Fighting Healthcare Disparities | COVID-19 Vaccine Access

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare committed to advancing effective evidence- based care. I'm your host, Paul Anderson. For more than 10 years, I've overseen our patient safety, risk, and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality, and cost- effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. Today's episode is part of a series we're recording for the ECRI and the ISMP Patient Safety Organization's annual Deep Dive report. This year's Deep Dive focuses on issues of racial and ethnic disparities in healthcare. And we're talking to PSO members and others to hear about their initiatives to fight these disparities. Our guests today are from Cooper University Health Care, serving Southern New Jersey and Northern Delaware. They'll discuss outreach around access to the COVID- 19 vaccine, how they've worked to overcome barriers to care and how those efforts fit into a larger program to fight inequities. To get us started, I'll ask our guests to introduce themselves. First, Dr. Porter, and then Dr. Kirchhoff.

John Porter: Good morning or good afternoon, depending on what time you're all listening to the podcast. I'm Dr. John Porter. I'm professor of surgery at Cooper Medical School of Rowan University and the director of the trauma center. And more importantly, for this conversation, I'm the medical director of diversity.

Michael Kirchhoff: And hello, I'm Dr. Michael Kirchhoff, emergency physician at Cooper University Health Care. Been here practicing for nearly 20 years. And my role today is also as patient safety officer to help draw a bright line from diversity and inclusion to its importance for patient safety.

Paul Anderson: So we'll talk in a second about COVID-19 vaccine outreach, but first I wonder if you could help us set the stage a little bit. I mentioned that Cooper serves patients in Southern New Jersey and Delaware. So Dr. Porter, maybe I'll start with you. Can you describe a little bit more about the patient population or other things that might be important to know about who you serve. And particularly, in latest days conversation, some of the barriers that you might see in that population?

John Porter: Well, since inaudible, we serve all of Southern New Jersey and we're the only level one trauma center in Southern New Jersey. We're also a pediatric certified trauma center. We get 5, 000 contacts and 4, 000 admissions a year, making us one of the busiest trauma centers in the country. Unfortunately, access is not an issue with the trauma center as much as it is with other folks because 911 works well for everybody regardless of your economic status or your race or ethnicity. However, the population that we serve is predominantly African American and Latinx. And so we are actually proud of the fact that our complication numbers, our length of state numbers and our mortality numbers are the same for the majority population, which in our case is the Hispanic and black community as it is for the white community. And I think quality of care has to be looked at from a diversity point of view to make sure that you're delivering the same care to all the people. And so there are access problems that we deal with all the time and we're working to solve those, but in the trauma world, we have solved those quite well.

Paul Anderson: Dr. Porter, Let's talk a little bit about some of your efforts more specifically around the COVID- 19 vaccinations. I know you've done a lot of work to reach out to the African American community about the importance of the COVID- 19 vaccination. So I wonder if we could start by talking about what concerns were you hearing? What prompted you to start that specific outreach around the COVID vaccination?

John Porter: Well, it's a good question. And thank you for asking that. It started with two things. One, we were having a meeting about the different studies that were going to come out for treating COVID before the vaccine was actually released and the concept of vaccine shaming came up where you would shame folks for not getting the vaccine. And then I brought up that it was appropriate for people of color to be hesitant about the vaccine because the history of vaccines and experimentation on people of color in this country is not a good history. And then when the vaccine came out, they wanted me to be one of the first people to get the vaccine and I said," No." The reason I said no is that when you read the Pfizer study and the Moderna studies, the number of African Americans in the study was very small. So I'm saying, is the reason why more people of color were getting COVID because of systemic racism, because of access or because of co- existing diseases, or was it because there could have been genetic differences? And so I didn't know if the vaccine was going to work for me. And so I waited several weeks until the CDC could quote some higher numbers and show that the complication rate and the safety rate in people of color was the same. And then I got the vaccine. So now when I go to give a talk and someone says," I was hesitant," and you know what I say to them?" So was I, I understand." And so there's no vaccine shaming, like why would you not get the vaccine? And then quote a lot of medical literature. I say," So was I." And then all of a sudden I become one of them and I become trusted. And then that's when I switch it and turn to the science. But because I listened to them about the hesitancy and said I had the same hesitancy, now when I quote the signs, even though Dr. Kirchhoff can quote the science equally as well as I can and has done it in groups, he can establish that relationship with the hesitancy that I have. And so we then work together. So I may give a talk to some folks and he may come in a week later and talk some more science and then we work together to get it. And I've given probably over 50 talks on vaccine hesitancy. One of the ones of which I'm most proud of, and I won't embarrass anybody by saying it, it was from a local clergy in Camden. And he said at the beginning of the talk that he's telling his congregation not to get the vaccine. And so then I talked to him and said," Yeah, they're probably going to be hesitant just like I was and et cetera," and told the story. And he told me at the end of that that he was going to get the vaccine himself and he was going to tell his congregation to get the vaccine. So I do think some of the talks are making a difference and you have to meet people where they live and they live with the different experimentations and things of American medicine on people of color. And when you live there and start from there and then branch it off into the science, I think you can change people's minds.

