Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study.

BACKGROUND: Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS: Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION: This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Sustaining Area Agency on Aging Services During a Pandemic: Innovation Through Community-Based Partnerships.

BACKGROUND AND OBJECTIVES: Area Agencies on Aging (AAAs) have funded, coordinated, and provided services since the 1960s, evolving in response to changes in policy, funding, and the political arena. Many of their usual service delivery programs and processes were severely disrupted with the onset of the coronavirus disease 2019 pandemic. Increasing evidence suggests the importance of partnerships in AAA's capacity to adapt services; however, specific examples of adaptations have been limited. We sought to understand how partnerships may have supported adaptation during the pandemic, from the perspectives of both AAAs and their partners. RESEARCH DESIGN AND METHODS: We conducted a secondary analysis of qualitative data from an explanatory sequential mixed-methods parent study. Data were collected from 12 AAAs diverse in terms of geographic region, governance structure and size, as well as a range of partner organizations. We completed 105 in-depth interviews from July 2020 to April 2021. A 5-member multidisciplinary team coded the data using a constant comparative method of analysis, supported by ATLAS.ti Scientific Software. RESULTS: AAAs and their partners described strategies and provided examples of ways to rapidly transform service delivery including reducing isolation, alleviating food insecurity, adapting program design and delivery, and leveraging partnerships and repurposing resources. DISCUSSION AND IMPLICATIONS: AAAs and partner organizations are uniquely positioned to innovate during times of disruption. Findings may enhance AAA and partner portfolios of evidence-based and evidence-supported programs.

Perspectives on National Institutes of Health Funding Requirements for Racial and Ethnic Diversity Among Medical Scientist Training Program Leadership.

Importance: Since 1964, the National Institutes of Health (NIH) has funded the Medical Scientist Training Program (MSTP) MD-PhD program at medical schools across the US to support training physician-scientists. Recent studies have suggested that MSTPs have consistently matriculated more students from racial and ethnic backgrounds historically underrepresented in science than MD-PhD programs without NIH funding; however, the underlying basis for the increased diversity seen in NIH-funded MSTPs is poorly understood. Objective: To investigate how administrators and faculty perceive the impact of MSTP status on MD-PhD program matriculant racial and ethnic diversity. Design, Setting, and Participants: This qualitative study used a positive deviance approach to identify 9 high-performing and 3 low-performing MSTPs based on the percentage of students underrepresented in science who matriculated into the program between 2014 and 2018. This study, a subanalysis of a larger study to understand recruitment of students underrepresented in science at MSTPs, focused on in-depth qualitative interviews, conducted from October 26, 2020, to August 31, 2022, of 69 members of MSTP leadership, including program directors, associate and assistant program directors, and program administrators. Main Outcomes and Measures: The association of NIH funding with institutional priorities, programs, and practices related to MD-PhD program matriculant racial and ethnic diversity. Results: The study included 69 participants (mean [SD] age, 53 [10] years; 38 women [55%]; 13 African American or Black participants [19%], 6 Asian participants [9%], 12 Hispanic participants [17%], and 36 non-Hispanic White participants [52%]). A total of 51 participants (74%) were in administrative roles, and 18 (26%) were faculty involved in recruitment. Five themes emerged from the data: (1) by tying MSTP funding to diversity efforts, the NIH created a sense of urgency among MSTP leadership to bolster matriculant diversity; (2) MD-PhD program leadership leveraged the changes to MSTP grant review to secure new institutional investments to promote recruitment of students underrepresented in science; (3) MSTPs increasingly adopted holistic review to evaluate applicants to meet NIH funding requirements; (4) MSTP leadership began to systematically assess the effectiveness of their diversity initiatives and proactively identify opportunities to enhance matriculant diversity; and (5) although all MSTPs were required to respond to NIH criteria, changes made by low-performing programs generally lacked the robustness demonstrated by high-performing programs. Conclusions and Relevance: This study suggests that NIH funding requirements may be a powerful incentive to promote diversity and positively affect representation of students underrepresented in science in the biomedical scientific workforce.

The role of leadership in times of systems disruption: a qualitative study of health and social care integration.

