Equity Actions: Overcoming Health Disparities in the Inpatient Setting

October 7, 2022

In this episode of Equity Actions, our Health Equity Manager Adrienne Thornton interviews Myriam Roby, Clinical Director of Equity and Inclusion, about how to overcome health disparities in the inpatient setting. Join them in this discussion about everything from mental health care to how to effectively communicate with patients and families, and how we can use data effectively to improve health outcomes for some of our most vulnerable patients.


Dr. Angela Kade Goepferd:  This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.

Welcome To Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. On this episode of Equity Actions, our Health Equity Manager, Adriene Thornton, interviews Myriam Roby, Clinical Director of Equity and Inclusion, about how to overcome health disparities in the inpatient setting. Join them in this discussion about everything from mental healthcare, how to effectively communicate with patients and families, and how we can use data effectively to improve health outcomes for some of our most vulnerable patients.

Adriene Thornton: We are back for another episode of the Equity Action segment of the Talking Pediatrics podcast at Children’s Minnesota. And I am Adriene Thornton, the manager of Health Equity at Children’s Minnesota, and I am so glad to welcome my guest today. She is fairly new to Children’s Minnesota, but she feels like she’s been here forever. She feels like an old friend, an old colleague, someone that has been with our system for a while, and she is Myriam Roby, and I am going to let her introduce herself. Myriam, please introduce yourself to the audience.

Myriam Roby: Such a warm welcome, Adriene. Thank you. As Adriene so graciously started off, I’m Myriam Roby and I’m the Clinical Director of Equity and Inclusion, working in the Collective underneath James Burrows and many other colleagues. And small bio. I’m a family nurse practitioner by trade. I work in internal medicine and to the hospitalist realm. So I am internal. I have been practicing about nine years now, and prior to that was a registered nurse for 10 years, so close to 20 years in the game. And I’ve had some advances in the equity and inclusion forum at my prior organization and participating in some lunch and learns in regards to that field. So I’m excited to be at Children’s. I’m excited to partner. I’m excited for the robust nature that we’re planning to transform the organization to make it an inclusive one for all.

Adriene Thornton: I think what a lot of people don’t realize is that as a nurse, as a nurse practitioner, as a clinical person, if you are a health care minority, you tend to automatically become involved in working on health disparities and health equity and diversity and inclusion. It becomes second nature because for most of us, we are very forward thinking. And so if we see something that doesn’t look right, or doesn’t feel right or doesn’t really jive with a personal and/or professional vision and mission, then we feel it’s our duty to say something or do something.

Our theme for today is overcoming health disparities in the inpatient setting, because we’ve talked about what do we do for mental health and what do we do with data and what can we do in the community, and all of that is important, but it all impacts the care that people receive when they come into the hospital. And so I’m just going to throw some words out here. These words again are key words for me, but I just kind of want you to maybe speak to them in how you see them relating to the care that patients receive when they come into a healthcare system. The first word is communication. How important is communication to making sure that we bridge the gap on health disparities?

Myriam Roby: Communication is paramount. To place context, racism permeates in every aspect of society. Health care is no exception. Numerous, numerous studies has documented that disproportionately negative health outcomes for people of color and worse, medical care has exacerbating existing social factors that has led to poor health outcomes for our disadvantaged groups. Communication, how that can coincide with that, would be to open up that dialogue to be able to clue in, to have a clear understanding. That’s where we would be completely transparent and open, and understanding that this is something that we need to understand, that we need to fix, and that we need to move forward so that all individuals are able to have equal access to healthcare with no disparities.

Adriene Thornton: You know, have to have the communication piece in order to bring about transparency. That is where communication is really important. But I think also we as consumers have to take responsibility for pushing the conversation.

Myriam Roby: That’s right.

Adriene Thornton: And getting the communication that we need, but it kind of feeds into the next word, which is trust. The impact of trust. How do we build those trusting relationships and how do they impact health disparities?

Myriam Roby: Combating systematic racism and health care systems starts with the understanding that many forms of racial discrimination, prejudice is embedded in them. We have to understand that first and foremost, as an organization, as providers, we have to accept that and understand that that is something that is part of what we’re dealing with. The crucial first step, Adriene, is to identify and then understand how multiple forms of the racial injustice affects patients, healthcare professionals as well. And then what changes can we do so that we can align that with our consumers, patients so that we connect with that open dialogue, that transparent communication, which will eventually lead to trust. We cannot expect that our consumers or patients that are going to automatically trust us, nor should we.

This is something, this is us, we have to own that. We have to understand that with all of that understood, mentioning as far as the systemic racism, and this is years upon years of conversations that are having, personally within family members, that we now have to destruct that and then say, We’re here for you. We are an advocate. Children’s Minnesota wants to be that organization, that beacon to embed to say, not only with our consumers but with our community, that we are an organization that you can trust, that will have your best benefit in regards to your healthcare.