Paul Anderson: Hey, Dr. Porter, you talked about giving, I think you said more than 50 talks that you've given to different groups. I'm assuming both in the community and within the hospital. Are there other sort of specific outreach efforts that you would want to talk about?

John Porter: No. Other outreach is not really what I do because I'm doing this sort of, to quote some of the young people, as a side hustle. So I don't really want to do more than I'm being asked. And I think when people ask me, they're ready to receive the information. As opposed to me going to somebody and saying," I have information to give you," they may not be ready to receive it. So when I get called from the owner of one of the high rises in Camden saying," I want my maintenance folks to get the vaccine and they're hesitant to get it, can you come talk to them?" Everybody's ready to hear that. That's different than me calling them up saying," Do you want me to come give you a talk about vaccine hesitancy?" And then they may be given a talk taking my time and their time when they're not ready to hear it. So that's why there's no specific outreach programs on my point of view. That doesn't mean that the hospital isn't doing things, we're working with the Kroc Center, Dr. Kirchhoff is going to talk about those other things. And the hospital's been big in their outreach as well as the medical school. But personally, I wait until I'm asked because then I think they're ready to hear it.

Paul Anderson: Well, and that's also really well aligned with the point you made earlier about being trusted, right?

John Porter: Yes.

Paul Anderson: If they're coming to you, not only do you have the personal experience to speak from, but now you've got that sort of added, presumably they wouldn't have come to you if they didn't want to hear the message you were going to say one way or another.

John Porter: Correct.

Paul Anderson: Yeah. So Dr. Kirchhoff, let's bring you into the conversation here. Dr. Porter talked about doing work within Cooper individually, a little bit of a side hustle there, but how does that work fit into the broader context of what Cooper's doing both with the COVID vaccine specifically, but even more broadly?

Michael Kirchhoff: Yeah, certainly. So it fits into the broader context of our drive to improve culture at Cooper and in our communities specifically around inclusion. So Dr. Porter really talked about giving space to acknowledge systemic racism and the history of medical testing in the United States, et cetera. And we carry that conversation out into the community and to our leadership, not only in our county, but in the state. Many of our efforts were around talking about specific vaccine programs to really have an eye towards meeting the community needs, especially communities of color and underserved communities. For example, as Dr. Porter mentioned earlier, the Kroc Center, Kroc Center's a great community resource here in Kansas City, really serves to support the community and the members of that community, including healthcare as well as many other social programs. And when the county started rolling out the vaccine, our leadership went to the county and said," Look, it's really important that we limit the vaccine at the Kroc Center to our Kansas City residents so that we can tailor the approach, we can tailor the education and we can make sure that we meet their needs. Historically, when programs roll out, we, quote unquote, are colorblind, but that's really, that's a fallacy, right? On many levels, not the least of which is that if we don't take into consideration and have space to have these conversations around systemic racism and the history of care for underrepresented minorities in this country, then we don't create programs that meet their needs. The members of our community have different needs for different communities and to have a blanket state and say," Hey, we meet the needs of the majority of our patients," well, that's great, but it really doesn't meet the needs of the individual communities that we deal with. So as part of our change of culture here at Cooper is to really give space and have a focus on the very needs of the different communities that we serve and to make sure we meet those needs and don't take the easy way out and just say we have a general approach to everybody, right? Because that's not fair. The needs of one community may be very different than the needs of another community. And that was born out in our approach to our partnership with the Kroc Center around making sure that we create processes that support Kansas City. And then we might have different processes for other communities that we serve