OBJECTIVES: To understand whether and how effective integration of health and social care might occur in the context of major system disruption (the COVID-19 pandemic), with a focus on how the initiative may overcome past barriers to integration. DESIGN: Rapid, descriptive case study approach with deviant case sampling to gather and analyse key informant interviews and relevant archival documents. SETTING: The innovation ('COVID-19 Protect') took place in Norfolk and Waveney, UK, and aimed to foster integration across highly diverse organisations, capitalising on existing digital technology to proactively identify and support individuals most at risk of severe illness from COVID-19. PARTICIPANTS: Twenty-six key informants directly involved with project conceptualisation and early implementation. Participants included clinicians, executives, digital/information technology leads, and others. Final sample size was determined by theoretical saturation. RESULTS: Four primary recurrent themes characterised the experiences of diverse team members in the project: (1) ways of working that supported rapid collaboration, (2) leveraging diversity and clinician input for systems change, (3) allowing for both central control and local adaptation and (4) balancing risk taking and accountability. CONCLUSIONS: This rapid case study underscores the role of leadership in large systems change efforts, particularly in times of major disruption. Project leadership overcame barriers to integration highlighted by prior studies, including engaging with aversion to clinical/safety risk, fostering distributed leadership and developing shared organisational practices for data sharing and service delivery. These insights offer considerations for future efforts to support strategic integration of health and social care.

How Do Area Agencies on Aging Build Partnerships With Health Care Organizations?

BACKGROUND AND OBJECTIVES: Partnerships between health care and social service organizations may contribute to lower health care use and spending. Such partnerships are increasing, including Area Agencies on Aging (AAAs) working and contracting with health care organizations. Nevertheless, knowledge about how AAAs establish and manage successful collaborations is limited. We sought to understand how AAAs establish and manage partnerships with health care organizations. RESEARCH DESIGN AND METHODS: We conducted an explanatory sequential mixed-methods study using a positive deviance approach. We used national-level data to identify AAAs with multiple health care partners serving areas with low utilization of nursing homes by residents with low-care needs (n = 9) and AAAs with few health care partners and high utilization for comparison (n = 3). We conducted in-depth interviews with key informants from these 12 AAAs and their partner organizations (total n = 130). A 5-person multidisciplinary team used the constant comparative method of analysis, supported by Atlas.ti software. RESULTS: Highly partnered AAAs were characterized by 3 distinctive features of organizational culture: (a) attention to external environments, (b) openness to innovation and change, and (c) risk-taking to learn, improve, and grow. AAAs and partners describe a broad set of organizational strategies and partnership development tactics, depending on their local contexts. These features were underdeveloped in AAAs with few health care partnerships. DISCUSSION AND IMPLICATIONS: While federal and state policies can create more favorable environments for AAA-health care partnerships, AAAs can also work internally to foster an organizational culture that allows them to thrive in dynamic and challenging environments.

Leadership development in complex health systems: a qualitative study.

OBJECTIVE: Leadership is associated with organisational performance in healthcare, including quality, safety and clinical outcomes for patients. Leadership development programmes have proliferated in recent years. Nevertheless, very few have examined participant experiences in depth in order to understand which programmatic aspects they regard as most valuable relative to leadership in increasingly complex systems, or whether and how learnings may sustain over time. Accordingly, we explored experiences of participants in an interdisciplinary leadership development programme using qualitative methods over an extended look-back period. SETTING: Health and social care sectors in the UK. PARTICIPANTS: Key informants from three cohorts of individuals working in leadership roles in health and social care in the UK: 2013/2014, 2015/2016 and 2017/2018. We contacted 32 participants, and 26 completed interviews (81% response rate). PRIMARY AND SECONDARY OUTCOMES: We explored (1) whether and how specific skills and competencies developed during the programme were applied and/or sustained over time, and (2) whether and how the impact of the programme changed as alumni progressed through their career. RESULTS: Three major recurrent themes emerged from participants' experiences: (1) specific features of the programme meaningfully impact professional development at multiple levels; (2) the coupling of a professional network and practical tools allowed participants to address system-wide problems in new ways and (3) participants describe a level of learning that sustained and amplified over time with increased complexity in their work. CONCLUSION: This work highlights specific design characteristics of leadership development programmes that may help promote relevance and impact. Programme learnings can be translated into practice in substantive ways, with potential for the benefits of successful leadership development efforts to amplify, not fade, over time.