Coach’s Playbook

A Crisis in American Health Care

(and No, It Isn’t COVID-19!)

by Kay Kendall, special to Arkansas Hospitals magazine

It’s November 2020, and you’re the parents of a beautiful, 5-year-old daughter. Less than 15 hours after she tests positive for COVID-19 and is sent home from the ER, she’s dead. Did she die from COVID-19, or because her skin was black? You’ll never know.

(This is just one of many similar incidents reported by media outlets over the past year.)

A NEW LOOK AT DISPARITIES

The disparities in health care and health outcomes have been known for decades, but nowhere have they been more evident than during this pandemic. Rather than focus on differences as they apply to infection and mortality rates, it’s time we take a broader, more strategic, longer-reaching look at the social determinants of health.

Dr. Donald Berwick, known to many as a pioneer in health care’s modern qualitycare movement, refers to these disparities as the moral determinants of health.1

“Attacking racism and other social determinants of health is motivated by an embrace of the moral determinants of health,” Berwick says. “These include, most crucially, a strong sense of social solidarity in the U.S. ‘Solidarity’ would mean that individuals in the U.S. legitimately and properly can depend on each other for helping to secure the basic circumstances of healthy lives, no less than they depend legitimately on each other to secure the nation’s defense. If that were the moral imperative, government – the primary expression of shared responsibility – would defend and improve health just as energetically as it defends territorial integrity.”

Experts generally agree that four factors (and their weighted percentages) contribute to health: • Clinical Care Factors, including access to care, quality of care, and safe care. These contribute about 20% toward a person’s health and well-being. • Social and Economic Factors, including food security or insecurity, adequacy of housing and/or lack of housing (homelessness), employment security, adequacy of income, level of education, and community safety. These contribute about 40% toward a person’s health and well-being.

Editor’s Note: This winter, Kay Kendall interviewed Dr. Donald Berwick, Dr. Randy Oostra, and Dr. David Ansell to get their input on one of today’s most significant – and most frustrating – public health challenges: the ever-widening gap in health equity, and how social determinants play into every neighborhood’s health and its residents’ longevity. She asked these preeminent health leaders for their ideas on bringing health equity home to individual communities, and how hospitals can play a role in improving health inequities. Here is the result of those interviews. • Behavioral Factors, including choice and quality of diet, amount of physical exercise, drug use, and mental health.

These determine about 20% of a person’s health and well-being. • Environmental Factors, including quality and availability of safe water and clean air, and availability of safe transportation. These comprise the remaining 20%.

In his seminal opinion piece, “The Moral Determinants of Health,” Berwick paints a compelling picture of how these moral determinants combine with startling effect on life expectancy. “From midtown Manhattan to the South Bronx in New York City, life expectancy declines by 10 years,” he says. “[That’s] six months for every minute on the subway. Between the Chicago Loop and [the] west side of the city, the difference in life expectancy is 16 years. At a population level, no existing or conceivable medical intervention comes within an order of magnitude of the effect of place on health.”

WHERE DOES ARKANSAS STAND?

Arkansas Department of Health data indicate that both life expectancy and infant mortality are alarmingly affected by the county in which Arkansans live. This backs up Berwick’s claim – location, or where we live, is the major determinant of health.

It is no secret that Arkansas is one of the least healthy states in the U.S. It has the sixth-highest poverty rate in the nation, and it is ranked 42nd in level of education. And in terms of overall health, in 2019 (the last year for which reported data are available), Arkansas ranked 48th in the nation. Only Louisiana and Mississippi were ranked lower.

This is not an insurmountable problem. Leaders of multiple health systems are working every day with their community leaders to form powerful coalitions addressing each of the factors impacting community health.

For example, Toledo, Ohio’s Root Cause Coalition is chaired by Dr. Randy Oostra, President and CEO of ProMedica, a non-profit health care system with locations in northwest Ohio and southeast Michigan.2

In the 10 years since ProMedica developed its strategic plan to address the social determinants of health, huge strides have been made. The coalition has conducted 971,000 food screenings and 118,030 full screenings over 10 domains. It has embedded numerous solutions for providing food to those in the community suffering from food insecurity. It has provided financial coaching to community residents and access to low-interest funding so entrepreneurs can create businesses and jobs. I urge you to listen to Dr. Oostra in his powerful TED talk.3

In my interview with Dr. David Ansell, he described forming West Side United as a coalition of six local hospitals and a variety of community organizations, faithbased institutions, and businesses to focus on four impact areas: Economic Vitality, Education, Health & Healthcare, and Neighborhood & Physical Environment.4

