Episode 05: Safety with Equity

Are Black and Brown people at greater risk of medical errors in the U.S.? What are federal agencies doing to track and reform practices to make health care safer for those most at risk of preventable harms? Join host Karen Wolk Feinstein and special guests Dr. Cara James, president and CEO at Grantmakers In Health, and Dr. Kimá Joy Taylor, founder of Anka Consulting and a nonresident fellow at the Urban Institute, as they explore health equity issues within patient safety and the work that is needed to create a fair and just opportunity for every person in the U.S. to be as healthy as possible.

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Up Next for Patient Safety: Ep. 05 Safety with Equity

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Episode Transcript

[00:00:00] Cara James: I think that in our time today, we’re seeing a lot of people who are focusing on health equity, but we’re not all talking about the same thing…

[00:00:13] Kima Joy Taylor: When looking at these within hospitals, we found that black adult patients had worse patient safety indicators compared to other patients. But to have the data to see if it’s really working, to have the data to change it if it’s not working and having the outcomes we want to see in real-time would be incredibly helpful…

[00:00:31] Karen Wolk Feinstein: Welcome back to the Up Next for Patient Safety podcast, where we envision a world where medical errors, adverse events and preventable harms are avoided, and where we also examine promising paths to prevent tragedies before they occur. I’m your host, Karen Feinstein, CEO, and president of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, a multi-stakeholder quality collaborative. We’ve been working to reduce medical error for over 20 years, mostly unsuccessfully, but we can’t give up because there’s too much at stake. That is the loss of approximately 250,000 lives a year and long-term injuries for many more.

On today’s episode, we’ll be talking about health equity. Data indicate that black, indigenous, and other people of color, and marginalized or disadvantaged groups are more at risk for medical errors. We’ll examine how we might begin to reduce those risks in a sensitive and effective way. So to do this, I’m proud to welcome two esteemed guests to the show today, doctors Cara James, and Kima Taylor.

Dr. Cara James is president and CEO at Grantmakers in Health, a non-profit organization dedicated to helping foundations and corporate giving programs improve the health of all people. Previously, she served as director of the Office of Minority Health at the Centers for Medicare and Medicaid Services (CMS), where she provided leadership to reduce disparities and achieve health equity for vulnerable populations. Under her guidance, CMS developed its first equity plan to improve quality in Medicare and its first rural health strategy.

Dr. James also served as director of the disparities policy project and director of the Barbara Jordan Health Policy Scholars program at the Henry J. Kaiser Family Foundation. Dr. James is a past member of the National Academies of Sciences, Engineering and Medicine’s Health and Medicine Roundtable on the Promotion of Health Equity. Welcome, Cara!

Dr. Kima Joy Taylor is founder of the Anka Consulting, a healthcare consulting firm, and is a non-resident fellow at the Urban Institute. Dr. Taylor collaborates with Urban Institute researchers on a number of topics very appropriate to today, including analysis of racial disparities and medical errors, disparities in screening and treatment practices for parents with substance use disorders, management of neonatal abstinence syndrome and hospitals in California. And prevention and early detection of mental and behavioral health problems among adolescents. In 2001, she was awarded a Commonwealth Foundation Fellowship in Minority Health Policy at Harvard University.

Dr. Taylor has served as the director of the Open Society Foundation’s National Drug Addiction Treatment and Harm Reduction program. She also served as deputy commissioner for the Baltimore City Health Department. As a health and social policy legislative assistant for Senator Paul Sarbanes and as a pediatrician at a federally qualified health center in DC. So welcome Cara and Kima, we couldn’t have two better participants today for this topic.

Cara, could you start us off by helping us define health equity? What does that term mean to you and from your own research, what populations are most likely to experience lower quality care, less care and unsafe care?

[00:04:15] Cara James: Well first of all, Karen, thank you so much for inviting me to be part of this important conversation. I’m really pleased to be joining you and my colleague Kima, to talk about this really important issue. And I’m so glad you asked the question about “what is health equity?” because I think that in our time today, we’re seeing a lot of people who are focusing on health equity, but we’re not all talking about the same thing. And so it’s really good to ground us in a common definition to start the conversation off and the one that I really like is from the Robert Wood Johnson Foundation. And health equity means that everyone has a fair and just opportunity to be as healthy as possible. And to attain that, it means we’re not giving everyone the same thing, but recognizing the unique needs that each individual has and addressing those needs to help them achieve their highest goals.