Paul Anderson: Well, and I think maybe not too specifically around this issue, but broadly I think when we see organizations, places say that," Okay, I've got this policy that is colorblind that I'm just going to make this universally available." It often ends up favoring those who are more privileged. But even if that's not intentional, it doesn't matter. That becomes the outcome and those who are disadvantaged socioeconomically, racially, whatever, they have more trouble accessing those programs, whether they're healthcare or other types of programs. And so if I could sort of paraphrase back to what you're saying, if you don't find those disadvantaged groups and affirmatively bring them into the healthcare program, housing program, whatever, they're going to be left out even if you think you are being color blind. Is that sort of a fair way to crosstalk?

Michael Kirchhoff: Sure. And to Dr. Porter's point, it's inclusion and partnership. We are partners with them. Just telling them we're giving them a program that's tailored to their needs doesn't really meet their needs. There needs to be a partnership. And when they come to us, we have a dialogue with them and give space for these conversations.

John Porter: Right. And if I can add to what Dr. Kirchhoff said, because I think it's really important in two areas. One is Cooper took the lead in going to the state and actually getting permission to limit the vaccine to Camden City residents. And we were the first place in the state that was actually allowed to get that limit. All the other places that were super vaccine sites were supposed to be able to deliver it to everybody who came and made an appointment. But because Cooper really wanted to focus on Camden City and be a member of the community, wanted to make sure that the vaccine was available for those folks and made an effort to get an exemption from the state. And we were the first ones to get that. And then to tie in what I was doing with what Cooper was doing, I then made a video discussing vaccine hesitancy, similar to the answer that I gave you in your question. And then that video was run at the Kroc Center. So when people were in line, if they had questions, they could sort of see that and maybe help answer the question why they were waiting in line to get the vaccine or showing up to see if they actually wanted the vaccine. So you would ask, was there a relationship between what I was doing and what Cooper was doing? And that's a perfect example of what the relationship was.

Paul Anderson: Yeah, that's great. So we've been talking about COVID- 19 vaccination. Let's broaden that conversation out a little bit. And I'm going to maybe start with you Dr. Kirchoff, but if it should go to Dr. Porter, then by all means. But please, both answer. Let's broaden this a little bit more. Can you give me some examples of some other programs, processes, steps that you've taken at Cooper to really drive this partnership and this equity work.

Michael Kirchhoff: Well, Dr. Porter is raising his hand. That's the number one example, right? We have a chief inclusion officer and we have a medical director of inclusion. Full stop. I'm going to let Dr. Porter talk about that. He's living proof of the commitment of Cooper to this concept and this culture change.

John Porter: Right? And I want to give praise to the co- presence and co- CEOs and the chief physician executive who saw that something needed to be done and then put titles and money where that needed to be done. But I'm going to take it back a little bit further than that. I just met with somebody in my office today in a meet and greet. And I asked them what was their first impression of Cooper? And they happened to have lived in Philadelphia their entire life. And they always thought Cooper was one thing or another, but they didn't want to come work there. When they saw that the job became open, they went to the Cooper website and they saw a video of me talking about Cooper and why I came to Cooper. And the reason I came to Cooper, when I was deciding to leave my last job, I could have went anywhere in the country, is when I interviewed, I said," Look at all this nice housing you have next to the hospital." I said," Can I get some of that? That would be nice. My kids are grown. I could live across the street, it would be cool." And they said," No, unless you want to take a pay cut because we renovated all of that poor housing and made it a low income housing." Most hospitals, when they do that, they bring in all the people that can afford to live there and kick the poor people out. But what Cooper did was renovated all the housing to make it good housing and then kept it low income housing and let the people back in. And so that's an example way outside of the vaccine of trying to make the community better. You made the community better, then access is better, complications are less, people are showing up in emergency department as Dr. Kirchoff knows those down, et cetera, et cetera. And so it began way back then that ended up getting me attracted to the place, allowed this person of color to actually come get the job. Now that increases the diversity. And then the co- presence in the chief physician executive realizing that something needed to be done and not just sort of talk about it at a board meeting but get people to actually do it.

