inequalities, prejudices, and discrimination based on gender, gender identity, and/or gender expression.

Topics & Objectives

1. IPC: Ensuring an Effective Environmental Cleaning and Disinfection Program   
   1. IPC-1: Identify the process to review the disinfectants available in the facility and to ensure proper coverage for anticipated microorganisms in the facility
   2. IPC-2: Discuss guidelines and best practices surrounding the selection of disinfectants to meet infection prevention and control needs in your facility
   3. IPC-3: Describe elements of an environmental cleaning and disinfection audit for the purpose of quality assurance practices and improving compliance 

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Key Takeaways:

• The EPA regulates products that sanitize and disinfect surfaces
• Not all disinfectants are effective against all organisms
• A successful cleaning and disinfection program will include different options for different work uses/work areas

Topics & Objectives

1. QI: Spread and Scale
   1. Objective 1: Differentiate between spread and scale as strategies for expanding on successful tests of change
   2. Objective 2: Describe the factors that indicate whether spread or scale is a more appropriate next step for your project
   3. Objective 3: Analyze project examples to determine whether spread or scale is a more appropriate next step

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Key Takeaways:

• Spread involves implementing a tested approach in a new setting or audience
• Scaling a change means expanding its scope across multiple settings and/or audiences
• In cases where spread is most appropriate, a spread plan helps with preparation for testing by identifying assets, barriers, and critical differences across settings and/or audiences.
• Scaling a change requires addressing issues that are not essential to spread, including infrastructural constraints, greater resource needs, greater complexity of settings and audiences, relationships between adopters, and a lower level of control

Topics & Objectives

1. HE: Community and Stakeholder Engagement
   1. Objective 1: Explain at least one strategy to engage community members
   2. Objective 2: Define criteria for identifying and prioritizing stakeholders
   3. Objective 3: Describe community-oriented medicine

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Key Takeaways:

• Community Oriented Primary Care (COPC) was defined by S.L. Kark (1983) as “a way of providing primary care, which is focused on care of the individual who is well or sick, or at risk for illness or disease, while also focusing on promoting the health of the community as a whole or any of its subgroups.”
• When prioritizing a certain community/population for an intervention, work with members from the community from the inception of the intervention all the way through to ensure community voice, perspective, and buy-in.
• Recommendations for community engagement: foster trust and show commitment and spend time in the community on an ongoing basis, and at the request of partners; provide assistance (academic/technical) that may not be directly related to the initial project; meet with other collaborators that a stakeholder wants you to meet. Go out of your comfort zone; be always prepared to face criticism (positive and negative), at the end of the day all can be translated into learning lessons.

Topics & Objectives

1. QI: Sustaining Changes
   1. Objective 1: Describe how outcomes metrics help you plan and measure sustained change
   2. Objective 2: Describe how a process metric impacts your ability to sustain
   3. Objective 3: Articulate the roles and responsibilities required to sustain a change over time

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Key Takeaways:

• Scaling a change means expanding its scope across multiple settings and/or audiences. This requires addressing issues that are not essential to spread, including infrastructural constraints, greater resource needs, greater complexity, relationships between adopters, and a lower level of control.
• Just because a change is effective does not mean that it will be sustained. Sustainability planning starts with measurement, including monitoring process and outcomes metrics for negative signals and planning for how measurement will change over time.
• Sustainable changes require clear ownership. There may be different owners for the daily work associated with a change and the measurement that supports sustainment.

Topics & Objectives

1. HE: Trauma-Informed Approaches to Providing Care
   1. Objective 1: Describe NEAR Science
   2. Objective 2: List the six trauma-informed principles
   3. Objective 3: Identify an example of trauma-informed communications style

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Key Takeaways:

• Trauma broadly defined as experiences that produce intense emotional pain, fear, or distress, often resulting in long-term physiological and psychological consequences. Experiences of trauma, especially in childhood, can change a person’s brain structure, contributing to long-term physical and behavioral
  health problems.
• Shift the question from “what’s wrong with you?” to “what happened to you?” In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) outlined a series of strategies and principles for trauma-informed approaches. The six principles are: safety; trustworthiness and transparency; empowerment, voice, and choice; collaboration and mutuality; peer support; and, cultural, historical, and gender issues.

Topics & Objectives

1. Injection Safety and Infection Prevention
   1. Objective 1: Define safe needle use never shared between patients; limited to only one needle, one syringe, and only one time
   2. Objective 2: Describe clean areas for safe medication and injection preparation
   3. Objective 3: List at least three differences between single-dose vials and multi-dose vials

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Key Takeaways:

• One needle, one syringe, only one time. Needles and syringes are used for only one patient.

Topics & Objectives

Health Equity: Disability and American Sign Language

1. List important needs deaf and hard of hearing (DHH) American Sign Language (ASL) users have when accessing healthcare
2. Identify different accommodation and interpreting needs among DHH, including ASL users
3. Discuss strategies for increasing inclusion for DHH ASL users at your healthcare institution

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Key Takeaways:

• Consider ways to make health care processes as inclusive as possible for people with hearing loss
• Identify ways to implement best practices for ASL interpretation in various healthcare settings
• Recognize unique linguistics needs that may go into understanding equitable ASL interpretation including representativeness of the interpreter, additional presence of a deaf Interpreter, and variants of ASL

Topics & Objectives

Health Equity & Cultural Sensitivity Wrap-Up: Case Studies

1. Health Equity & Cultural Sensitivity Objective 1: Describe key health equity considerations in a case example.
2. Health Equity & Cultural Sensitivity Objective 2: Describe key cultural sensitivity considerations in a case example.
3. Health Equity & Cultural Sensitivity Objective 3: Discuss how health equity and cultural sensitivity content from this ECHO has been applied to organizational improvements.

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Key Takeaways:

• Qualitative data can be used to identify and scope a QI project on health equity.
• Actively engage an equity-focused advisory council if possible.
• Bringing qualitative data to this conversation can better inform the council's decision making.
• Consider how an individual or community's intersecting social identities may be compounding to create additional barriers and hardships.
• Incorporate the following items into your services to ensure you've addressed the multifaceted identity of your patients/community members.
• The concept of intersectionality describes the ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination “intersect” to create unique dynamics and effects.

Topics & Objectives

Infection Prevention and Control: Implications of this ECHO for Infection Prevention and Control

1. Infection Prevention and Control Objective 1: Recognize how our understanding of effective infection prevention and control (IPC) has changed since the onset of the COVID-19 pandemic.
2. Infection Prevention and Control Objective 2: Discuss how IPC content from this ECHO has been applied to organizational improvements.
3. Infection Prevention and Control Objective 3: Associate core principles of IPC from this ECHO with improvements of organizational preparation for future pandemics and outbreaks.

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Key Takeaways:

• An effective infection prevention and control (IPC) program aims to reduce healthcare associated infections (HAI), address emerging infections and pathogens, and improve patient safety.
• IPC programs require infrastructure, including policies and procedures, annual risk assessment, prioritized interventions, surveillance, trained staff, and committed leadership.
• COVID-19 has had an immense impact on health care workers in terms of mortality, physical and mental health, with this impact disproportionately impacting healthcare workers from minority populations.
• COVID-19 has highlighted the need for infection prevention and control programs to focus on addressing health disparities although evidence of disparities in healthcare-associated infections has been noted prior to COVID-19 pandemic.