Samuel Washington: Hi everyone, I'm Samuel Washington, Editor of the Center of Excellence for Healthcare Disparities as part of UroToday. Today I have with me Dr. Christopher Warlick, who has several roles, Department Head for Department of Urology, Associate Professor at University of Minnesota Medical School, and serves as a commissioner for the HOPE Commission. Thank you for speaking with us today.

Christopher Warlick: Thank you for having me. My pleasure to be here.

Samuel Washington: Yeah. Now, I wanted to pick your brain about a few different things because you're doing amazing things where you are now. As one of the bosses, you have several different leadership roles that are focused on health equity, and I just wanted to know a little bit about your path to these roles and the driving forces that guide your leadership efforts.

Christopher Warlick: This is a great question and one that I, over time, have, I think, developed a more insightful answer to. It's a deep question, as it turns out. It sounds easy on the surface, but as it turns out, it's actually a deeper question. And to be honest, I think that I owe a lot of my leadership capabilities and certainly style to my father. My father, he played football for the Buffalo Bills in the early sixties and stayed around in Buffalo after he retired. He used to joke and say he didn't make enough money to go home. He was originally from North Carolina. And so I ended up growing up in Buffalo. And turns out my father was a pretty popular player and maintained that popularity until his passing in his eighties in about 2012. And one of the things that was very impactful as I was growing up, I now recognize, is how my father treated people in the public.

And so it would be very common if we were out to dinner that somebody would come by the table and say, "Hey, Ernie, hey, good to see you. Hey, the Bills could use you this week. Blah, blah, blah," and sort of disrupt our dinner. My father was always gracious. Always gracious and always acknowledged the individuals and joked with them and made them feel in that moment that they're seen and recognized, and despite the fact that it was sometimes an inconvenience for the family. And I think that I've been impressed by that and recognized the value of treating people, all people, well, and the value that that brings. And so I've tried to bring that in my leadership roles to create an environment where everybody, all of our faculty, our students, our staff, and those that interact with us, feel welcome and valued and seen. And I think it comes from that.

Samuel Washington: That is amazing. When we talk about how treating the individual has shaped healthcare, as we move forward, we talk about personalized medicine, some of these leadership roles, you're able to affect change beyond just one patient, but at a broader system. Would you be able to speak to how you've been able to leverage your roles towards health equity or more equitable treatment for all the patients that you're seeing?

Christopher Warlick: I think in the broadest sense, that impact has been largest through what's called the HOPE Commission at our institution. And HOPE stands for Healing Opportunity People and Equity. And the HOPE Commission was formed in response to the killing of George Floyd here in Minneapolis in 2020. And following that, there was an outcry, of course, that started in Minneapolis, but of course went worldwide to draw attention to disparities and eventually broaden to health equity among other pursuits of equity. And several of the healthcare organizations around the Twin Cities decided that they wanted to take action. There were public letters written to this effect. And our institutions were no different. And we have a complex structure that includes a partnership between the University of Minnesota Medical School, the University of Minnesota Physicians Faculty Practice Group, and the Fairview Health System, which is our health system partner.

And the HOPE Commission was formed with representatives from each of those three organizations. And we were charged with the task of trying to set a roadmap and helping to coordinate and organize a change toward a more anti-racist and inclusive posture for all three of our organizations in concert. So just a small task there. Just a small task. But we have been able to achieve some things in relatively short order. So we envisioned this as sort of a five-year plan that would be a five-year transformation. And really there were a few guiding principles that we had when we were setting this up. So one of the things that we did was to organize our thoughts around this, how we were going to tackle this enormous task. And we decided to organize the work into four key domains. So we looked at how our organizations functioned. So one was as a healthcare provider, of course, one is as an employer, one is as an academic institution, and then as a corporate citizen. And we divided, at least intellectually, the work into these four buckets.

And one of the key things was to identify what we refer to as key role leaders. So it was clear that the three of us, and I'm just one of the commissioners along with Dr. Taj Mustapha and Diane Tran representing the medical school and Fairview. I was representing University of Minnesota Physicians. It was clear the three of us could not do this work by ourselves. And one of the key things that we thought was very important is to establish these key role leaders because we really wanted this work to be integrated into the day-to-day work of the organizations. So health equity work, making the environments more inclusive, cannot just be one-off projects being done by this person here, this person who's passionate about doing it there. In order for this change to be real and sustainable, it needed to become part of the DNA of the organization. And so one of the ways that we felt would be helpful to do that is by charging people that are in high leadership roles with responsibility for integrating this work into their daily workflows. And the key role leaders have embraced this. They have taken on this charge and have managed to make some significant impacts even in just a couple of years.

Samuel Washington: And that's really amazing because, as you said, oftentimes the studies, the papers, the interventions are on one level, the patient or provider, but really you guys transforming to a multi-level or multi-domain approach has really changed it to some more reflective of the entire system, the environment in which these observations exist.

Christopher Warlick: Absolutely. And what you also gained then is synergy. So you get synergy between these domains, and so the impact ends up being a little bit greater. So people are not just working in silos on their little project, but as the work disseminates down, you recognize, "Aha, we can leverage what they're doing, what the folks in the academic domain are doing. We can use that in the healthcare provider domain." And you can start to, again, capitalize in some of those synergies and it builds some momentum. And I won't go so far as to call it self-perpetuating because it does require continued effort and attention. But that being said, it's more efficient.

