Vivian Anugwom was only a few months into the job of program manager of health equity at a Minneapolis hospital when 46-year-old George Floyd was killed during an arrest in her city.
She'd started just weeks after the pandemic began shutting down the country and hadn't even visited her new office.
But as protests broke out in the very neighborhood around non-profit health system Allina Health—and in cities across the country—Anugwom quickly saw her work take on a new visibility.
While her colleagues had always indicated they saw the value of working on equity, they seemed to gain a deeper understanding and interest, she told Fierce Healthcare.
We caught up with Anugwom recently to talk with her about her work to address the protracted problem of systemic racism in healthcare—including one example where Allina Health used data from Health Catalyst to identify and begin to address implicit bias in its hospice program—and her advice for other health systems building their own equity programs.
Fierce Healthcare: For starters, what do you do in this role as heath equity program manager?
Vivan Anugwom: We are a system of about 12 hospitals so it’s a very large health system. I’m the system resource for health equity. I partner with our hospitals, our service lines and various business units to figure out how do we apply an equity lens to all the work we do. ...
This process is fairly new for our system so it's a combination of "Hey, let's do the right thing to actually close this disparity, or at least try to," while at the same time building the processes and skills we need to continue to do this work.
FH: How has your role changed in recent months with this changing national conversation on race?
VA: In the last few months or so, with the national conversation shifting, I think people are finally becoming more aware the disparities exist. But they [also] are starting to move into the action phase. People want to actually do something about it. In my work, I've received a lot of requests from my colleauges around the system saying, "We want to do something. Help us figure out what to do."
FH: One place where you found implicit bias impacting patients was with the health system's hospice program. Can you describe what you found?
VA: That project started back in 2018. ... We went through what I would call a disparity assessment looking at 'What are the disparities that exist within our heath outcomes at the system level?' We uncovered various disparities and decided to land on this one hospice disparity and do some focused intervention work toward it. ...
The first program we identified was that African-American patients were not utilizing hospice even if they were eligible. Then we drilled it down to say: "Let's look to whether they're even being referred to hospice." We saw that, again, there was a disparity for African American patients compared to what we called the comparison patient who is white, U.S.-born and English speaking.
If you start with people [who aren't] using hospice, your first thought is: "Let's go tell them how great hospice is and try to change their mind." What I said was: "Well, let's take a step back and see what we're doing internally because we don't want to go out there an be imposing our beliefs on other people when, if they do come into our system and we're not even referring them, it doesn't make sense. We need to take a step back, look internally and make sure we were prepared to provide the best hospice care from a cultural perspective before we go out and tell people to come to us."
FH: Why weren't providers referring these patients?
VA: For some, they said: "Wow, I didn't even know that was the case." The conversation a lot of times went towards the provider saying: "A lot of times in our experience, African-American patients don't typically want hospice, right? So either we don't bring it up or it doesn't seem like it's the right time." The reason why we decided to do bias training was because hearing some folks saying. "In my past experience, they don't want...", we want to make sure we acknowledge those past experiences but that it's important to treat each individual as an individual. ... It's not fair to withhold information about the service just based on your past experience.
FH: How did you decide to land on focusing on the hospice disparity for your first project?
VA: The department I was part of at the time was willing to take that deep dive. I used to be the hospice and palliative care operations manager.
FH: That detail feels important. Did you find the connections you already had there helped you gain traction in a different way than you would have in other departments?
VA: Exactly. It really is about getting buy in. We had great buy in from our VP of home care services where hospice lives. She was a champion for the work, which is critical. Then I also had some experience working with a federally-qualified health center in north Minneapolis really around how do we share this program we'd created internally around supporting seriously ill patients and pairing them with a community health worker. So I used some of my experience in that program and sort of tied it into this hospice disparities work.
FH: I feel like in this position, you must have to have a lot of awkward or hard conversations dealing in the intangibles with professionals that are more comfortable dealing in the concrete.
VA: I think the way we set up the training was helpful. In some cases we had people come to the training saying, "I don't need to take this class." But by the end of it, everyone was engaged and saying, "Wow, I didn't know I needed this." With the training, we try to make it as comfortable as possible considering the topic. We encourage people to be vulnerable—which they often are—and it's really about showing the data and acknowledging their experiences. So in the literature, you do see a lot of research that seems to back up their experiences in a lot of cases saying African American patients typically do aggressive treatment: There is some truth to that for some folks. So we validate those experiences. But then we say: "OK, now that we all know that. We used personal stories. ... Now, these are the tools you use to mitigate bias. You need to individuate people. Use perspective taking. There are a number of tools."
FH: Can you describe the training from a more logistical standpoint? How do you do this in a COVID context?
VA: So we first did the training pre-COVID so it was in person, two-hour training in a group setting about 10 to 15 providers in each. This year, we are working on expanding it to address how to serve all underserved patients and we're hoping to do virtual sessions or small group sessions. We are looking at how to give a foundational implicit bias training for all of our providers. I've gotten a lot of requests and interest in doing that and we're still figuring out how to scale that in such a large healthcare system. In a weird way, the push to do things virtually could make this more efficient for us.
FH: So you took this job at a pivotal time. What were your expectations as you started the job?
VA: I'll be honest: My outlook on my job was: "OK. Who can I convince to do some more work? I can't be talking about this hospice project forever." I'm not saying it's not valuable but we have to do more. I was meeting with key leaders and explaining how I want to approach health equity for the system. Also, I was trying to embed myself in some of the COVID work as well because, I mean, no one had to tell me. there were going to be disparities. So I was trying to figure out how to help others begin to look at their work from an equity lens when things are being created from the beginning instead of it being an afterthought.
FH: Being in Minneapolis, how did the killing of George Floyd impact your work?
VA: This work has always been personal for me. But being in this position at this time, it gave me a sort of outlet. Like I think people have different ways and opportunities to fight for justice and this is sort of my way to contribute to the struggle. It's hard. It's heavy. But I'm grateful for the opportunity.