Michael Kirchhoff: And those kinds of changes take time. So it's a commitment to nominal culture change, which is a five to seven year journey at best, but also a willingness to differ the benefit of that. Having ties with the community, working with community development to really have the neighborhood support families and support inclusion, support access, to see that bear fruit takes time. And I know we're going to talk a little bit later on about what your members can do today to meet this need tomorrow. And the answer is you got to start today because it's a systemic problem, requires systemic solutions. And those solutions have to take root not only in your organization, but in the surrounding communities, in your employees. And if you're not putting your money where your mouth is by investing in smart, talented people like Dr. Porter to really help us steer our organization in a good direction in terms of inclusivity, equity, you can't do it overnight. It's not going to happen. You can't just tell people to go out there and be inclusive. You have to demonstrate that. Culture is demonstrated through actions. And not only speaks of individuals, but speaks of the organization. And if the organization is not acting in a way that reflects inclusion and equity, then we're not doing it.

John Porter: And one of the things I would like to add on that as Dr. Kirchoff importantly said, you have to put your money where your mouth is. But one of the things that I'm fond of saying is that different people have different amounts of money, but everybody has the same amount of time. So it's actually probably more important to put your time where your mouth is instead of your money. And what the people here at Cooper have been doing from the top down is putting the time in. And as Dr. Kirchoff said, to change a culture, it takes time. You have to put your time in. If you only put your money in but don't put your time in, you don't get anything accomplished. So I think personally that's an important distinction.

Paul Anderson: And I think the other thing that Dr. Kirchhoff mentioned that sort of brings back to a conversation we had had previously when we were discussing setting up this recording was this idea that Dr. Porter, when you came to Cooper, nobody was thinking about COVID. It wasn't a thing in our consciousness. But you wouldn't have been able to have the role that you had to fight COVID to help share that message about the vaccination, or you wouldn't be able to have it at Cooper if you hadn't been at Cooper. You might've had that role somewhere else. And so I think that's your point, Dr. Kirchoff of you're doing this work now to reap benefits in the future. Part of that, how much of that may be, but how much of that is making sure that from your leadership on down, that your staff reflects the communities that you're serving.

Michael Kirchhoff: It's vitally important to reflect our communities. Well, it's really important, again, as we're a large organization, we have a three county primary catchment area, seven county secondary service area. We get parts of Philadelphia, Northern Delaware. There are many, many communities there. And I think the trap a lot of folks fall into when we're talking about inclusion is we still paint with very broad brushes. We can't do that as an organization. So you need to look like those communities, but those communities are varied. And that means you need to have a diverse workforce. It doesn't mean your workforce necessarily. When we talk about diversity, we're not saying employees of color. What we are saying is we need to look like our communities. Kansas City looks a certain way. We need to reflect that community. Other communities that we serve look different, but the idea is you can't take your policy and you can't take your approach to these communities through a single lens. You really need to get into each community, partner with those communities. And you can't partner with those communities if you can't communicate with them. And for many of us, looking like those communities fosters a communication and an open dialogue and a shared experience that then allows us as an organization to understand and empathize with those communities and meet their needs more effectively.

Paul Anderson: Let me pivot very, very briefly before we wrap up. We've been talking a lot about the outreach to the community and we used the example of COVID vaccination specifically, but what about, I'll say within the Cooper staff, to the extent that we're able to talk about this. Dr. Porter, I think you shared a really great example when we very first got started about wanting to see the appropriate information before you felt comfortable making a decision to get vaccinated. And then being able to communicate that concern in your personal story to folks in the community. I'm guessing it's the same exact scenario with your colleagues, whether they're physicians or other staff of the hospital, same exact scenario?