And when we think of disparities and particularly in quality of care, we have decades – unfortunately – of research that shows disparities in quality. So the National Health Care Quality report, National Health Care Disparities report from the Agency for Healthcare Research and Quality or AHRQ has shown us since that first report that Black and American Indian, Alaska natives, as well as Hispanics have worse quality of care for a variety of the indicators that they tend to look at. And these are in some cases hundreds of indicators that they’re looking at of quality of care and it consistently, compared to non-Hispanic White, Black, American Indians, and Hispanic communities fare worse.

And more concerning is that when we look at the change over time, while we have improved quality of care for everyone, overwhelmingly, we have not made any progress on disparities, and they have remained stagnant. So we’re looking at about 90 plus percent of those disparities have remained the same over time. So we clearly need to do something different to address these issues.

[00:06:16] Karen Wolk Feinstein: Thank you, Cara. We’ve suspected for a long time that people of color who are disadvantaged in many ways vis-a-vis the medical system might also be disproportionately affected by medical error. Well, we needed confirmation and we didn’t have confirmation until recently. So Kima, you recently advised on the Urban Institute’s report in July of this year, that was titled “Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital?” So could you just tell us what did this report find in terms of disparities related to patient safety?

[00:06:57] Kima Joy Taylor: Absolutely. I just want to take a moment to thank you for inviting me and allowing me to join Cara in this great conversation. But I also want to make sure that I give deep credit to my colleague, Anuj Gangopadhyaya who did all the heavy lifting. While I advised, he really dug into this issue in a great way, and I recommend that people look on the Urban website to actually look at the two papers that came from the work.

But this study looked at 11 AHRQ-developed patient safety quality indicators and AHRQ is as Cara mentioned, the Agency for Healthcare Research and Quality, and part of the reason that he chose these indicators, right, was because they were something that had been in the literature for quite a while, and people recognize them as patient safety quality indicators that could be trusted and that people would look at and use. And so he used four general indicators, which are like pressure ulcers or central venous line infections, and then seven surgery related measures, which are like perioperative hemorrhage, post-op sepsis, and post-op respiratory failure. And when looking at these – so it’s not a surprise to many – when looking at these within hospitals we found that Black adult patients had worse patient safety indicators compared to White patients.

I know this is something we’re going to get to later on, but because of data, it was just Black and White, and we need to do a better job on that, but it did show this disparity on six of the eleven indicators, including four out of seven of the surgery indicators. And these indicators, just to give an idea, were the central venous line infection, perioperative hemorrhage, post-op kidney failure requiring dialysis, post-op sepsis, post-op deep venous thrombosis, and post-op respiratory failure, so we’re not talking minor events. Here’s your events that not only can lead to death, but land or cause chronic illness that people have to live with. It did demonstrate that on two measures that Whites had worse patient indicator outcomes on the iatrogenic pneumothorax, which is when your lung pops, and in-hospital falls that lead to hip fracture. And some of the comments have been like, “a-ha! See then there’s not an inequity.” And it gets to Cara’s definition that inequities are looking to achieve high-quality outcomes for everyone. So this information is equally as important.

And then lastly, similar rates for three of the patient indicators. A further look at the data, really tried to see if there are differences among insurance and that became harder, but he did look at Medicare-covered patients and found that those disparities persisted. So there’s a lot that goes into whether and how a person gets to hospital, when a person gets in the hospital, but as you alluded to Karen, we’ve known that we suspected disparities existed. Now even indicators show that they do exist and now it’s up to all of us to actually do something to eradicate them. And this research hopefully is the first step, not just identification, but looking and working with communities to uncover those remedies.

[00:09:51] Karen Wolk Feinstein: Thanks, Kima, isn’t it sad that we’re not surprised? I think that’s the saddest given what goes on in our society. We’re not surprised, but now that we know… now that you and the Urban Institute and Anuj have uncovered this, at least now we have proof. So to our listeners, if you’re at all confused, we are Karen, Cara, and Kima!

So now I am going to turn to Kara to tell us a little bit about what’s happening at the federal level to measure and respond to these patient safety disparities, or let me also put it this way, what should federal agencies be doing to address inequities in medical safety? And what are some promising interventions?

