In 2020 Washington-based health system Providence launched a $50 million fund to address health disparities, focusing on reducing inequities across various demographics. The initiative includes a fellowship program aimed at embedding health equity into daily operations. Healthcare Innovation recently spoke with Whitney Haggerson, M.H.A., Providence’s vice president of health equity and Medicaid, about the program's effectiveness in scaling impactful interventions.

HCI: Can we start by talking about where the idea for the fellowship program came from? 

Haggerson: In 2020, at the beginning of COVID and right at the precipice of this racial awakening that we were seeing across the globe, Providence allocated this $50 million fund aimed at reducing health disparities. Think of it as like an internal grant-making mechanism where we funded pilots aimed at reducing inequities.

We acknowledged that in addition to those pilots, there was work that we needed to do to change the way that we think about health equity. It's not a project, it's not an initiative. It needs to be the way that we think about patient safety and quality. So we ran an IHI [Institute for Healthcare Improvement]-type learning collaborative where we brought together teams that did continuous improvement work to reduce inequities in our ambulatory quality measures. 

The next iteration of that was the fellowship. We had a really fantastic response to that IHI-type learning collaborative, but we wanted to take it a little deeper. What we were hearing from our senior leaders was that the work to advance equity restores joy in practice for our providers. It helps people feel more connected to our mission. It frequently tends to be people of color and/or those from other marginalized identities. This is also a way to improve their stickiness with Providence. So we made a pivot and said that our core leaders, our people managers don't necessarily have the expertise or skill sets to help people who have an interest in health equity, but we do, so we developed this fellowship with the idea that we would take about 20 fellows a year and go deeper with them and really teach them how to embed health equity in their day job. 

Ideally, we would have been able to hire a bunch of people whose titles were health equity, and this is the work that they eat, sleep and breathe. But realistically, that's not the best way to approach this from a resource-constraint perspective, but also from a spread perspective. Health equity is the work of all of us, whether we're in quality or patient safety or marketing or legal, but people didn't know how to do it. So the idea was that we would take people who were interested and teach them what it looks like to approach their work with an equity lens.

HCI: Do people generate ideas for projects they want to work on, and then you pick the ones that sounded the most impactful? Or do they just come to you and say, I want to work on equity, but I don't know where to start?

Haggerson: When we ran that collaborative, we were a little more directive and said that we were going to focus on reducing inequities in ambulatory quality measures — breast cancer or colon cancer screening, for instance. But when people apply to the fellowship, they actually come to us with ideas. And the cool thing about that is that because these are frontline staff, they see things that we might not see, and they also get to come with a project that they're really passionate about. 

When they apply for the fellowship, they apply with a health equity improvement project. A core tenet of the fellowship is actually the practical application of this. So they all run a project during the year that they're in the fellowship, and we prioritize those projects that are aligned with our organizational goals and that have widespread applicability. I think of this a little bit as a test bed. We get to pilot these things with our fellows, but ideally, if we see success, we're scaling these across the enterprise.

HCI: Do you have to help them shape a project to know how big to make the pilot and how to measure the impact of their intervention? 

Haggerson: One of the core tenets of the health equity fellowship curricula is around continuous process improvement. Healthcare, I think, is notoriously bad at running pilots. We launch a program and then we come back six months later and say, Hey, did it work? Did it not work? What we really want to do is try to get more granular and run very small tests of change — we’re talking about not even a whole clinic yet, but maybe a couple of providers in that clinic, and watch it really closely, running shorter PDSA [plan, do study, act] cycles before we actually make the attempt to scale.

HCI: What kind of evolution are you seeing in terms of the types of employees who apply and the types of projects? 

Haggerson: We’re in our third cohort. The first cohort of fellows was almost exclusively quality leaders — people who already own accountability for ambulatory quality or acute care quality. The cool thing is that not only have we seen the number of applicants grow year over year, we're seeing a pretty drastic shift in the types of people who are raising their hands. We still have a lot of quality leaders, but we’re starting to add more clinicians, community health workers, and faculty from our residency clinics — a wide array of clinical perspectives, including social work. We're also starting to see shared services leaders apply. For example, we have had people who focus on marketing and brand trust metrics say, ‘Hey, we measure brand trust, but do we actually stratify it and see if our brand trust looks different across different populations?’ 

HCI: Could you talk about a couple of examples of fellowship projects that have successfully scaled up?  

Haggerson: I’ll give you one ambulatory example and one in the acute care space. 

One fellow was specifically focusing on improving rates of hypertension control in our Latinx patient population. This was a quality leader in Southern California, and she ran a pilot in a single clinic in Northern California, where they already had a team-based care model. When they looked at the population that they served, it was primarily a Latinx population, but when they looked at the makeup of those team-based care units, they didn't have any bilingual, bicultural staff. So they said, What if we add in multilingual and multi-modal outreach to our patients? What if we add in a community health worker and a clinical pharmacist? What they saw was that not only did overall quality improve, but by the end of the fellowship, the Latinx population had slightly higher rates of control than our white and Asian populations, who typically have the highest rates of control. 