John Porter: Yes. And one of the things I left off for the study of the process in the interest of time is it actually started in the hospital. I got a call from a person and said that 80% of the people in my area that aren't physicians are afraid to get the vaccine. Would you mind talking to them? And that was the first time that I spoke about the vaccine hesitancy. So it started in the hospital. And then some of those folks ended up telling their church members and police and everything, and it spread from there. But I've given several talks in the hospital where the vaccination rate was in the 20% range. But the percentage of people of color in those areas was in the 70% range to make a change in the hospital. So it actually started inside of the hospital and spread out because remember, like I said, I have no outreach, it's all word of mouth stuff. And it started with people of color in the hospital. They spread it," Hey, Dr. Porter said some stuff. And he's one of us. He was scared too." And then I get invited and whatnot. And then I ended up giving talks as far as The Oranges, which is in North Jersey and spoke to city council and mayors and whatnot, and tried to do it giving talks in Philadelphia from employees and employers trying to figure out going back to work and can they make the people take the vaccine? And I sort of said," I'm not going to talk for the employers. I'm going to talk for the employee because I'm for the people." And trying to get people to understand I don't want to be used to get everybody to take the vaccine so you can tell the people who didn't get the vaccines to stay home. But it started inside of Cooper and it only started inside of Cooper because quite frankly, the leadership created the position of medical director of diversity and inclusion so that the people knew to contact me. Without that position having been created, I would have been a black trauma surgeon. And who knows if the black trauma surgeon wants to speak. But once you give the black trauma surgeon the title of medical director of diversity and inclusion, it falls into my purview to speak so they weren't afraid to ask me. And so for people listening, sometimes the title matters. And so that they know who to talk to because every person of color may not want to come out and speak about what they're saying-

Paul Anderson: Sure.

John Porter: ...and what they're feeling. But once the person has that title, then they know to call me. And I've been called by some Jewish folks on Jewish matters. I've been called by some women on some feminist matters. I've been called by some transgender folks on some transgender matters because I'm the medical director of diversity. I'm not the medical director of blackness.

Paul Anderson: I'm really glad you made that point though about wanting to bring a whole range of different voices and groups in. When we say sometimes diversity, we often in our minds may be shortcut that to racial diversity. Or when we say inclusion, we may be shortcut that to racial inclusion. And I don't mean to diminish the importance of that, but I also want to make sure that we elevate the importance of other types of inclusion, whether it's gender identity or sexual expression or all these other various characteristics that people have. We want to make sure that folks have different avenues to access to information, to care, to services.

John Porter: Right. And as Dr. Kirchhoff said about making of the staff of both non- physician staff, non- physician staff look like the communities that we serve, he was implying that we're going to make it look like the communities that we serve because we're covering ethnic diversity, racial diversity, sexual orientation diversity, and that we look like all of those different diversities in our employees and in our providers.

Michael Kirchhoff: Dr. Porter raised a very important point. And I really wanted to raise a point about the history of us internally reaching out to our employees around vaccination. So when vaccination was first rolling out, I was one of the first ones to get the vaccine. And as such, they said," Oh, well go talk to these groups." And I did as the patient safety officer. And what we were finding was just what Dr. Porter said, which is my message wasn't ringing true with that audience. And what's really important here it is the fact that we pivoted to make sure that we had the right people sending the message and that those people believe the message as well. But what's also really important is that when you have leadership, especially leadership that looks like me, middle- aged white guy, they have to be okay with a space for conversation about this. That nobody's saying," You're not a good leader, you're not a good speaker, you're not a good scientist because you can't convince this community to do X." We have to, as organizations be open and provide space for these conversations and that we can't let pride get in the way. It was super, super important for some of the leaders at Cooper to realize that and make space for this conversation. This is the trap we fall into many, many times, and it repeats itself throughout history. If we don't have frank conversations about how we're failing and why we're failing, then we can't fix those problems. And one of our failures in the past has been having messengers not look like those receiving the message. And we very quickly realized that, hey, I might not be the right guy to talk about these things. And I subsequently got a lot of other requests to go talk to other constituencies. And I said," Hey, let me remind you of Tuskegee. Let me remind you of many racial and socioeconomic disparities in this country. And now that I've reminded you of that, am I the right person? Do you think this is the right messenger?" Because we tend to forget those things. And they're germane to our conversation about engaging with these communities. And I was on many a call reminding people of the history of really some very tragic events in American history, because that's important. People who look like me may forget about that, or may never have learned it. But those other communities, they know and they remember, and they should remember because it's important. And if we don't give space to bring these considerations into our planning for communicating with these communities, we're going to fail hands- down. So it's really, when we talk about what your members can do right away, it not only start on this path, but it's also to make sure that your leaders understand that when you're not asked to do something, it's not because you're not good at it. It's because you're not the right person. And that's okay. It's subtle, but a super important conversation to have with everybody in your organization.