[00:10:39] Cara James: Thank you. So I think that, you know, one of the things I would say is this has been a focus of the federal government for a while. And one of the things that we have seen is the Hospital Acquired Conditions Reduction program that has been in place at the Centers for Medicare Medicaid Services, focusing on Medicare and a number of those conditions that Kima talked about. So included in there are things related to, adverse events, the CLABSI, which was the central line associated bloodstream infection, as well as catheter-associated urinary tract infections (CAUTI), surgical site… these sorts of things are included in these indicators that hospitals are no longer getting the same payment if you’re having too many of these events happening.

And so those… it’s a downward adjustment for those who are performing worse. So that’s been in place for a while. We are seeing some improvements and some that are still just really hard to deal with and are not making much progress on, so we still have more work to do there. This is also a focus of work within the CDC, the National Healthcare Safety Network, that is also looking at these issues and trying to provide data at a more sort of hospital-local level that can be actionable. In that report that Kima talked about that’s so important is it starts to get into sort of what’s happening in your own shop and how we can start to improve things there and so it’s really important.

What is a challenge – and I know we’re going to talk about this a bit more – is we’re still having difficulty getting some of this information by race and ethnicity, to understand where we’re having these disparities. And so there are a lot of efforts, the hospitals have been focused on this. There have been patient safety initiatives, partnerships that have been happening through CMS, but we still have some challenges where we don’t have great insight into what’s going on in some places. And there’s still more that needs to be done there. I’ll stop there cause I know we’re going to talk more about one of the central pieces, which is we need the data to understand what’s happening. And I know that some of these are really all quantity events that are happening, which makes it harder to sort of break down the data, but it’s still important because in some cases we’re struggling just to even collect it.

[00:13:04] Karen Wolk Feinstein: Well, I like to be an optimist at times, and I will say that during COVID-19 at least, during this pandemic, we did start to collect information by race and ethnicity and linguistic affiliation. And so maybe we are making some progress… maybe a good thing to come from the pandemic. So Cara, thank you. I will have to say as a 31-year member of Grantmakers in Health, I am so glad that someone with your background is in a leadership position now. So that’s a good thing.

Kima, how do we incentivize change in an environment where workers are scared and they’re also overwhelmed? And as we know, sadly, so many nurses are leaving the profession it’s the crisis that I don’t think America has dealt with. There’s the pandemic, but there’s also the aftermath. How can we move from collecting data to acting on it in the current conditions?

[00:14:10] Kima Joy Taylor: Yeah, and I thank you for mentioning that. The healthcare system is going to undergo some serious workforce challenges. And diversification and expansion needs to be a part of our efforts. But it’s also… as we look at this, I think some of the help would be to really look at systems and not just individuals. A lot of times and a lot of programs we’ve done have been focused on why X provider, isn’t doing X and why Y providers and doing Y. And for some of the measures that Cara was talking about, some of the sepsis bundles and other ways we’re gonna improve outcomes, it really had started talking about how do you change systems? And for this in order to achieve health equity, it really has to start with teaching and incentivizing, like not going straight to the punishment, but saying, one, where is the data? Who’s collecting it? And do we trust who’s collecting it? Because there’s a lot of mistrust there, whether it’s fair or not but we need to have it out there.

But we need to work in partnership with community, see what values – what patients value – listen to what communities have already developed, listen to how they value our outcomes, and really have systems work together to understand what data we should be collecting, what it looks like and what they’ve already done. For a lot of this work, folks know, as you mentioned, these disparities exist. They’ve had to overcome them in their own community with their own resources. Let’s listen and see what they’ve done so that we can expand that. The other thing we really need to do is support the systems to then change the workflows and processes and electronic health records that keep them doing business the same way, which hasn’t had the outcomes that we’ve wanted to see.

And so some of that is thinking through work models, reflecting on these changes, and then ultimately there does have to be a little bit of carrot and stick. We need to start – and the health system is moving towards paying for outcomes – but we need to do these value-based payments in a way that also incentivizes actual achievement of equity. And some of that’s going to take time and work in the community to get to that point. But really, it’s teaching folks to not only collect data, understand data, and analyze it in partnership with community and then act on it and reevaluate, check that data again to see if it’s working. And I know that we all keep talking about data… there is an important aspect to that also using data for good. I do a lot of work in the substance use space and sometimes data can be used in punitive measures. So, having kind of that third-party or having protections in place to make sure it’s used for good is going to be incredibly important, but we need to start paying for what we want to see and requiring that to happen.

