- In the U.S., rates of maternal morbidity and mortality are significantly higher for Black people, Indigenous people and people of color than for white patients
- Even so, there is no standardized process to ensure the roles of race and racism are investigated during patient case reviews
- In this commentary, obstetrician-gynecologists from five academic medical centers describe how their departments have begun to implement health equity morbidity and mortality conferences
- The authors also propose a 10-item framework for conducting meetings that will engage a wide range of participants and produce systemwide improvements
Morbidity and mortality (M&M) conferences are held regularly and focus on systemwide improvement, so they're an ideal venue for examining systematic inequities in patient care. Many obstetrics and gynecology departments across the country are starting to hold health equity M&M conferences, but there's little published guidance.
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In Obstetrics & Gynecology, Allison S. Bryant, MD, MPH, maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Massachusetts General Hospital and senior medical director for Health Equity at Mass General Brigham, Erin Bradley, MD, obstetrician and gynecologist at Mass General, and colleagues from four other academic medical centers, recently outlined how their departments have begun to address biases and oppressive systems that contribute to the maternal morbidity and mortality crisis in the U.S. The other authors practice at Brigham and Women's Hospital, Wright State University, Tufts Medical Center, and UMass Memorial Medical Center.
The authors also developed 10 recommendations for implementing health equity M&M conferences. None of the institutions has fully implemented every item, but all authors agree these are necessary for success:
- Minimize bias in case selection. For example, focusing exclusively on instances of presumed interpersonal bias or instances in which patients had financial barriers to care limits opportunities to highlight the more subtle (and much more common) examples in which race influences patient care. One way to avoid this is to ask nonmedical experts on race and racism to help the medical team plan which details to emphasize during discussions.
- Host a multidisciplinary group. Along with physicians, include clinical staff (e.g., non–obstetrics and gynecology physicians, medical students, residents, fellows, nurses, social workers, midwives, lactation specialists, geneticists), healthcare administrators, and representatives of nonclinical university departments (e.g., public health, sociology, gender studies and queer studies). Incorporate case review points from both clinical and non-clinical disciplines.
- Ask a trained facilitator to lead discussions. Facilitators need to guide discussion in a way that avoids superficial analysis and fosters an environment that's safe and engaging for all community members. Examples of formalized trainings that help facilitators acquire these skills are programs on antiracism education, intergroup dialogue, intergroup conflict management, structural competency, nonviolent communication and upstander interventions.
- Create an environment with a focus on "Just Culture" as described, for example, in The Ochsner Journal. Before beginning the presentation, present ground rules for discussion. Sample language: "This case is being reviewed through the lens of Just Culture, with the assumption that those involved in providing care intended to do their best, and yet the patient was harmed. We aim to explore the systems that allowed this to occur in the hopes of changing them and preventing such harm in the future. In addition, when hearing the patient perspective, listen with the intent to understand the patient's point of view, rather than listening to rebut or respond."
- Center the patient's voice. Prioritizing the voices of those who experience health inequities is critical for better understanding injustice and inequity at both the individual and community level. Some ways this can be implemented include inviting patients to join the discussion and describe their experiences, pre-recording an interview with them, incorporating patient satisfaction survey data or using anonymous patient reporting tools.
- Analyze beyond implicit bias. Implicit bias is a key component of addressing inequities in healthcare, and implicit bias training should be part of department initiatives. However, implicit bias is inherently abstract, difficult to quantify and difficult to target through interventions. Care should be taken when discussing implicit bias to prevent it from exonerating other factors that contribute to inequity, including explicit biases and problematic behavior.
- Be purposefully intersectional. Intersectionality is the concept that racism, classism, sexism, homophobia/transphobia, and other forms of oppression are interrelated. Racism plays a key role in health inequities and should be centered in the discussion, but it's important to address other aspects of patients' lived experiences.
- Acknowledge the full spectrum of racism's harmful effects. By focusing only on the patient's experience within the healthcare institution, opportunities to analyze community-level structural factors will be missed and opportunities for change will be limited. Clinicians must learn the historical context of racism and how that history continues to influence patient care.
- Identify ways to interrupt problematic systems. Participants in peer review processes can feel hopeless, frustrated and even traumatized if there is no discussion of how systems can be changed. Possibilities include creating department-wide protocols, instituting staff training, hiring patient navigators, improving access to interpreter services, improving direct communication with patients through an online portal, analyzing and providing feedback on the differential provision of pain medications, and acknowledging patient and community factors in obstetric and surgical case debriefs and huddles.
- Evaluate the session. Feedback should be collected from diverse participants, and the facilitators should discuss whether the session met their objectives. Department and healthcare system leadership should receive a summary for review and action.
It is hoped that this framework can be applied widely regardless of the local structure, style and formatting of M&M conferences.
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