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Creating a Health Equitable Organization at Navicent Health

• Dr. Ninfa M. Sa und ers, FACHE

CEO a nd Presid ent Na v icent Hea lth

5 Decem ber 20 16

About Navicent Health

Navicent Health, located in Macon, Georgia, is central Georgia’s premier health system whose primary purpose is to coordinate the Medical Center, Navicent Health and other affiliated entities in their mission of providing a comprehensive continuum of high quality, reasonably priced healthcare services to the region. Navicent Health has more than 800 beds for medical, surgical, rehabilitation and hospice purposes as well as diagnostic and home care services. The health system includes:

• Medical Center, Navicent Health, a nationally recognized tertiary teaching hospital
• Children’s Hospital, Navicent Health, the region’s only dedicated pediatric hospital
• Medical Center of Peach County, Navicent Health, a rural critical access hospital
• Rehabilitation Hospital, Navicent Health, the region’s oldest and most experienced rehabilitation provider
• Pine Pointe Hospice, Navicent Health, which provides palliative and hospice care in homes and in its facility
• Carlyle Place, Navicent Health, the area’s first continuing care retirement community
• Navicent Health Foundation, the philanthropic arm of Navicent Health
• Putnam General Hospital, a rural critical access hospital (Management Agreement)
• Monroe County Hospital, a rural critical access hospital (Management Agreement)

Ex Execut ecutive S e Sum ummar ary

• Many

any ef effor

• rts

in H n Heal ealth h out

• utcom

comes es di dispar parities es r res esol

• lut

ution and r

• n and res

esear earch ch hav have e

• ccur
• ccurred

ed or

• r ar

are under e underway ay

• Progr
• gram

am i in cul n cultur ural al com compet petency ency and and engagem engagement ent f for

• r al

all as associ

• ciat

ates es, phy physici cians ans, l leader eaders ar are ex e expandi panding ng

• Ongoi

ngoing di ng diver ersity and and i incl nclus usion

• n in l

n leader eadershi hip p and gov and gover ernance nance ar are cr e critical cal for

• r

succes uccess

• Com
• mmuni

unity par partner nershi hips ps and engagem and engagement ent ar are r e robus

• bust
• Equi

Equity 1 123 pl pledge has edge has been a been a cat catal alyst f for

• r t

the nex he next lev evel el of

• f per

perfor

• rmance

ance

Equity at Navicent Health

Ini nitiat atives es

• Mer

ercer cer S School chool of

• f M

Medi edici cine ne-Nav avicent cent Res esear earch par ch partner nershi hips ps (~5 ~50)*

• Funding
• Staffing
• Patient contacts
• Qual

uality / /Saf afet ety pr progr

• gram

am addr addres esses es di dispar parities es 2 2015

• Heart Failure outcomes in African Americans
• Asthma admissions in African American children
• Geriatric trauma care improvement
• All PI projects will address disparities going forward
• Pediatric suicide prevention

Reducing Disparities

Ini nitiat atives es

• Coor
• ordi

dinat nation n with h Me Mercer cer C Cent enter er for

• r Rural

al H Heal ealth/ h/Dispar parities es

• TRACE-CORE HF Outcomes disparities resolution
• Res

esear arch r ch res esul ults impl plem ement ented i d in n al all pa patient ents

• Transition in Palliative care counselor interventions
• Screening ETOH brief intervention and referral treatment (SBIRT)
• Ongoi

ngoing r ng res esear earch ch

• Bereavement care in SNF elderly (grant)
• Reproductive Health disparities
• ED utilization reduction
• Ongoi

ngoing s ng staf affed ed pos positions

• ns wor
• rking

ng in n dispar parities es r reduct eduction

• n
• Population Health case managers (5) intervene for underserved
• WT Anderson Health clinic operated , funded services (many)
• Palliative care outreach (10) for EOL patients

Reducing Disparities

Ini Initi tiati atives es

• Recom

ecommitted to tted to Cul ultur tural al com competenc petency cor core e tr trai aini ning 2 ng 2013