And I’m all for doing the systemic measures that are necessary to get us there and join them in partnership so each provider doesn’t feel like they’re plagued. You go to providers often and they’re like, “look, I’m exhausted I see 30 patients a day, they’re dying and now you’re saying, it’s my fault that people are dying disproportionately.” That’s not a conversation that’s going to get you where you need to go and it’s not going to get us the equity meetings. We really do need to focus on these systemic changes.

[00:16:58] Karen Wolk Feinstein: And you bring up that sort of sticky-icky issue of incentives, right? So people say, “oh, the health system, you know, we’re charitable, we’re humane. We have all the right impulses; we’re just going to do things right even if no one gets rewarded.” And in fact, hospitals pay a penalty for putting in the investment to keep increasing safety. So we want to stick – you want to stay away from that issue – but it’s right to bring it up. If two workers are working alongside each other and one is doing extraordinary work, that’s kindly, that’s best practice, that’s safe; and a coworker is actually not… and then they’ll both get the exact same pay the next year.

You know, we know what human nature is, and I’m glad you brought up that issue of incentives. So sometimes I think that our most promising interventions to address racial disparities exist upstream at the community level, through community-based organizations and community health workers who come from the racial, ethnic, linguistic groups who are most affected. And this approach might work to prevent hospitalizations and serious illness before they occur, putting less burden on the frontline staff.

So Kima, you’ve done so much work on improving infant and maternal health, substance use and mental health. In many countries… I’ve gone to global health conferences and I see what’s happening in India, Rwanda, South Africa, and believe it or not even in Afghanistan, from deploying community health workers who are armed with technology – I mean smartphones and tablets – that not only can give them the immediate useful practical information and guidance that they need, but can actually nowadays do some diagnostics. What is taking the United States so long to deploy similar interventions? Are we afraid of arming community health workers with the right technology and trusting them to achieve worthy results?

[00:19:05] Kima Joy Taylor: Yes, I think we are. And you know, one of the big issues I would say is racism, classism, and other -isms, but it’s also the U.S. purposely developed a healthcare system that often doesn’t listen to, believe, or trust patients in the communities in which they serve. That trust piece and who we trust to provide those services is big, but it’s also the payment piece, who gets paid to do it, right? And as we move to a value-based system, we have to remember that the healthcare system was set up to value and pay the most expensive person, regardless of all else, including regardless of equity. And so again, we have to deconstruct these systems and think differently.

And I too like to be optimistic at times, Karen, and I feel like perhaps this movement towards outcome-based payments can allow payments to align with desired teams and equitable outcomes you want to see. And if you start doing that, you start to realize that folks on the ground who can best engage, work with, have that culturally, and linguistically affective interaction are going to be the ones that get you the outcomes you need to achieve. And often that is the community health workers the peer workers, the promotoras, and they’re the ones who need to be paid and part of the team in order to get us the outcomes we need to see.

So I’m hopeful that – and these exist in small pockets – it’s just that they’re not scaled and reimbursed at the level they should be. And so I’m hopeful to move forward towards these outcome based payments that’ll happen. I will say though, that I also have a little issue in the sense that they have to be paid, they have to get benefits, they have to have a career ladder. So many times I’m doing this work, and people are like, “let’s have them volunteer as community health workers.” No! They’re an integral part of the team and they need to be funded as such.

[00:20:45] Karen Wolk Feinstein: And sometimes that’s a sensitive issue cause we know that people who’ve been doulas, some people have done community health work, they say, “we don’t need to be certified” but our problem at this end is it’s hard to get you reimbursed if you don’t get certified. So that’s what the ongoing dialogue is in our community and others. Cara, I don’t know if you wanted to comment on this issue.

[00:21:09] Cara James: I think, I mean Kima has said a lot there that is really spot on. And I think one, I just want to lift up in terms of what we need to think about from a policy perspective, because that’s when it comes down to reimbursement. And as she mentioned, we’ve set up a system that pays the most expensive people the most money. But we’ve also set up a system where only certain people can get paid. When we think about, you know, who’s an eligible provider, which is a term in policy of how Medicare reimburses, community health workers are not an eligible provider.