The group developed a scorecard with measures for each of these areas so that progress can be monitored, documented, and shared with neighborhood residents. Other communities might utilize that scoreboard as they try to make related impacts.5

Similar to Richard Rothstein’s observations in his book The Color of Law: A Forgotten History of How Our Government Segregated America, Dr. Ansell observes that, “Life opportunities are limited when you’re surrounded by poverty.” Rothstein notes longitudinal studies reporting that children born into poverty are likely to be even more impoverished than their parents when they become adults.6

RACISM: A PUBLIC HEALTH CRISIS

Many medical schools are declaring racism as a public health crisis.7 Following the Memorial Day 2020 killing of George Floyd in Minneapolis, the states of Michigan, Nevada, Wisconsin, and Colorado acknowledged and proclaimed

FOR YOUR REFERENCE SHELF

THE IHI EQUITY COLLABORATIVE

A treasure trove of information with practical guides to address key areas to improving health care equity: •Make Equity a Strategic Priority. •Build Infrastructure to Support

Health Equity. •Address the Multiple Determ- inants of Health. •Eliminate Racism and Other

Forms of Oppression. •Partner with the Community.

Also included are many additional resources and lessons learned from the health care organizations that have joined the IHI Equity Collaborative. www.ihi.org/Engage/Initiatives/ Pursuing-Equity/Pages/Resources. aspx

THE ROOT CAUSE COALITION

From the report, The Status of Health Care Equity, to a series of webinars with presentations by executives of health care organizations on the journey to improve equity in health care, this site is another source of information to help you explore this critical topic for your own organization. www.rootcausecoalition.org/ webinars/

THE DEMOCRACY COLLABORATIVE

The Healthcare Anchor Network offers a playbook for how health systems can collaborate to improve community well-being by building inclusive and sustainable local economies. democracycollaborative.org/learn/ publication/anchor-mission-playbook

Donald M. Berwick is the world’s foremost scholar, teacher, and advocate for the continual improvement of health care systems. He is a pediatrician and a longstanding member of the faculty of Harvard Medical School. He founded and led the Institute for Healthcare Improvement, now the leading global nonprofit organization in its field. Appointed by President Barack Obama as Administrator of the Centers for Medicare and Medicaid Services (CMS), he served in that role in 2010 and 2011. He has counseled governments, clinical leaders, and executives in dozens of nations. He is an elected Member of the National Academy of Medicine and the American Philosophical Society. He is the recipient of numerous awards, including the Heinz Award for Public Policy, the Award of Honor of the American Hospital Association, and the Gustav Leinhard Award from the Institute of Medicine. For his work with the British National Health Service, in 2005 Her Majesty Queen Elizabeth II appointed him Honourary Knight Commander of the British Empire, the highest honor awarded by the United Kingdom to a non-British subject.

Randy Oostra is the President and Chief Executive Officer of ProMedica, a not-for-profit, mission-based, integrated health and well-being organization headquartered in Toledo, Ohio. Oostra is regarded as one of the nation’s top leaders in health care and has earned recognition as one of Modern Healthcare’s 100 Most Influential People in Healthcare and Becker's Healthcare's 100 Great Leaders in Healthcare. He has a strong commitment to the health care industry and community, and he serves on the board of trustees of the following national organizations: Local Initiatives Support Corporation (LISC), American Hospital Association, Health Research and Educational Trust, and The Root Cause Coalition, which ProMedica founded.

David Ansell, MD, MPH, is the Michael E. Kelly Presidential Professor of Internal Medicine and Senior Vice President/Associate Provost for Community Health Equity at Rush University Medical Center in Chicago. He is a 1978 graduate of SUNY Upstate Medical College. He did his medical training at Cook County Hospital in Chicago, and he spent 13 years at Cook County as an attending physician. He ultimately was appointed Chief of the Division of General Internal Medicine at Cook County Hospital. From 1995 to 2005, he was Chairman of Internal Medicine at Mount Sinai Chicago. He was recruited to Rush University Medical Center as its inaugural Chief Medical Officer in 2005, a position he held until 2015. His research and advocacy focus on eliminating health care inequities. In 2011 he published County: Life, Death and Politics at Chicago’s Public Hospital, a memoir of his times at County Hospital. His latest book, The Death Gap: How Inequality Kills, was published in 2017.

racism as a public health crisis.8 Could racism be contributing to the health disparities in Arkansas communities? How would you know?