• Core training module developed
• Part of the improving the patient experience program
• Mandatory for all patient care associates; voluntary, and encouraged for all others
• Mandatory for all beginning associates
• Computer based learning module addressing diversity in place
• Additional Cultural awareness training is offered in many different departmental formats
• Hum

uman an res esour

• urce

ce pol polici cies es, addr addres essing ng di diver ersity ty:

• Equal opportunity
• Patient Right’s
• Language (interpreting) services
• Com
• mmitm

tment to ent to di diver ersity ty and i and incl nclus usion n in n hi hiring ng

• Employment application states commitment to non-discrimination based on compliance with state and federal
• Mandatory Equal Employment Opportunity posters displayed in all the areas where interviews are conducted
• Diver

ersity ty and and incl nclus usion

• n pol

policy cy i in n suppor upport t of

• f our
• ur pati

patients ents, em empl ploy

• yees

ees, as associ

• ciate

ates, vendor endors and and

• ther
• ther par

partner tner as associ

• ciates

tes

Becom ing Culturally Com petent

Ini nitiat atives es

• Onl

nline t ne trai aini ning ng modul

• dules

es av avai ailabl able e to

• al

all em empl ploy

• yees

ees to us

• use

e in our n our C Cent enter er for

• r

Lear earni ning ng to cont

• continual

nually bui build cul d cultur ural al com compet petenci encies es

• Language

anguage S Ser ervices ces av avai ailabl able e to i

• ins

nsur ure e al all pat patient ents needi needing ng thi his as assistance ance ar are accom e accommodat

• dated

ed

• An

n engaged engaged and and di diver erse e leader eadershi hip t p team eam com committed ed to cr

• creat

eating and r ng and ret etai aini ning ng a di a diver erse and e and incl nclus usive or e organi ganizat ation:

• n:
• Encouraging proactive steps to insure diverse candidate slates of qualified candidates to fill

positions

• Processes in place to identify and develop high performers; insuring leadership development

(including cultural awareness and engagement) is provided

• Internal and external coaching opportunities for executives and top talent leaders with goal to

"coaching culture" by 2017

• National Standards for Culturally and Linguistically Appropriate Services (CLAS)

Becom ing Culturally Com petent

Ini nitiat atives es

• Dev

evel elop an engaged

• p an engaged and di

and diver erse l e leader eadershi hip p team eam com committed ed to cr

• creat

eating ng and and ret etai aini ning a di ng a diver erse e and and incl nclus usive or e organi ganizat ation:

• n:
• Proactively develop talent to ensure diversity among qualified candidates
• Identify and develop high performers thorough leadership development training
• Create a "coaching culture"
• The f

The fol

• llow
• wing or

ng organi ganizat ational

• nal changes

changes w wer ere m e made ade to s

• suppor

upport t the i he ini nitiat atives es:

• Redesign of Navicent Health’s governance structure
• Restructuring of the executive team and integration of diverse talent profiles
• Use of the Best People Review to identify talent for promotion and upward mobility

Senior Leadership & Governance Diversity

Ini nitiat atives es

• Progr
• gram

ams and and chan changes es impl plem ement ented d by by Nav avicent cent H Heal ealth h pr prov

• vide t

de the he fram amew ewor

• rk and

and the abi he ability t to

• ex

execut ecute e our

• ur com

commitment ent to

• di

diver ersity and and incl nclus usion.