Samuel Washington: Yeah, I would say. So there haven't been that many examples of this multi-level intervention or transformative change at a systems level. What would you say in its early stages have been one or two key findings or changes, results?

Christopher Warlick: So a couple of things I want to point out before in background as I answer that question. So one of the things that we felt was very important in the beginning was to actually just start by listening. And so one of the key things that we did was hold listening and learning sessions. Over the last three years, we've held in the fall large scale listening and learning sessions from different stakeholders. So from employers, from patients. This most recent round was in patients that do not speak English as a primary language. And we wanted to hear from our stakeholders what was important to them, the people that are most affected by these problems. And that is largely what informed in large part, some of the first things that we felt were important to address were some of the concerns brought up in these listening and learning sessions. So that's just a little bit of background.

One of the key things that have come out of the HOPE Commission actually really is the establishment of further infrastructure, again, in order to do this work. So again, we had talked about that we had identified key role leaders for each of the four main domains that the work is occurring in. But additional positions were created along the way to help do this work as well. And this goes including a chief health equity strategy officer. So really someone like a C-level individual within the Fairview organization. The University of Minnesota Physicians created an Office of Diversity, Equity and Inclusion, which it really had not had before. We are fortunate that around the same time that the HOPE Commission was starting, the new Vice Dean for Diversity, Equity, and Inclusion within the medical school was just starting at around that time and her office resources that were also expanded.

So we have created a much more robust infrastructure and resources have been dedicated to help carry out this work. And again, that's largely a credit to our executive sponsors, the head honchos as it were, that really helped support this work and made it possible. But through that, we have been able to do things. So for instance, on the academic side for the first time, the surveys regarding the clinical learning environment that all of our trainees are functioning within, there was an equity analysis that was done of those results to look for areas of disparity and things that could be addressed. And that had never been done before. Some of the researchers have been partnering with the Community Health Equity and Engagement Team, which was also a new center really, to increase research participation in specific communities in the Twin Cities that have been underrepresented in research.

And this has resulted in achieving greater than expected recruitment in some of these very traditionally difficult to reach populations. We've also increased cancer screening specifically in some of the populations around the city through efforts that came out of the HOPE Commission. Those are just a couple of examples. We've also done an analysis on our interpreter services and how our interpreter services, how well those are serving our non-English first language English-speaking patients, which is again, something that really hadn't been paid attention to in the past. And needless to say, there's lots of others. But those are some examples of things. Review of job descriptions for bias as well. So again, not just on a patient care level, but really at higher levels in the organization.

Samuel Washington: It's interesting how you've been able to fold an introspection at the system provider level, but then also taking in feedback from stakeholders outside of the medical environment and merge those two together, which just doing one of those can be a Herculean task in and of itself.

Christopher Warlick: Absolutely. Well, and understanding, of course, that we are them. So there's a lot of overlap between a lot of the people that work for the system are also the community members. And so by attacking it at both points, I think it has the potential, again, to be more effective. But yeah, there are lots of different stakeholders that we have benefited from listening to.

Samuel Washington: Well, in this case, multi-directional communication has really been fostered with the development of infrastructure, which does not happen overnight as well. One question that I would have is, there are others who want to do something, but they're often not sure of how to do it, or it's just limited to them in and of themselves. What advice would you have for those people who are hoping to use this as a framework or roadmap in their own environment?

Christopher Warlick: I think that one of the things, to be fair, that we were very fortunate is to have the support from the dean of the medical school, the CEO of UM Physicians and the CEO of Fairview that were all vested in this. And so that, needless to say, facilitated the work tremendously. And we met regularly as the HOPE Commission with those leaders directly and informed them about the process of how things were going. And it gave us the opportunity to ask for things that we felt that we needed. And so we had buy-in at the highest levels, and that's really important. Admittedly, it's not always readily available, but it's extremely helpful. It's good work if you can find it, as they say. It really helps facilitate things.

But the other thing, or without the ability to have that sort of access, I think one of the things is just trying to eliminate silos. So there are lot... And we found this in our own organization when we first started. One of the other things that we did was take an inventory of all of the work that was going on. Turns out there was a lot of stuff going on already, but just individual projects occurring here, there. And I think that this is a common phenomenon where, again, the difference being is that those are passion projects by people who care deeply about the topic. It's not necessarily the institution doing it because it's what we do. It's individuals that are doing it because they care.

And while that can be effective, turns out it's likely to be even more effective if those individual groups can connect in some way and, again, leverage resources that each group is already using to help facilitate each other's work. And that is one of the things that the HOPE Commission was able to do is because we were at a level up across organizations even that we were able to identify, "Oh, hey, did you know that they're doing this in that organization? Did you know that that group's doing this? Maybe you guys should talk and get together." And that makes a more efficient use of the resources that you have and is going to make things more effective. So even if you, again, don't have resource allocation coming from the highest levels, finding a way to organize and find out what's going on at your institution and connect people, I think is a great first step.

Samuel Washington: Great. Well, thank you so much for taking time out your day to chat with us.

Christopher Warlick: My pleasure. My pleasure. Thank you again for having me.