Mass General Department of OB/GYN Develops and Executes Three-Pronged Diversity Strategy

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The Department of Obstetrics and Gynecology (OB/GYN) at Massachusetts General Hospital has long had a multidisciplinary committee tasked with implementing innovative methods to initiate important conversations and prompt change in diversity, inclusion and health equity.

"One of the strengths of our department is that we really are a team-based culture, but we don't have a particularly diverse workforce," says Caroline Mitchell, MD, co-chair of the OB/GYN Diversity, Equity and Inclusion Committee and researcher with the Vincent Center for Reproductive Biology, which reinvigorated its work in early 2020 with the creation of a 3-year roadmap. "So we've created a three-year strategic plan in support of our mission statement, which is to make real the promise of inclusive excellence by embracing our differences and promoting the equitable treatment of all."

The committee includes members from across the OB/GYN Department (obstetrics, gynecology, gynecologic oncology, the fertility center and research), as well as people from all role groups—administrative staff, nurses, medical assistants, midwives, physicians, post-doctoral fellows and residents. Together, they are launching initiatives in three strategic areas:

1. Awareness and skills building
2. Equity and quality of care
3. Hiring practices and work environment

"All of these things are intricately linked to one another," says Allison S. Bryant, MD, MPH, vice chair of quality, equity and safety, and specialist in the Maternal-Fetal Medicine Program. "For example, if we are able to hire a more diverse group and retain them, that will improve the overall culture and awareness—and also improve health equity. This issue belongs to all of us. It affects marginalized communities the most, and marginalized communities can lead some of this effort, but they cannot do it alone."

Awareness and Skills Building

One of the most innovative and active tools the committee has developed is the (In)equity Inbox, an anonymous system that allows department employees to report instances of bias or microaggression.

"We recognized that people wished they had a way to report that those things were going on. They wouldn't necessarily be instances that would rise to the level of a Human Resources complaint, but something that was really bothersome and distressing during a workday," Dr. Mitchell says.

An employee can use a QR code or a link to access a survey and describe a troubling incident. The system cannot identify individuals or follow up in any way. Rather, Drs. Mitchell and Bryant review the entries—about 50 so far—and categorize them:

• Homophobia
• Inequity involving people with a substance use disorder
• Patient access issues
• Racism
• Sexism

Then they present aggregate data with illustrative text excerpts during departmental faculty, trainee and staff meetings. Drs. Bryant and Mitchell say the presentations have generated productive, enlightening conversations.

"This is a way to hold up the mirror and say, 'Look, this experience was distressing to someone,'" Dr. Mitchell says. "It's been enlightening for many people in the majority. They've realized, 'Oh, I've said things like that, but I didn't realize it was distressing to someone else.'"

The (In)equity Inbox also includes a link to Mass General's safety reporting system in case an employee decides to officially report an incident, but that function has yet to be used. Other Mass General departments have inquired about the system, and the committee has presented on it internally and nationally.

Other initiatives of the Awareness and Skills Building subgroup, led by Dr. Mitchell, include:

• Several Grand Rounds speakers who addressed issues of equity, diversity and inclusion
• A resident-driven addition to morbidity and mortality (M&M)conferences called Health Equity Rounds, where cases in which bias, discrimination or unequal treatment may have occurred are reviewed.
• A series of seven-minute video summaries of chapters from the book So You Want to Talk About Race, presented by Dr. Mitchell and Alison Packard, MD, obstetrician/gynecologist. The videos will be accessible online to department members who want to view them in the future
• An online tutorial about best practices to avoid bias while interviewing
• Conversations about inequities in patient care and workplace issues during departmental town halls, where committee members start or continue a conversation. They structure the town halls by practice group, rather than by role

Equity and Quality of Care

Led by Dr. Bryant, another subgroup is working on making patient care and outcomes more equitable. They are examining metrics at the departmental and institutional levels for outcomes including access to pain management after procedures, breastfeeding rates and Cesarean delivery in low-risk populations. The goal is to identify differences in outcomes based on domains such as race, ethnicity, language, health literacy and insurance status.

"These examinations will lend themselves to many quality improvement efforts," says Dr. Bryant. The committee has instituted a process when an adverse outcome occurs to determine how social determinants of health may have contributed. "We're reviewing those things through the lens of our M&M or quality assurance meetings. We carve out specific time to present cases that have an inequity focus, and we try to lead with the patient's race, ethnicity, language proficiency and insurance status. Ultimately, if they are readmitted or have a complication, we want to know how much of that might have to do with transportation barriers or language barriers or not understanding the prescription label that was not in their native language, for example."

The intention is that such discussions reveal ways to measure equity and quickly make changes and adjustments.

Other examples of the committee's work in this domain include efforts by Adeline Boatin, MD, MPH, co-director of Global Health, and Anne Plante, MD, medical director, Resident Gynecology Practice, to implement social determinants of health screening in the gynecology clinic, as is used in the obstetrics clinic. And Jennifer Boyle, MD, obstetrician/gynecologist, is exploring how care and outcomes might differ between patients seen in health centers versus those seen in outpatient settings.

Among the discoveries: "There appears to be a trend that patients in certain populations are being treated more often by residents as opposed to faculty," Dr. Plante says. "Our resident gynecology practice has a higher prevalence of patients with lower health literacy, patients of color and patients who are non-English-speaking, even if there's no structural reason why they would wind up in the resident practice versus the faculty practice. That does not mean that they're getting a lower quality of care, but they may just be getting a different practice pattern."

The committee is also looking forward to results of the Sacred Birth Study out of the University of California, San Francisco. The research will lead to a scale that measures racism in obstetrics, which will help establish a common vocabulary and useful tool, Dr. Bryant says.

"Equity is partly measured in the patient experience, and patient experience is very intimately linked to people's experience of discrimination and racism. Just being able to measure that effectively would have a major impact."

Hiring Practices and Work Environment

The final strategic focus is workplace culture, including hiring and retention. This portion of the committee's work is co-led by Susan Hernandez, CNM, MSN, chief of the nurse-midwifery services, and Tatiana Cadet, project manager.

"Many studies have shown that concordance between provider race and patient race, especially for patients of color, is an important determinant of outcomes," Hernandez says. "That's one of the motivating factors for improving the diversity of our workforce."

As a first step, the subgroup is in the process of gathering data about departmental employees. The data will provide a baseline understanding of which employees patients interact with through the care trajectory. Because patients interact with many people throughout the hospital system who are not departmental employees, the subgroup is working with other institutional entities to collect broader data on the full patient experience.

The committee has also implemented training among physicians who select residents and fellows to teach them best practices for avoiding bias in the interview process.

Synergy with Institutional Vision

Drs. Bryant and Mitchell say the committee's work aligns with the institution's and department's overall vision related to equity. Jeffrey Ecker, MD, chief, Department of Obstetrics & Gynecology, has made this a priority for the department and dedicated resources to this endeavor. Joseph Betancourt, MD, MPH, Mass General's vice president and chief equity and inclusion officer, introduced a 10-Point Plan to Address Structural Equity, which calls for specific activities that will apply resources, leadership and accountability to eliminate racism and achieve equity and social justice. Mass General Brigham also launched the United Against Racism initiative to examine and try to eliminate the effects of racism on patients and employees.

"It's been very gratifying to work on our departmental committee. I think we've accomplished a lot, and it seems like so much more is possible. It feels like there will be more resources and support and places for us to synergize with the hospital," Dr. Mitchell says. "We're all flawed, and we all fall down, but we have a plan in place to make progress on this initiative and a committee of colleagues to support us in this endeavor."

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