• n. The i

The inf nfor

• rmat

ation

• n no

noted ed bel below

• w suppor

upports t the he signi gnificant cant pr progr gres ess m made ade in n creat eating a ng a di diver erse e leader eadershi hip p team eam:

Senior Leadership & Governance Diversity

Ini Initi tiati atives es

• Par

artner tnershi hips ps (B (Boar

• ard

d par parti tici cipati pation, n, fundi funding, ng, suppor upport, t, for for an an under underser erved ed popul populati ation) n)

• Com
• mmuni

unity ty Heal ealth th Wor

• rks
• First

t Choi hoice ce Feder ederal ally Qual ualifi fied ed Heal ealth C th Center enter

• Macon

acon Vol

• lunteer

unteer cl clini nic/S c/Sur urger gery for for Peopl eople i e in n need (S need (SPIN IN)

• Rock
• ck Spr

prings ngs Vol

• lunteer

unteer cl clini nic

• Day

aybr break eak pr progr

• gram

am

• Area

ea Agency gency on

• n Agi

ging ng

• Shal

halom

• m Zone

Zone

• Bo’
• ’s Cam

amp

• Heal

ealth th Fai airs with th di dispar pariti ties them themes es (4 (4-6 per per year ear) )

*Innumerable *Innumerable Navicent avicent Healt Health h employees participate employees participate in in these hese programs programs

Engaging with Com m unity on Equity*

Key ey Achi chiev evemen ents ts

• Took
• ok the

the AHA Equi Equity ty 1, 2 ,3 pl pledge edge in n 2015

• Took
• ok acti

action

• n
• Est

Establ ablished shed an an Equi Equity y of

• f Car

Care e Over versi sight ght com committee ee

• CEO chair, including staff and community members
• Diver

versi sity y and and Incl nclusi usion

• n in

n Leader Leadershi ship p subcom subcommittee ee

• Assuring access in hiring process for diverse candidates
• Mentoring and coaching diverse candidates
• Cul

Cultur ural al Engagem Engagement ent subcom subcommittee ee

• Cultural competency training program expansion
• Utilize the National Standards for Culturally and Linguistically appropriate Services (CLAS) as a guide
• Heal

ealth h Dispar sparities es Resol Resolut ution

• n subcom

subcommittee ee-Qual uality y Impr provem

• vement

ent Pr Proj

• ject

ects s (2) 2) under underway ay with h di dispar sparities es resol esolut ution

• n goal

goals

• Disparities confirmed (Adult HF, Ped asthma)
• Interventions under development
• Disparities assessment will be ongoing in all PI projects
• Dial

alogue

• gue with

th Boar

• ard/l

d/lead eader ershi hip p is under underway ay

• Board HR subcommittee presentation
• Board of Trustees Equity plan presentation May 2016

Equity at Navicent Health

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 89
• Population “African American”: 684
• Defects in Population “White”: 47
• Population “White”:514
• Significance Level: 0.05
• Two Tailed Z Test

Result: The Z-Score is 2.0886. The p-value is 0.03662. 0.03662. The result is significant at p <0.05. The proportion of Yes or No responses for Observation 1 is 0.13. The proportion for Observation 2 is 0.091. Interpretation: The proportion of African American and and White persons with Heart Failure are not equal at a 95% level of significance. Updated 11/18/2016

Risk Adjusted HF Data- Race FY 20 15 (Baseline)

In Initi tiati tives

• Pop

Pop Heal ealth-pal palliat ative car ve care e case m case manager anager dedi dedicat cated ed (NP backup) backup)

• Focus

Focus on

• n hi

high gh risk sk popul populat ation

• n
• Pre

re-di dischar scharge ge connect connection

• n and

and assessm assessment ent

• Insur

nsure e post post di dischar scharge ge physi physici cian an fol

• llow
• w up

up in n seven seven days days (HF F Cl Clini nic c def defaul ault)

• Mot
• tivat

vational

• nal int

nter ervi view ewing ng

• Heal

ealth h liter eracy acy

• Medi

edicat cation

• n adher

adherence ence pr progr

• gram

am

• Behavi

ehavior

• ral

al heal health h assessm assessment ent

• Diet

etar ary y com compl pliance ance pr progr

• gram

am

• Int

ntegr egrat ated ed Car Care e managem anagement ent/post post di dischar scharge ge pr provi

• vider

der com communi unicat cation

• n
• Advanced

dvanced di direct ective, ve, pal palliat ative ve and and suppor supportive ve car care e det deter erminat nation