And so thinking about how we also need to not only change the systems in which people are practicing, but change the policies that are creating the incentives that are misaligned to get us health. And I think the other thing is that our system is set up to pay providers to do stuff, not to pay providers to prevent stuff from happening, which is a different way of also kind of thinking about that when we’re thinking about our community workforce and how do we keep people healthy in their homes and in their communities rather than having them in the hospital.

So I think it’s also looking at this and thinking about how we change those pieces so that we can continue to align at not only paying for outcomes, but also making the supports that are needed to make sure people can get the outcomes we’re trying to achieve. But I would also just say, when we talk about sort of the technology piece, it is still worth remembering we still have some work to do in technology gaps that can also create and also contribute to some of the disparities. We still have portions of our community that are not connected to broadband, but in rural areas and frontier spaces that make that a little bit challenging.

There’s been a lot of effort with the pandemic and resources to help expand access to broadband, but we also need to think about how that technology is used. Wearables, for example, now that we’re thinking about apps that can help keep track of how much sleep you’re getting and how much you’re exercising and those sorts of things, but also understanding when we’re looking at communities, there are some communities that aren’t having as much access or utilization of those technologies as well. So just being mindful that we are and continuing to be on a spectrum and a continuum of opportunity and challenge.

[00:23:28] Karen Wolk Feinstein: I love your point about giving a more flexible scope of work and reimbursement mechanism and breaking through some of the regulations in our country that’ll hold us back. So, we visit other countries where midwives and doulas and community health workers have so much more flexibility in terms of what they can do and in what setting, and we hold so many valued healthcare workers back by regulations that are long outdated. So that’s something to look for and there’s an area of research, Kima, that we should be pursuing.

So, one thing we are working on here, we looked at a National Patient Safety Board and we’ve got a national coalition looking to create it. And one of the things that we often worry about is that wonderful things that are discovered, improvements at are local level, even so local as a unit of a hospital or practicing federally qualified health center… it may never get shared, it never gets spread, and doesn’t get scaled and sustained. And so one thing we… the one area of this country has really awakened to, which is great, are the racial disparities as they affect maternity.

The disproportionate African-American women and infants who suffer from this, regardless of income, education, or professional status, which I think is really interesting because this vulnerability is sort of an equal opportunity thing unfortunately. We often see great state-led efforts like perinatal quality collaboratives. And then we see local efforts, community efforts, state-wide efforts, but I always worry that it takes so long for those to spread. And could you ever imagine a national entity such as a National Patient Safety Board that could help spread, scale, sustain worthy efforts?

[00:25:33] Kima Joy Taylor: I do, but can I back up in that I see another role for it as well? Yes, to share these efforts, but actually just for people to have a place to see data, compare data, and trust data. And so many places, you know, part of the reason we’re in this quandary… it’s not new that disparities exist. It’s who in the past has researched those and brought that data forward that people are like, “oh, well, that’s not really it.” Or, you know, there’s always some reason that it’s not. And so having this place that nationally says, “this is the data, these disparities exist, we’ve been able to disaggregate it,” actually could help all of us researchers, et cetera.

So, starting from there, but then also definitely disseminating some of these community-based efforts and its dissemination recognizing that each community is different. Some of them will be altered. Some of them will need to be made culturally, linguistically effective, but then being able to do that rapid evaluation, right? So many times – and I worked in government – but so many times you put a program in place because you really want it to and it seemed great, and they were like, “sure, that’s going to work.” But to have the data to see if it’s really working, to have the data to change it if it’s not working, and having the outcomes you want to see in real-time would be incredibly helpful. And then to be able to compare and contrast how you’re doing, because again, governments often are moved for good or ill by what the next town over or the next state over is doing. So it can also be a bit of an incentivization.

And then the last thing I’ll say, one thing, and I’m a big proponent of data disaggregation, but I’m also a big proponent of knowing who your community is so you know which data you’re supposed to be disaggregating. A lot of times, we will import data from other places that doesn’t reflect their community, they may have a huge Somalian and Hmong community and they’re importing African-descendant of slave data. And so, I think it’s very important also for communities to understand the capacity of disaggregation that other folks are doing. Some states are really getting into the disaggregation movement and it’s also a teaching experience, right, to see what other folks are doing. So I think it could have many positives.

