Covid-19: a positive legacy for health outcomes and equity? Derek Feeley, immediate past President of the Institute for Healthcare Improvement

July 2020

About The Speaker

Derek Feeley is the former President and CEO at the IHI in Boston, Massachusetts. He has driven IHI’s strategy and programmes to improve health and the quality and accessibility of healthcare in the USA and worldwide. Prior to joining IHI, Derek served as Director General for Health and Social Care in the Scottish Government and Chief Executive of the National Health Service (NHS) in Scotland. During his Harkness Fellowship, he researched the management of chronic diseases, with placements at Kaiser Permanente and the Veterans Health Administration. In 2013, he was made a Companion of the Order of the Bath by Her Majesty, Queen Elizabeth II, in recognition of his services to health and health care.

Summary

Derek Feeley (Harkness Fellow 2005-06), former President of the Institute for Healthcare Improvement (IHI), has been part of the tremendous response to help the US healthcare industry survive the Covid-19 pandemic.  In our first ever Zoom Talk he shared the lessons he and colleagues at IHI are taking from the last few months.

The level of inequity in the US, and indeed in many other countries, has been highlighted by the Covid experience.  The Black Lives Matter campaign has been galvanised by the inequitable outcomes for people of colour during this pandemic, exposing long standing inequities that we must address. Racism is the major factor that has led to these inequitable outcomes.

 

Setting the scene, Derek shared the CDC’s age adjusted Covid-19-associated hospitalisation rates per 100,000 people for March through June 6 2020, by racial group.  These are 193.8 for Native American/Alaska Native; 171.8 for Black; 150.3 for Latinx; 44.9 for for Asian American/Pacific Islander; and 37.8 for White. The IOM Report, Unequal Treatment, published in 2002, noted that racial and ethnic disparities exist regardless of socioeconomic status. There is higher morbidity and mortality from leading causes of death, poorer quality of care, and worse outcomes.  The report noted that racial and  ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access related factors such as patient’s insurance status and income are controlled. Later in his talk Derek highlighted the issue of people losing employer sponsored health insurance with up to 40.2% uninsured in Non-expansion States.  Five and a half million lost insurance in three months earlier this year, a consequence of an employment related health insurance system and the economic downturn. The lifetime likelihood of imprisonment gives another clear indicator of the impact of racism 1 in 17 for white men, 1 in 3 for black men, and 1 in 6 for Latino men. Or the fact that the share of net worth of all US households is very heavily skewed to white citizens.

 The Institute of Healthcare Improvement (IHI) have been focusing on improving health equity, including examining their own organisation. Derek shared the definitions he uses; this is essential for us to do in organisations too, so that action can address key issues effectively.

  • Health Equity – everyone has a fair opportunity to attain their full health potential
  • Health Inequity – differences in health outcomes that are systemic, avoidable and unjust
  • Racism – a system of advantage, oppression and injustice based on race.

Covid 19 and our responses to it have given us evidence that we can work in different ways.  Don Berwick, Founder of IHI, has listed six key lessons that will help us develop a ‘new normal’ in effective health care, one of these being stark evidence on the inquity in our health care systems, https://jamanetwork.com/journals/jama/fullarticle/2765699

Derek presented his audience with 5 Choices for the new future.

Will we finally tackle health inequalities?

Will we recognise that the healthcare system is a dinosaur?

Will we take seriously the physical and psychological demands of healthcare staff?

Will we take the opportunity to democratise knowledge?

Will we see healthcare as a basic human right ( especially in the USA)?

With regard to equity he felt we need to work at four levels to achieve improvement through the classic IHI PDSA model.  First at an Individual level – examining and improving our personal understandings and beliefs. He explained the concept of Authentic Allyship – a series of points to address to improve your understanding.  A key part of this is Listening to Amplify, not to replace; the Scottish proverb ‘Wide Lugs and a short tongue is best” fits well in this case, or as he was told when young – you have two ears and one tongue and should use them in that ratio. This approach helps at the Interpersonal level; the ways that we relate to, work with and understand each other.

At the third level, Institutional, we must consider our systems, processes, and procedures. IHI has produced a guide for health care organisations “Achieving Health Equity”.  An absolute must is to make health equity a strategic priority, demonstrating leadership commitment to improving equity at all levels of the organisation. This may require new payment models to secure sustainable funding, but also includes fundamentals such as ensuring the ethnic mix of the workforce reflects the local population at all levels of the organisation. IHI’s own strategy is summed up on one page with health equity being a key driver. IHI have also listed Equity as one of their four values, along with Love, Courage and Trust,  amplified in the statement “We work to prevent and undo unfair systems and forms of racism and discrimination that drive gaps in our organization and in our work. We tell the truth about inequities and value all voices. We believe that we are interconnected and that inequities lead us all to lose, We want everyone to thrive and none of us can truly thrive until we all do.”

Here, Derek shared the emphasis IHI now place on Joy in Work.  It is reflected in their strategy, but also as a key element for their work on Radical Redesign. He noted the high rates of depression, emotional exhaustion, PTSD and suicide in health care professionals even before Covid.

Alongside creating Joy at Work and promoting wellbeing, IHI recommend that we standardise what makes sense.  He noted how telehealth has grown exponentially in the last few months, though it has been effective in rural communities for years. He shared an example from his days as CEO of NHS Scotland, when a patient was delighted to be ‘seen’ on video, not only to avoid the lengthy travel to hospital but also to have his family who cared for him listening in to the consultation. Other elements of radical redesign include:-  move knowledge not people; collaborate and cooperate; make it easy; customise care to the individual; and change the balance of power. They also advocate assuming abundance (i.e. using an assets based approach that recognises the contribution that community members can make) and retuning the money(i.e. removing the waste in healthcare and reinvesting in the social determinants of health).

At the fourth level, the Cultural level, we must consider our values, organisational norms and ways of working.  He spoke about moving from performance management, which involves keeping power, through quality improvement which involves sharing paper, till we reach the third curve of power; ceding power to achieve co-production.

After noting the difference in the stances of the leading candidates for the Presidential election in 2020, Derek concluded with the five things he had learned about good leadership during Covid.  We must be transparent, work together, keep a sense of trusted calm and recognise that our values are being tested.  Most of all we must recognise that Normal is what got us here, and that we all need to seize this moment to make things better.

For further information about the Institute for Healthcare Improvement (IHI) click here