• n
• Post

Post di dischar scharge col ge collabor aborat ation

• n and

and al alignm gnment ent

• Sel

Self managem anagement ent (pat patient ent/fam amily) y) engagem engagement ent

• Post

Post di dischar scharge l ge lifel eline ne ‘cont contingency’ ngency’ est establ ablishm shment ent

Heart Failure Outcom es Disparities Resolution

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 39
• Population “African American”: 328
• Defects in Population “White”: 14
• Population “White”: 226
• Significance Level: 0.05
• Two Tailed Z Test

Result: The Z-Score is 2.2399. The p-value is 0.02510. 0.02510. The result is significant at p <0.05. The proportion of Yes or No responses for Observation 1 is 0.119. The proportion for Observation 2 is 0.062. Interpretation: The proportion of African American and and White patients with Heart Failure are not equal at a 95% level of significance. Updated 11/18/2016

Risk Adjusted HF Data- Race March – August 20 16 (YTD)

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 59
• Population “African American”: 366
• Defects in Population “White”: 27
• Population “White”: 278
• Significance Level: 0.05
• Two Tailed Z Test

Result: The Z-Score is 2.3679. The p-value is 0.01778. 0.01778. The result is significant at p <0.05. The proportion of Yes or No responses for Observation 1 is 0.161. The proportion for Observation 2 is 0.097. Interpretation: The proportion of African American and and White Males with Heart Failure are not equal at a 95% level of significance. Updated 11/18/2016

Risk Adjusted HF Data- Race – Males FY 20 15 (Baseline)

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 23
• Population “African American”: 180
• Defects in Population “White”: 9
• Population “White”:128
• Significance Level: 0.05
• Two Tailed Z Test
• Result: The Z-Score is 1.6289. The p-value is

0.10310. The result is not significant at p <0.05. The The proportion of Yes or No responses for Observation 1 is 0.128. The proportion for Observation 2 is 0.07.

• Interpretation: The proportion of African American and

American and White Males with Heart Failure are not statistically different at a 95% level of significance. Updated 11/18/2016

Risk Adjusted HF Data- Race - Males Mar – Aug 20 16 (YTD)

Updated 11/18/2016

Risk Adjusted HF Data- Race – Fem ales FY 20 15 (Baseline)

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 30
• Population “African American”: 318
• Defects in Population “White”: 20
• Population “White”: 236
• Significance Level: 0.05
• Two Tailed Z Test
• Result: The Z-Score is 0.3897. The p-value is

0.69654. The result is not significant at p <0.05. The proportion of Yes or No responses for Observation 1 is 0.094. The proportion for Observation 2 is 0.085.

• Interpretation: The proportion of African American

American and White Females with Heart Failure are not statistically different at a 95% level of significance.

Updated 11/18/2016

Risk Adjusted HF Data- Race - Fem ales Mar – Aug 20 16 (YTD)

Z Score Calculator for 2 Population Proportions

• Defects in Population “African American”: 16
• Population “African American”: 148
• Defects in Population “White”: 5
• Population “White”: 98
• Significance Level: 0.05
• Two Tailed Z Test
• Result: The Z-Score is 1.5687. The p-value is

0.11642. The result is not significant at p <0.05. The The proportion of Yes or No responses for Observation 1 is 0.108. The proportion for Observation 2 is 0.051.

• Interpretation: The proportion of African American and

American and White Females with Heart Failure are not statistically different at a 95% level of significance.

Updated 11/18/2016

Risk Adjusted HF Readm ission Data FY 20 15 com pared to Mar-Aug 20 16

Z Score Calculator for 2 Population Proportions

• Defects in Population “FY15”: 138
• Population “FY15”: 1215
• Defects in Population “Mar-Aug ‘16”: 53
• Population “Mar-Aug ‘16”: 562
• Significance Level: 0.05
• Two Tailed Z Test
• Result: The Z-Score is 1.2199. The p-value is

0.22246. The result is not significant at p <0.05. The The proportion of Yes or No responses for Observation 1 is 0.114. The proportion for Observation 2 is 0.094.