[00:27:33] Cara James: And to that, I think those are all good points, and one of the things that is worth remembering as we think about our health as a community and a country, where you live matters. And so Karen, you lifted up, you know, there are some states who are doing some really great work with perinatal collaboratives and there are others who aren’t, and so I think, you know, the opportunity with the board like this, the National Patient Safety Board is that it can do a lot of the things that Kima talked about in terms of the data.

But it can also help to encourage and give tools and best practices for some of those places that are not quite where we want them to be. And I think it’s worth noting that they’re not there for a variety of reasons. There are some that are not there because they’re not sure how to do it, but they want to do it. There are some that just don’t have the resources to do it and are struggling to figure out what to do. And there are others that we’re going to need to use some of those sticks that Kima was talking about a little bit earlier.

I think the board can serve in a variety of ways of both making sure we have the data and looking at the data because a lot of times we find people have data, but they’re not analyzing the data that they have. Let’s use what we have to look at these issues and I think the board can also help in a space where there may be some places that are resource constrained, because we do know states and localities don’t have some of that analytic capability or the manpower to be able to implement a lot of these quality initiatives. The safety board could help with that, and again, giving some of those best practices.

The other thing that I think that would be helpful is, we know that everybody is getting pulled in so many different directions and it’s hard to stay focused on a particular issue but having a National Patient Safety Board can help keep a light and keep a focus on these issues. And to lift up and connect to some of the agencies and organizations that are working on these at the national level – and the policy space as well that we’ve talked about – to reduce some of those barriers that would allow us to continue making meaningful progress in this space.

And lastly, I would just say that I would hope that, you know, the National Patient Safety Board, if we have one, could also bring in that patient perspective, because at the end of the day, it’s all about how people experience the healthcare system and how they’re trying to obtain that highest level of health. And having that voice at the table can make sure that we’re not doing things to people, but with people and helping them achieve their goals.

[00:30:01] Kima Joy Taylor: That is totally true, but it also arms them, right? And so, it arms them so they make the policymakers actually focus on the issue and achieve the outcomes that need to be done. It’s a place where advocates and patients can go to understand their own data and use it for good.

[00:30:19] Karen Wolk Feinstein: I love it. And it arms them and empowers them. It says, “you do have a voice.” We need to listen to that voice. And I think that would play out in many productive ways. Instead, they feel like this is a system where you’ve got to have a credential or nobody wants to listen to me, or I don’t know enough to make a useful comment. I hear that on hospital boards, people say, “well, whatever you tell us is, okay, because you know… who are we to challenge you?” So, I think it plays out in a lot of ways. I was amazed at some countries we’ve visited where at the national level they’re constantly scanning for hotspots. When there’s a flare up of maternal mortality or infant mortality, they immediately sent out a SWAT team led by midwives – let me mention that – but they send out these SWAT teams because at the national level, they’re constantly looking at the environment to see where extra help is needed.

I’ve also seen as you guys have mentioned, so many small experiments that we’ve done, but actually they were big discoveries in a unit or a practice or skilled nursing or a health center, but here’s what happens… if our coach leaves and the champion leaves as well, for example, they may get transferred or may leave, everything goes back to baseline, because there’s no national organization to keep spreading and sustaining best practices and feeding that information to the other appropriate federal agencies or the Joint Commission. Things don’t get cemented. They kind of drift and people can write books about all the worthy things or a peer-reviewed article, but that doesn’t mean it’s going to change anything.

So, I really think you touched on all of the reasons why I would want a National Patient Safety Board to constantly be mining the best available patient safety data, looking for disparities by race, ethnicity, gender, and geography, and then doing something. Doing something! Coming up with solutions, testing solutions, but that is why we liked the NTSB as a model, because the one thing they’re not about is endless research. What they are about is making sure that harms do not occur before they happen. I cannot thank you both enough for your really invaluable observations and your expertise and commitment to this area.

So for our listeners, if you want to learn more about the effort to establish a National Patient Safety Board, please visit npsb.org. We also welcome your comments and your suggestions on any of our podcasts, particularly today’s. I’m sure there’s some listeners who have ideas for us and topics within equity that we did not get to cover.

If you found our conversation enlightening or helpful, share today’s podcast or any of our podcasts with your friends and colleagues. We can’t improve the effectiveness of our healthcare systems without your help. It’s you our listeners, friends, and supporters who are the essential part of the solution. Thank you all for today.

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