Paul Anderson: Well, okay, so that's a good segue then, Dr. Porter, to ask you for your thoughts. I, again, always try to wrap up with something we can do today. We're not going to solve this problem by supper. I don't know, maybe we could, but I doubt it. So what is the starting point for an organization? I'm going to ask you two ways. Maybe this is an organization that it's never occurred to them before that they need to think about this issue. Or maybe it's an organization that they're giving good lip service. They've got the idea that they want to deal with some inequities, but they don't know where to start. They've done some ineffective things and now they want to pivot to actually doing effective things. Well, what's a starting point?

John Porter: I think the main starting point is the leadership has to create the positions that are going to do the work. And what we did here was we created a vice- president of diversity, inclusion and equity and talent acquisition, and they're in charge of all the non- physician stuff. And then they created a position for medical director of the same in charge of the physician stuff. So now the people know where they can go to for things. And we had or we were trying to, since it's June and pride month, we were trying to increase the areas there and our work in the hospital. And then I helped the person who had the ideas interface in the hospital because he had all the ideas, but he didn't know Cooper politics and whatnot. And then I can run with that. But without having that title created by the senior leadership, he would have never known who I was, and I wouldn't have known who he was. And so you need that to get it started. And then it starts from the top. I can't give myself that title. Someone else has to give it to me, but that shows everybody. So then the number of emails that I got when they put out the all Cooper email that said that this position was created, and it was, a lion's share was from non- physicians because it went to all Cooper and it was a medical title, but people in housekeeping, people in security, people saying," Yeah, this is good. This is a good thing." They're serious about doing something now. And so I think that's where you start. And I think that is key because it's about the time and whatnot. Because to be honest with you, the way I asked for the position, I didn't ask for any money. So they didn't have to put the money where their mouth was. They had to put their time and importance where their mouth was to get it done. And I think all organizations can do that. And then all of a sudden people come out of the woodwork willing to help me, willing to set some things up. We just worked center rounds on the diversity topic. We had over 200 people on WebEx talking about it. We typically average 50 on our round. It come out of the woodwork ready to talk about it. And then as Dr. Kirchhoff said, that's how the change happens. That's how the culture change happens over the next five to seven years. You get everybody talking about it because it's a place that's safe to talk about it now because the leaders said," We got this title, so we can talk about it." Before we couldn't talk about it.

Michael Kirchhoff: And I'm going to draw a very bright line for what Dr. Porter just said to the reality, which is on our ambulatory operations pedal today, the conversation was a discussion around how medical assistants and front desk staff can better meet the needs of the sexual identity of our patients. And we had a whole 15 minute primer on pronouns and how not only the importance of pronouns and why it's important to patient care and the engagement of patient care. Because if we have patients that feel alienated or not engaged, they're not going to have the outcomes we want. We want our patients to be successful. We want them to be healthy. And if they're not engaged, they won't have those good outcomes. And if you're using the wrong name, you're using the wrong pronoun, you're not acknowledging a person's identity, then they're not going to be engaged. And because we have Dr. Porter in his position, and because we have senior leaders talking about this important topic, it's given space now for our ambulatory leaders to say," Hey, can we give us a talk about the use of pronouns?" And now we have patient care techs and medical assistants talking about pronouns, which to me, is miraculous and very, very important. But if you don't make it a priority, if you don't say this is important as an organization, then you don't connect those people and the right circumstances don't happen and we're not having the conversations. And it's very important that it is the sharp end of the organizations, the people that are caring for our patients. Yes, senior leaders are driving it. Middle managers are holding people accountable to it. But if the frontline folks aren't acting it, if their actions aren't speaking the culture we're trying to engender here at Cooper, then we're not going to have the outcomes we want. And that's just one example of 75 people from ambulatory operations eagerly awaiting a conversation about pronouns. I don't think that would have happened five years ago. Matter of fact, I know it wouldn't have happened five years ago.

Paul Anderson: Okay. I think that's a great place to end our conversation. Thank you both Dr. Kirchoff, Dr. Porter for taking the time to be with us today. Learn more about ECRI and the ISMP PSO from the equity website at www. ecri.org, where you'll also find our 2021 Top 10 Patient Safety Concerns report, which features racial and ethnic disparities in care as the top issue for the year. You can find out more about Cooper University Health Care at www.cooperhealth.org. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes. And we welcome your feedback. Please visit us at ecri.org or email us at ecri-podcasts@ecri.org.