• Interpretation: The proportion of African American and

American and White Females with Heart Failure are not statistically different at a 95% level of significance.

Heart Failure Driver Diagram

Project Title: Decreasing Health Care Disparities In Heart Failure Care at Navicent Health

Date: 5/19/2016 Version Number:1

To reduce readmissions and avoidable readmissions, improve

• utcomes, and establish

advanced directives for Heart Failure Patients Access to care Health Literacy/ Education Resources Caregiver Support Understanding patient preference (SNAP) Psychological State

Key Drivers

Insurance Coverage Education Depression/stress/fear Transportation In-home care Virtual Care Home Health Care

Secondary Drivers

Working on now New Idea Completed

Mobile Integrated Health Coordination Rehab Motivational interviewing Professional access Timely access

Aim

Childhood Asthm a- Risk Adjusted

Pediatric Asthma Driver Diagram

Project Title: Decreasing Health Care Disparities In Asthma Care at Navicent Health

Date: 5/18/2016 Version Number: 6

SMART Aim: Decrease the number of NHEC visits for acute asthma exacerbations by patients followed by physicians in Children’s Health from a mean of 5 per month to 2 per month by September, 2016. Families understand the gravity of asthma Educated families know the early signs of an asthma exacerbation Appropriate early intervention by families Educated parents contact the PCP when child is in the “Yellow Zone” Standard protocol for asthma follow up Appropriate medication prescriptions

Key Drivers

Educate families to the reality Assess caregiver understanding of asthma Monitor missed appointment Follow up appts

Secondary Drivers

Working on now New Idea Completed

Aim

Standard approach to treatment Global Aim: Decrease pediatric asthma morbidity and mortality in the Navicent Health primary service area.

Equity of Care Oversight Com m ittee

Equity of Care Executive Oversight Committee Diversity in Governance and Leadership Cultural Engagement Training Health Disparities Resolution Heart Failure Task Force Pediatric Asthma Task Force Executive Sponsor:

• Dr. Ninfa Saunders

Ini nitiat atives es

• Princi

ncipal pal S Standar andard

1. Provide effective, equitable, understandable and respectful quality care and services that responsive to diverse cultural health beliefs and practices, preferred languages, health

• ther communication needs.
• Gov
• ver

ernance, nance, L Leader eadershi hip p and W and Wor

• rkfor
• rce

ce

2. Advance and sustain organizational governance and leadership that promotes CLAS and equity through policy, practices and allocated resources 3. Recruit, promote and support a culturally and linguistically diverse governance, leadership workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership and workforce in culturally and linguistically policies and practices on an ongoing basis.

Culturally and Linguistically Appropriate Services

Ini nitiat atives es

• Com
• mmuni

unicat cation

• n and L

and Language anguage Assistance ance

5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and 6. Inform all individuals of the availability of language assistance services clearly and in their language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages used by the populations in the service area.

Culturally and Linguistically Appropriate Services

Ini nitiat atives es

• Engage

Engagemen ent, C Cont

• ntinuo

nuous I Impr prov

• vem

ement nt and and Accoun ccountabi bility

9. Establish culturally and linguistically appropriate goals, policies and management accountability, them throughout the organizations’ planning and operations.

• 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-

measures into assessment measurement and continuous quality improvement activities.

• 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact
• n health equity and outcomes and to inform service delivery.
• 12. Conduct regular assessments of community health assets and needs and use the results to plan

implement services that respond to the cultural and linguistic diversity of populations in the

• 13. Partner with the community to design, implement and evaluate policies, practices and services to

cultural and linguistic appropriateness.

• 14. Create conflict- and grievance-resolution processes that are culturally and linguistically

identify, prevent and resolve conflicts or complaints.

• 15. Communicate the organization’s progress in implementing and sustaining CLAS to all

constituents and the general public.

Culturally and Linguistically Appropriate Services

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