Many great resources are publicly available at no cost (see sidebar), but I asked Drs. Berwick, Oostra, and Ansell what specific actions individual hospitals and health systems can take to address racism, social inequities, and public health improvement. Here are their recommendations: • Discuss racism, social inequities, and social determinants of health with your board members.

They are likely to include constituents represented by all four areas of impact. • Set ambitious goals, publicize them, and post your progress toward achieving them with data segmented by ethnicity, gender, household income (or poverty level), and average levels of education.

Consider breaking the data down by county or by zip code so communities can chart their progress. • Remember to canvass your own employees.

How many of them suffer from food insecurity, homelessness, or other factors impacting their health? You might be surprised, and again, your board will want to address these issues. • Reduce your carbon footprint. It’s good for the planet, good for creating healthier neighborhood environments, and it can be surprisingly good for your business. • Join one of the latest collaboratives, such as the

Institute for Healthcare Improvement’s “Pursuing

Equity Learning and Action Network,”9 or

Arkansas’s own “Healthy Active Arkansas.”10

What first steps will you take?

The team at BaldrigeCoach would be glad to help guide your hospital’s quest for process improvement. As CEO and Principal of BaldrigeCoach, Kay Kendall coaches organizations on their paths to performance excellence using the Malcolm Baldrige National Quality Award Criteria as a framework. Her team, working with health care and other organizations, has mentored 24 National Quality Award recipients. In each edition of Arkansas Hospitals, Kay offers readers quality improvement tips from her coaching playbook. Contact Kay at 972.489.3611 or Kay@Baldrige-Coach.com.

This model from America’s Health Rankings® is based upon the World Health Organization’s definition of health: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”The model includes four drivers, or determinants of health: social & economic factors, physical environment, clinical care, and behaviors, all of which influence the central model category, health outcomes.

Endnotes

1Berwick DM. The Moral Determinants of Health. JAMA. 2020;324(3):225–226. Retrieved from URL https://jamanetwork.com/journals/jama/fullarticle/2767353. 2The Root Cause Coalition: Achieving Health Equity through Cross-Sector Collaboration. https://www.rootcausecoalition.org/. 3TEDx. (2020, August 4). Five Numbers That Could Reform Healthcare/Randy Oostra [Video]. YouTube. https://youtu.be/JybvaX9kN0M. 4Ansell D. (2020). West Side United. Retrieved from URL https://westsideunited.org. 5Ansell D. (2020). Metrics Dashboard. West Side United. Retrieved from URL https:// westsideunited.org/our-impact/metrics-dashboard/. 6Goudie C, Markoff B, Fagg J. (2019, November 20). The Challenge to Cut Chicago30Year Life Expectancy Gap in Half by 2030. [Video and Print] WLS-TV. Chicago. Retrieved from URL https://abc7chicago.com/health/the-challenge-to-cut-chicagos-30-year-lifeexpectancy-gap-in-half-by-2030/5710399/. 7Cornell Health. (2021). Racism as a Public Health Crisis. Campus Leadership & Health Campaigns. Retrieved from URL https://health.cornell.edu/initiatives/skorton-center/ racism-public-health-crisis. 8Kaur H. and Mitchell S. (2020, August 14). States are Calling Racism a Public Health Crisis. Here’s What that Means. [Video and Print] CNN Health. New York. Retrieved from URL https://www.cnn.com/2020/08/14/health/states-racism-public-health-crisis-trnd/ index.html. 9Institute for Healthcare Improvement. (2021). Pursuing Equity Learning and Action Network. Initiatives: Pursuing Equity. Retrieved from URL http://www.ihi.org/Engage/ Initiatives/Pursuing-Equity/Pages/default.aspx. 10Healthy Active Arkansas. (2021). Healthy Active Arkansas: A 10-Year Plan for Arkansas. Framework. Retrieved from URL https://healthyactive.org.

Vince Leist

Planning it Through, Together

By Nancy Robertson

Every hospital is beloved within its community, but hospitals that serve rural areas perhaps receive an extra measure of open appreciation just for reliably being there. And the leaders who serve them are constantly on the lookout for new ways to serve emerging needs.

Vince Leist, President and CEO of North Arkansas Regional Medical Center (NARMC) in Harrison, is currently engaged in meeting the many challenges COVID-19 brings to the northern Arkansas region. Numerous successful projects mark NARMC’s pandemic path over the past year, and the key to this success lies in allied groups working together to help their fellow citizens.