Adriene Thornton: And the next word, which I absolutely love because you can go in many different directions with this, but it’s politics. And when I think of politics, one of the things that the health equity team is working on currently is how do we very accurately, respectfully and in a culturally competent way, collect race, ethnicity and language data? And people are thinking, “Well, what does politics have to do with that?” Well, until 2016, members of the LGBTQ+ community were not identified as being health care minorities. They were just kind of thrown into the mix with other health care minorities.

And then in 2016, the National Institute of Minority Health and Health Disparities said, “Hey, this is a minority group. They are experiencing disparities. We need to look at this group of patients closer, but also in a different way.” And so the politics comes into play because we collect the real data, the real data based on government standards. And so now we have to figure out how do we take those government standards, change the way we collect data so that when we’re collecting sexual orientation and gender identity, that we are actually reflecting the various members of the LGBTQ+ community and making sure that we capture any disparities that they’re experiencing because they are a member of that community.

Myriam Roby: That’s a key point. Discrimination, racial, gender bias. It’s prevalent in healthcare. It’s widely known that discrimination against our consumers of color, as well as our LGBTQ community, and this has severely, profoundly limited their access to healthcare and quality in their treatment. I’m going to piggyback off of your metrics, and in a seminal report by the Institute of Medicine in 2003, called Unequal Treatment, a team of physicians, behavioral scientists, public health experts and other professionals, concluded that even when access to care, there has been significant barriers that were identified for our racial, ethnic, gender, identifying consumers, and that they received, Adriene, worse health care in comparison to their white counterparts. That’s unacceptable. And what we, as an organization, under the guise of our CEO, what we’re planning to do is to break that continuum. We want to be that good trouble, if you will, the disruptor to say, “You know what, no longer are we going to accept what research has identified in our communities. Our communities deserve better.” And that’s what Children’s Minnesota plans to do, and we will make that happen. And that’s the plan that we have moving forward.

Adriene Thornton: As the manager of health equity, my sole focus is breaking down barriers to access and breaking down barriers that increase the gap in health disparities. And so when we talk about barriers, I think food and money play a big part in that. And I know as clinical people, we don’t typically think of that. When I’m a nurse on the floor, I’m not admitting a patient and just automatically thinking, “Oh, well, what did they eat today or what have they eaten in the last week?” Or, “Did they have enough money to go and get the prescription that they need to get?” Those thoughts just don’t naturally come to mind. But food and money are two very important factors in health care, especially after patients are admitted.

Myriam Roby: Correct.

Adriene Thornton: And so what can we do or what should we do to make sure that we’re considering those factors when we’re taking care of these kids and patients in the hospital?

Myriam Roby: You helped me introduce to your health equity coaches and what we did, we rounded on both campuses and we actually met with two key individuals at the Ronald McDonald House and then the Family Resource Center and blown away, completely blown away with the amount of compassion, the thought process that was placed by these two areas, to consider that our families may be struggling out there, as you mentioned, with food, with transportation, with housing. Using a example that was noted when I was rounding, this individual was excited when I met her, that she and her family member would be leaving, discharging from the organization and had been part of our organizational family for many weeks during the care of the family member. And what resounded, was how much that Children’s stepped up to help her with food, with a place to stay when her home flooded, was broken into.

And there was no way for her to be able to stay there and function while also needing to be a solid person for her family member. We stepped up in ways that I didn’t even know was possible, and I was so proud to be part of an organization that reached out to this individual and said, “How can we help?” And not just help in a way of giving a piece of paper and say, “Here are different contact information, reach out to them and good luck.” No, we took it a step further. We embraced her and we actually helped her acquire all of these things to the point where she was so ecstatic, Adriene, that she was leaving, but the one thing that she said was that I will be back.

Adriene Thornton: Yeah. And that’s the wonderful thing about Children’s Minnesota, but I think pediatric hospitals in general, we do really take seriously caring for the family. And at Children’s Minnesota, we also have our resource navigators who are focused in our ambulatory areas, but one of the things we’re working on is making sure that we expand their role to also assist our inpatients because when they leave the hospital, they are still going to need help with food and maybe getting work or resources when they are short on money and they can’t pay their rent, and our resource navigators can assist them with that and kind of help them with that process once they leave the hospital.

Myriam Roby: Yeah.

Adriene Thornton: Once you leave the hospital, we are still taking care of you. You know, don’t have to be within our four walls for us to help you and to be concerned about you and to provide care for you. And that’s what I love about being at Children’s Minnesota. And you mentioned going to Ronald McDonald House, and when I travel, if I stay in a hotel, I typically bring my own care products, so I don’t use the samples that they have in the hotel rooms, and so I collect those as I’m traveling, and then I donate them to the Ronald McDonald House. And that way if we have families that are coming in, oftentimes admissions are emergent, they’re not prepared, and they don’t have everything they need to even stay at the Ronald McDonald House. And so having those samples, one provides a basic need, but allows them to pamper themselves a little bit.