This fellow is actually in a quality role that spans the entire state of California. So they were able to take what they did in that single clinic and say, Okay, how do we change all of our quality work across the state? It didn't mean that they were able to hire bilingual, bicultural staff in every team-based care model, but they started to say, as we're hiring, how do we put an emphasis on that, and as we're doing our standard outreach to all of our patients, how do we adapt it to be more approachable for our patient populations that maybe have a primary language other than English, or don't identify as white. As a state they've actually seen astronomical improvements, not just in that Northern California market, but now also in L.A. and Orange County and in the high desert. 

The other example, also from California, is on the acute care side. We had a fellow in our first cohort who is a certified interpreter and managed an interpretive services program at one of our hospitals. One of the things that she noticed, just anecdotally, was that a lot of her interpreters were supporting patients in our hospitals with limited English proficiency who had sepsis. As she dug into the data, she saw a lot longer lengths of stay and higher readmission rates for those patients with sepsis with limited English proficiency. 

After running focus groups with these patients and their family members, they heard that patients didn't really understand what sepsis was. They didn't necessarily trust the hospital and our staff, and more specifically, they didn't know what to do after they discharged if they were having trouble. So they made some quick changes, including patient education in multiple languages. We have sepsis nurse navigators who work with patients to help them understand their diagnosis, help them transition back to the community. The fellow’s project asked what if we have bilingual sepsis nurse navigators? So they piloted that with a bilingual sepsis nurse navigator and saw a 25% reduction in length of stay and a 28% reduction in readmission rates in the limited English proficiency population that had sepsis. So now what they've said is, every time they hire a sepsis nurse navigator, they have a preference for bilingual staff who can support all of our patients regardless of the primary language that they serve. So it’s moved from being a pilot to just being the way that they think about those roles, and now we're in the process of taking that to our sepsis collaborative across the organization, and make sure all of our 52 hospitals are thinking about that if they have those roles.

Not only does this have a huge impact for these patients who don’t speak English as a primary language, but it also has huge financial implications for the organization when we think about length of stay and readmissions, which are metrics that all of our hospitals are constantly chasing.

This is a practice that has been applied now not only within Providence, but we have other hospitals and health systems that are emulating her learnings at scale. I think that's the thing about health equity: there are some things that we do as health systems that feels proprietary, that give us competitive advantage. But the way we've approached our health equity work is ‘all share, all learn.’ Nothing about the work that we do is proprietary. We would love to see all of our competitors be able to emulate this type of fellowship project.

HCI: Do some of the people in these cohorts have a hypothesis and an intervention that they want to do, and then they don't see it having the impact that they thought it might?

Haggerson: Yes, 100%. With any type of quality improvement work, whether it's focused on reducing inequities or not, we learn a lot more about what didn't work than we do from what went right. We really help set the expectation with the fellows along the way that not everything is going to be a slam dunk, and that's part of the reason we're starting with really small interventions. We're not using a ton of resources to do something at scale if we don't know whether it is going to work. A lot of these PDSA cycles they run don't yield the results that they thought they were going to yield, and we have to pivot.

 Each of the fellows gets coupled with an improvement coach, who works with them not only to deal with personal disappointment but also to think creatively about what to try next.  Frankly, that's one of the most valuable teachings that fellows get here — that if this work was easy, we wouldn't have disparities. If we knew the solution to fix inequities, they would be gone. Part of what we're reminding them is that this is the hard work that lays ahead of us. So get used to it not going the way you think it's going to go every single time.

HCI: Well, this is impressive work the fellows are doing. Looking to the future, is there anything else that you are hoping to do with this program? 

Haggerson: A long-term goal would be to roll this out with a cohort that's specifically focused on clinical care. The other thing that I think about is just being able to grow the cohort. Our fellows come back as alumni to coach. The more alumni we have, the more chance we have to grow the number of fellows.

 Also, I would love to see more organizations emulating this. Cedars Sinai actually just launched their first cohort of fellows. We worked pretty closely with them to share what we learned along the way. And we have another couple of organizations that are reaching out and saying we'd love to learn from what you've learned.

Even internally, we've taken this fellowship model and we've adapted it, and now we have a fellowship that's specifically focused on delivering success in value-based care. So we are taking the model of adult learning in a fellowship type setting and applying it to other bodies of work. I think those are my three goals: to be able to scale the health equity fellowship, see it applied externally with other health care systems, and then also take the concept of a fellowship and apply it to other challenges that have eluded healthcare all along.