Addressing Unconscious Bias in Healthcare

Addressing Unconscious Bias in Healthcare Highlights from the Unconscious Bias in Healthcare Symposium: Policy, Practice and the State of the Science October 14, 2022

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Institute for Advancing Health Equity

Highlights from the Unconscious Bias in Healthcare Symposium | Oct. 14, 2022


UNCONSCIOUS BIAS AND ITS HARMFUL IMPACT 3X MORE LIKELY Bias in healthcare — whether on the part of individuals (i.e., unconscious bias) or structurally built into medical education, algorithms, treatment protocols and devices — is well-documented by researchers and is known to be a key contributor to adverse health outcomes. 1 As just one of many examples, today, in the United States, non-Hispanic Black women are nearly three times more likely to die from preventable or treatable pregnancy-related complications than white women. 2 BUILDING EVIDENCE-BASED STANDARDS In recent years, unconscious bias training in healthcare has gained increasing recognition from policymakers and clinicians alike, however there is little evidence on its effectiveness. If policies are implemented without sufficient criteria for selecting effective anti-bias interventions, guidance on measuring impact and assuring accountability, opportunities will be missed to truly effect change. THE RECOMMENDED APPROACH

Unconscious bias is a substantial driver of inequity in health care. While the impact of unconscious bias in healthcare is well- documented, clear guidance on how to effectively mitigate it is not. On Oct. 14, 2022, the Sutter Health Institute for Advancing Health Equity, the California Medical Association, California Primary Care Association and Physicians for a Healthy California co-hosted a symposium aimed at changing that. Health equity experts, policymakers, clinicians, researchers and community leaders assembled for a day of focused discussion and problem solving around ways to advance effective mitigation strategies and interventions to reduce unconscious bias in healthcare settings and its detrimental impact on patients. Insights from the symposium will inform the development of interventions and recommendations to help establish future unconscious bias mitigation strategies that are measurable and effective. These tangible insights will be published in early 2023 to help providers move closer to achieving the intended goal – improved and equitable outcomes for patients.

Identify effective unconscious bias mitigation strategies.


Engage marginalized communities to guide the development of bias mitigation strategies.


Conduct comparative studies to determine which strategies are most effective.

03 .

Develop evidence-based standards and recommendations.


Implement the most effective strategies across the healthcare space.


1 Chapman, E., MD; Kaatz, A. MA, MPH, PhD; Carnes, M. MD, MS. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities, 2013 April. National Library of Medicine. DOI: 10.1007/ s11606-013-2441-1 Vyas, D.A., M.D.; Eisenstein, L.G., M.D.; Jones, D.S., M.D., Ph.D. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms, 2020 August. The New England Journal of Medicine 2020; 383:874-882DOI: 10.1056/NEJMms2004740 2 Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. DOI: https://www.

Highlights from the Unconscious Bias in Healthcare Symposium | Oct. 14, 2022



“In my mind the racism behind the unconscious bias of Shalon’s medical team led to the death of my highly educated, funny and loving daughter – Dr. Shalon Irving. I am not a big believer in treating the symptoms or applying the band-aid approach – I feel we have to acknowledge the root of the problem and deal with it. Though we have a long way to go, I acknowledge there is a lot of good work being done to change the paradigm. California is playing a big part in leading the way.” “ Spurred by the preventable maternal death of her daughter – Dr. Shalon Irving – Wanda Irving underscored the devastating impacts of structural inequities, the urgency to dismantle racism in medicine and encouraged healthcare providers to continue their work to address the national Black maternal health crisis. Speaker: Wanda Irving, MPA, Co-Founder and Chairman of the Board, Dr. Shalon’s Maternal Action Project


“ “Although there has been progress in supporting bills that deal with required bias training, that will only scratch the surface and it is imperative that we do so much more. We owe this to our patients, our communities and to this great state to utilize our knowledge, our data, our collective voice, which also includes the voices of our patients and their families, to advocate in every aspect of society to create healthier communities and a healthier California.” Assemblymember Akilah Weber, M.D., discussed the state of policy in California and how to reverse the harmful, historic impact of unconscious bias, noting the importance of not just designing policies, but ensuring policies and interventions are implemented and measured for impact. KEY INSIGHTS & STRATEGIES FROM SCIENTIFIC EXPERTS PANEL DISCUSSION: MEASURE WHAT MATTERS – IDENTIFYING & MEASURING CONSTRUCTS THAT ARE IMPACTED BY UNCONSCIOUS BIAS IN HEALTHCARE Experts from academia and clinical backgrounds discussed how to define success and measure impact of unconscious bias mitigation and interventions. Speaker: Akilah Weber, M.D., California State Assemblymember, District 79

Key Insights:

RETHINK HOW WE MEASURE IMPACT Racism and other forms of discrimination and mistreatment (e.g., sexism, classism, ableism, ageism) are integrated into every system, and healthcare must acknowledge its role in perpetuating harm among historically marginalized people. In addressing bias as both long-term and ongoing, we must also collect data from those experiencing marginalization to better document the role of racism and other forms of discrimination in health outcomes. Practitioners and scientists must build mechanisms that change how we measure bias – and collect data at the policy, health care system and provider levels to improve patient outcomes. INCLUDE COMMUNITY-LED INTERVENTIONS Community members – especially those who are disproportionately impacted by structural inequities – provide valuable insight into how interventions can be designed, implemented and evaluated for impact. Community members deserve to be equal partners. Funding boots-on-the-ground experts and organizations ensures interventions highlight the history and pervasiveness of structural racism, which is essential to mitigating bias. BE INTENTIONAL, ACTIONABLE AND TIMELY While rigorous research must be used to guide the development of interventions, delaying the implementation of novel interventions in favor of trying to find the perfect answer inhibits progress. Moving forward towards effective solutions requires a balance of making a decision to implement a strategy, while intentionally testing it and measuring its impact in real time.


Rashon Lane , Ph.D., MA, Senior Health Equity Scientist, Sutter Health Institute for Advancing Health Equity Amy Jin Johnson , MA, Executive Director, Project Implicit, Inc.. Brittany D. Chambers , Ph.D., MPH, Assistant Professor, Department of Human Ecology and Community Health Scientist, UC Davis Sylvia Perry , Ph.D., Associate Professor of Psychology, Northwestern University

Highlights from the Unconscious Bias in Healthcare Symposium Highlights from the Unconscious Bias in Healthcare Symposium | Oct. 14, 2022

PANEL DISCUSSION: MOVING BEYOND PASSIVE TRAINING: INNOVATIVE STRATEGIES TO ENHANCE UNCONSCIOUS BIAS MITIGATION Leaders and innovators in unconscious bias mitigation explored new and immersive learning interventions and how to overcome barriers to scale novel approaches and strategies to help ensure change is sustainable.

Key Insights:

IMMERSIVE LEARNING AND CULTIVATING EMPATHY CAN MOVE PROVIDERS AND LEADERS Convincing educators that the materials they have been teaching for decades are biased takes time. Encouraging provider empathy by immersing them in compelling patient stories – through learning interventions like virtual reality simulations – allows providers to visualize and better understand what it is like to experience discrimination or bias during a patient-provider encounter. This visualization is powerful and is intended to help move interpersonal empathy into intercultural empathy, improve patient-provider interactions and ultimately improve patient outcomes. CHAMPION INTERVENTIONS FROM THE TOP-DOWN To implement systemwide change within organizations, leadership needs to set a tone that prioritizes addressing unconscious bias. If leaders want a thriving, functioning, empowered institution, they must lead by example and establish standards where everyone is welcomed and respected. Speakers: Stephanie Brown , M.D., MPH, Clinical Lead, Sutter Health Institute for Advancing Health Equity Vandana Pant , Senior Director of Design and Innovation, Sutter Health Ronni Abergel , Founder & CEO, Human Library Organization Kelly Taylor , Ph.D., MPH, MSW, Director of Community Engagement, UCSF Pandemic Initiative for Equity and Action, Co-Principal Investigator, UCSF CULTIVATE

Nova Wilson , MPH, Program Manager and Researcher, UCSF Pandemic Initiative for Equity and Action, Institute for Global-Health Sciences, Department of Epidemiology & Biostatistics Helen Riess , M.D., Founder & CEO, Empathetics, Inc., Associate Professor of Psychiatry, Harvard Medical School Italo M. Brown , M.D., MPH, Assistant Professor in Emergency Medicine and Health Equity & Social Justice Curriculum Thread Lead, Stanford School of Medicine & Chief Impact Officer of T.R.A.P. Medicine

LOOKING AHEAD – A NEW FRAMEWORK TO DRIVE MORE EQUITABLE OUTCOMES Sutter Health, the California Medical Association, Physicians for a Healthy California and the California Primary Care Association are committed to moving unconscious bias training and other interventions beyond a performative ‘check the box’ exercise. We want to ensure providers have access to well-researched, community-informed standards, improved selection criteria for specific anti-bias interventions and a framework where effectiveness and accountability are both measured and valued. In early 2023 we will be publishing a framework and set of recommendations with this information to help providers make informed choices when investing in unconscious bias mitigation programs. We also will continue to collaborate and leverage the breadth of our organizations’ collective research and expertise to advance this field of science and help achieve our ultimate shared goal of improved and equitable outcomes for every patient.

INSTITUTIONAL LEADERS SUPPORTING THE SYMPOSIUM: Kristen M.J.Azar , RN, MSN/MPH, Ph.D.(c), FAHA, Scientific Director, Sutter Health Institute for Advancing Health Equity Leon Clark , MBA, Chief Research & Health Equity Officer, Sutter Health David “Buddy” Orange , Senior Vice President of Justice, Equity, Diversity & Inclusion (JEDI), California Primary Care Association Lupe Alonzo-Diaz, MPA, Vice President of Continuing Medical Education, California Medical Association, President & Chief Executive Officer, Physicians for a Healthy Califo r nia Donaldo Hernandez , M.D., FACP, President, California Medical Association Francisco J. Silva, Esq., President & Chief Executive Officer, California Primary Care Association

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