Myriam Roby: Exactly.

Adriene Thornton: Something a little bit nice. The last thing we’re going to talk about is cultural competence. Cultural competence doesn’t mean you know everything about everybody. It means that you realize that there are care needs that may be different for different people. Knowing that that exists is the first step, and a lot of people, I think they hear cultural competence and they think, “Oh, I have to know everything about my patients that identify as Muslim.” Or, “I have to know everything about my patients that identify as Asian.” And that’s not true. You just need to recognize that because your patient identifies as Muslim when they are admitted during Ramadan, you may have to change the way you provide care for them.

Myriam Roby: Systemic problems call for coordinated solutions. While no single clinician or hospital organization could hope to solve all racism or health equity disparities in the system once and for all, that’s a task that unfortunately, although we would love to have a utopian organization where it would not occur, that’s not the case. What can we do first? We have to say the words, racial discrimination, right?

Adriene Thornton: Yeah.

Myriam Roby: We have to say it. We have to be upfront with it. We have to be forefront with it. We have to not tag it, hide it, place a different word behind it, just let’s just say it. Racial discrimination. Reports and studies have documented how many manifestations of racism is in healthcare at length. We need to be able to not be afraid to call it out for what it is. Next, we just need to focus on the impact, rather intention.

We all have good intentions. I innately believe that. I don’t believe that every person is born cruel. However, we need action. We need a verb behind it. Implicit bias is subtle. It’s unconscious. It’s under the radar. We need to bring it to the forefront. We need to essentially open the wound, clean it out, and then move forward in a sustainable way so that what is known is that we will not expect this moving forward.

Zero tolerance for it, right? We have to put our foot down and say that this is not something that we will accept. Lastly, the important work of equity and inclusion is that there is a focus on clinical development and training that we as a collective can provide those tools. We can provide resources and how to mitigate bias, how to develop that intercultural competence, to create a more inclusive environment so that we minimize differential treatment that will enhance our patient care experiences and minimize the discriminatory practices. In all what I’m saying is that we can do better. We will do better, but we as a group have to be able to say that racial discrimination exists. This is what we’re going to do to move past that, and how do we create an inclusive environment at Children’s Minnesota for all?

Adriene Thornton: My least favorite sentence is, “I don’t see.” Anytime somebody says they don’t see something, I don’t think they realize that that means they don’t see the nuances. So if you say, “I don’t see race.” How can you not see race? If you are my physician, there is no way you can look at me and not see race. My skin is entirely too dark for you not to see it. But what it also says is that if you don’t see me, then you don’t see my needs. You don’t see what I need is different from the white person or the Asian person, or the Latino person that came in before me. If you don’t see faith, then you don’t see the nuances of what your patient may need because of their faith. And so I want to really encourage clinicians to refrain from saying, “I don’t see anything.” Just wipe that from your vocabulary, because when you don’t see something, then you’re not acknowledging it.

Myriam Roby: Exactly.

Adriene Thornton: And we can’t acknowledge structural racism and its impact on healthcare if we don’t see people for who they are.

Myriam Roby: Exactly. And to just tag onto that, Adriene, what we can do as a group is to help dismantle the structural inequalities in healthcare, especially in our organization. We can join together, but not just join in just the talk. Right? You and I, Adriene, we’re very active in the community. We’re very active in our ERGs. We’re very active in reaching out to other external sources to be able to consistently advocate to work together so that we can create this inclusive environment. That’s what we’re tasking others as well.

And so what I would ask in this podcast so that it’s disseminated to individuals, reach out to the health equity team. If you want to be able to be a beacon of change, we can help with resources so that you can do that, but it takes action. We need to be able to say again that this is a zero tolerance that we want to be displaying to our community, to our patients of color, of the LGBTQ community. They deserve better of us, and for us to be able to put ourselves out there and say that we’re going to foster health and wellbeing for our community.

Adriene Thornton: Thank you so much, Myriam, for joining me on the podcast. This was an amazing conversation. Again, we could go on for hours and hours, but we welcome everyone to, as Myriam said, reach out if you have questions, if you have comments, if you have thoughts, if you have feedback, if you just want to have coffee, we’re always available to have coffee and conversation. I think everything starts with coffee and conversation for me, or water and conversation, with tea and conversation, anything, but it starts with the conversation.

Myriam Roby: That’s right.

Adriene Thornton: So thank you to all of our listeners and we will see you on our next episode of Equity Actions.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.