“Editorials in the local newspapers point to ‘how organized’ North Arkansas’s COVID-19 project rollouts are,” Leist says, “and I can tell you why this is so. No matter what we’re working on, we bring together all the people who need to have a hand in the project. The groups change from project to project, but the key is to always sit down together from the very start.” He says the first question he most often poses is, “What do you need?” That question sets the tone for a team effort from the first meeting.

We bring together all the people who need to have a hand in the project. The key is to always sit down together from the very start.

“There are many tough issues arising because of the COVID-19 pandemic,” he says. “Like other hospitals of all sizes, the past year has brought financial struggles to our area, and to our hospital. But one unforeseen positive is the strengthening of relationships we see within the hospital and within the community. When we’re all working together toward the same goal, we see new partnerships emerge and closer working ties form.” When COVID-19 became a known entity, leaders at NARMC immediately began prepping for what was to come.

“We ordered PPE very early, and thus had some to share when other area facilities, like the Newton County Nursing Home, found itself in need,” he says. Also ordered early: an ultralow temperature freezer (to store the vaccines that were yet to be developed) and supplies that would be needed for NARMC to serve as a regional testing and vaccine hub.

“We purchased a previous bank building around the time the pandemic hit, and it became the perfect setting for a testing facility,” Leist says.

He credits NARMC leadership team members Chief Nursing Officer Sammie Cribbs and VP of Operations Josh Bright with laying a strong foundation for the hospital’s COVID-19 preparations.

Another group – physicians serving the hospital – had an immediate impact on preparations. “Our physician team guided every aspect of our clinical efforts at the hospital, at each of our clinics, and even at the Newton County Nursing Home,” he says. “The physicians developed a treatment protocol we utilized everywhere, and they trained all of our caregivers – even those at the ambulance station – in the proper ways of donning and doffing PPE.”

Speaking of PPE, Sammie Cribbs communicated with nursing homes in the area when national supplies of PPE ran low. She made certain NARMC supplied them with the PPE needed to stay aligned with the doctors’ management and treatment protocols. With every facility following one central clinical plan, it became easier to control viral spread. “Our physicians were integral to the assistance we offered the nursing home, an effort that became very aggressive when cases began to rise there,” Leist says.

Another coalition where groups work side-by-side is the partnership NARMC formed with the Boone County Emergency Management team, county officials, city and county law enforcement, and the Boone County health unit. This joint effort forms the backbone for regional testing and vaccination planning and delivery. “Harrison’s population is around 12,000-13,000,” Leist says. “But the hospital has a service area of 85,000 people. Working together with both city and county officials streamlines our COVID-19 response.”

We Asked...

What’s on your music playlist?

Stevie Nicks, Moody Blues, and Joe Bonamassa

What is the best advice you were ever given? A friend gave

me a picture of a Pony Express rider moving at top speed. The image came from the Cowboy Hall of Fame museum in Oklahoma City, and the title of the image is the advice, “Never Look Back.”

Do you have a favorite movie? Why do you like it? Not a movie

but a Prime series, “Yellowstone.” The story line, the scenery, and the acting quality make it enjoyable.

Who is someone you greatly

admire, and why? My Dad. He was a proud man of few words who worked extremely hard to make ends meet.

What would you be doing if you weren’t in health care? I

have always been interested in law, perhaps a lawyer.

What do you like to do in your

down time? I enjoy boating. Any excuse to be on the water.

What are you reading? (non-

work-related material) Hillbilly Elegy

Where would you travel if you could go anywhere? Alaska and

Hawaii; I have visited both and would enjoy returning.

What’s a life-changing lesson COVID-19 has taught you? A

crisis brings out both the best and worst in people. Some rise to the occasion, and some become more problematic.

Quality Care Rooted in Arkansashoperecovery Is The Foundation. Is The Journey.

In response to the growing needs of our community, The BridgeWay has expanded its continuum of care for substance use disorders. The acute rehabilitation program will provide hope and recovery for adults struggling with substance use disorders. Led by Dr. Schay, and a Board Certified Psychiatrist and Addictionologist, the Substance Use Disorder Rehabilitation Program is for adults at risk of relapse. Rehabilitation requires the supportive structure of a 24-hour therapeutic environment.

To learn more about our continuum of care for substance use disorders, call us at 1-800-245-0011.

Physicians are on the medical staff of The BridgeWay Hospital but, with limited exceptions, are independent practitioners who are not employees or agents of The BridgeWayHospital. The facility shall not be liable for actions or treatments provided by physicians.

