Children's Minnesota tackles racial health disparities: 'What gets measured, gets done'

Twelve-year-old Laila Moses was reluctant, at first, about getting a routine immunization shot.

So a medical assistant at her Children's Minnesota Partners in Pediatrics clinic in Brooklyn Park rubbed some cream on her arm to numb the injection spot. When it came time for the needle, Moses coughed to distract herself — another pain-reducing method she learned from a nurse earlier — and didn't even feel the jab. She laughed in relief about it afterward.

An offer of pain-reducing tactics, called a "comfort promise," is now routine for every patient at Children's Minnesota. It's part of an effort to make common procedures less upsetting for patients — especially patients of color who historically were not offered it as often.

It's a small part of a larger goal to combat racial disparities in patient care and outcomes in the Children's Minnesota system, where leaders have taken the unusual step of making their disparities and corrective efforts public.

Researchers published a paper late last year that highlighted a sampling of the system's shortfalls in the journal "Pediatrics," and are attempting novel and methodical ways to change them — a model that some health advocates hope others will follow.

"I think a lot of institutions are afraid of data like that," said Dr. Dowin Boatright, assistant professor of emergency medicine at Yale University. "The fact that they're actually willing to examine themselves and make the data transparent is very courageous."

Tackling categories

In a push for change that began in 2018, Children's Minnesota created a pediatric health equity dashboard using data it was already collecting in more than 500,000 patient encounters each year at its 12 outpatient clinics and two hospitals.

A work group analyzed more than 50 metrics to figure out where to concentrate efforts. Data showed, for instance, a 20% difference in how often Black and white children were offered a comfort promise — one of several racial disparities that existed. But after a change in medical assistant training and some new procedural norms, data a year later showed that disparity had been corrected. With no ongoing large disparity, the system moved it off the dashboard.

"One of the things that I learned a long time ago [is that] what gets measured, gets done," said James Burroughs II, the system's vice president and chief equity and inclusion officer.

Now Children's Minnesota is tackling other categories of disparity, a few at a time.

Priority is going to categories that offer "the greatest opportunities to improve," said Dr. Gabrielle Hester, medical director of quality improvement at Children's Minnesota and lead author of the journal article. That includes focusing on areas that potentially affect the broadest number of patients, she said.

The first categories they are addressing: controlling asthma, making sure children get all recommended vaccinations by age 2, and making it easier for patients to schedule and keep appointments.

Data showed a 15% difference in how often Black and white children achieved control over asthma.

Hester said the team noticed that some clinics were better at controlling asthma than others, so they are sharing practices from the top performers, such as making sure someone is responsible for calling families of asthma patients and making sure there are no barriers to getting medications. They also are concentrating on connecting families with community programs that can help them address environmental factors in housing, such as mold and other toxic agents that children inhale.

Dashboard data showed a 43% difference in Black and white patients receiving all routine early childhood vaccines, so Children's leaders are concentrating on finding new opportunities to deliver those immunizations.

"We previously focused on clinic annual visits" for wellness, Hester said. But now they are figuring out ways to allow medical staff to be more nimble. If a child comes into an emergency room with a broken arm, for instance, it may be a chance to also discuss and administer a flu vaccine or other immunizations.

Leaders also implemented mobile and drive-up vaccination clinics, and are partnering with schools to arrange for vaccinations.

And in an effort to make it easier to schedule appointments, some clinics are offering availability on evenings and weekends, Hester said, to better accommodate parents with varying job schedules.

Burroughs said part of the system's strategy is educating staff about their implicit biases and the mistrust of medical systems by some people of color, pointing out that historically, "Black and brown populations were used, for lack of a better word, as guinea pigs."

Children's is also partnering with leaders in communities of color to dispense accurate information about medical procedures, such as the efficacy of vaccines.

Hospital leaders are also encouraging anyone — patients and medical staff — to report instances of bias that they see, either anonymously or with names attached. Those complaints are reviewed daily by a safety team, which works with managers or other staff members to address them individually and on a systemic level.

Improvement takes money

Some observers in the medical field said they will be looking for updates to the efforts of the Children's Minnesota dashboard to see how well it works and if it can be replicated.

"It sounds like they understand their role in the community and are trying to align their actions with their values," said Dr. Tyler Winkelman, a clinician investigator at Hennepin Healthcare.

But he added that other health care systems might do more to address disparities if there were better funding incentives. Some of the work takes resources that aren't reimbursable, he pointed out.

"If you need to hire extra people to make lots of phone calls to improve these metrics, and you can't reimburse for the time of all these calls … it probably won't be prioritized within most health systems," Winkelman said. "You need to be able to do that good work and not go out of business doing it."

Burroughs said that at Children's Minnesota, equity is a priority "regardless of how much it costs.

"Just like quality and safety control is a standard across health care even though it's not something that's billed, we need to recognize that diversity, equity and inclusion work is just as important."

Children's Minnesota program leaders wrote in the journal article that health equity cannot be achieved without highlighting disparities.

"Importantly, we recognize that discussion of disparities often includes uncomfortable but necessary discussions of implicit bias and systemic racism," they wrote. "As an organization, we believe that becoming more open and transparent will continue to facilitate opportunities to better serve our community."

Time will tell how well the approach works, leaders acknowledged. But going public about their specific disparities will keep them accountable.

"We are a work in progress," Burroughs said. "We acknowledge that we need to get better, we're measuring where we need to get better … we're going to, on a regular basis, check into where we are with disparities, and most importantly change our behaviors."

Staff photographer Renée Jones Schneider contributed to this report.

Pam Louwagie • 612-673-7102