Dr. Schay Medical Director Of Substance Use Disorders & Patriot Support Program

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Testing began in March 2020. Since that time, nearly 16,000 tests have been administered. But the greatest story, Leist says, is NARMC’s service as a regional vaccine hub.

VACCINATION STATIONS

With the onset of vaccine availability, NARMC was designated as a point of distribution, or a regional vaccine hub. “NARMC provides vaccine to other area hospitals, including Eureka Springs Hospital and Mercy Hospital Berryville,” Leist says. Vaccination in the area began, as it did across the nation, with health care workers and those living in nursing homes; to date, more than 60% of hospital employees are fully vaccinated, as are most nursing home residents in the hospital’s service region. The first public clinic for people aged 70+ drew 549 people, all vaccinated in about six hours, or about 100 per hour. Today, vaccination clinics targeted at various age and demographic groups, including teachers, are taking place.

“We provide what we call ‘Strike Teams’ that go out to hold targeted vaccination clinics where they’re needed,” he says. “We have sent Strike Teams to the city of Jasper, to Madison and Johnson Counties, and to nine different school campuses in the area where we vaccinated faculty and staff.” There are also three pharmacies offering age-designated, on-demand vaccinations in northern Arkansas.

“We’ll hold vaccination clinics as long as there are people to vaccinate,” Leist says. “We can distribute the vaccine as fast as we get it; our distribution plan is working well, because we have put the right people in the right places to make it happen.”

Our Mission Is Twofold:

1. To improve clinical outcomes and operational efficiencies for Arkansas healthcare providers through the introduction of new technologies and innovations 2. To accelerate the development path of early stage healthcare companies by providing critical clinical engagement Thank You To Our Provider Partners For Making Arkansas A Center For Healthcare Innovation!

www.healthtecharkansas.com To learn how your organization can participate, please contact Jeff Stinson at jeff@healthtecharkansas.com

PANDEMIC LESSONS

Leist keeps coming back to all the good that has occurred amid the pandemic’s horrors. “Over and over again, we see professionals at all levels rising to the occasion for their community,” he says. “Groups of people come together to plan, to act, to follow through. We’ve seen our medical teams go into places at personal risk to care for those who are ill. We’ve seen groups form for the common good, people who are ethically and morally driven to do the right thing for their fellow humans.”

He says there’s no chapter in any administrator’s guidebook on how to manage during a pandemic. “And yet, we have managed, together. The pandemic brings to light the immeasurable value a rural hospital brings to its communities, and it constantly shows us the immea- surable good people do for one another. It’s an honor to serve here,” he says. “There is just so much good in this world.”

Statewide and National Recognition

Serving as President and CEO of North Arkansas Regional Medical Center (NARMC) since 2011, Vincent Leist has served the hospital field for more than 30 years. Under his leadership, NARMC has gained statewide and national recognition for care and service, including the ranking as a Top 100 Rural Community Hospital by Chartis iVangage Health Analytics and earning dual Arkansas Governor’s Quality Achievement awards.

He was selected by the American Hospital Association to represent America’s hospitals before the House Veterans Affairs Committee in 2015, testifying to the necessity for veterans to be granted health care access in non-VA facilities. Prior to his move to NARMC, he served for five years as Chief Operating Officer of San Antonio Community Hospital in Upland, California, where he executed programs in financial performance, operational efficiencies, cost management, and patient satisfaction positioning the facility to be recognized as a Thomson Reuters Top 100 Hospital. In addition, the facility was recognized by Thomson Reuters as one of 23 hospitals in the country demonstrating the most rapid improvement in a five-year period, earning it the Everest Award.

Named over a ten-year period to progressive management roles at Sunrise Hospital and Medical Center and Sunrise Children’s Hospital in Las Vegas, Nevada, Leist served as Administrative Director of Cardiovascular Service, Pulmonary/Respiratory Services, Assistant Vice President of Operations, Vice President of Professional Services/ Operations, and Senior Vice President of Professional Services/Operations. His service to the health care field also includes management roles in large facilities in Oklahoma, Iowa, and Kansas. He holds a Master of Public Administration degree from the University of Kansas and a Bachelor of Arts degree earned at Ottawa University in Ottawa, Kansas. He is a Fellow of the California Healthcare Leadership College, Berkley, and served as adjunct faculty at the University of Nevada Las Vegas, Rose State College in Midwest City, Oklahoma, and Washburn University in Topeka, Kansas. He currently serves as a member of the Arkansas Hospital Association board.

Opening its clinic in Berryville is a highlight of NARMC's service to the regional community. The hospital has a regional service population of 85,000.