For Erika Linnader, effective leadership is essential to addressing some of the world's most pressing public health challenges.
As director of Yale's Global Health Leadership Initiative, she leads a team advancing transformation in management, leadership, and organizational performance that aims to create stronger and more resilient health systems for all.
"Our prior research has focused on organizational culture change as a prerequisite for addressing all kinds of public health and clinical outcomes," said Linnader, also lecturer at the Yale School of Public Health. "The more complex, the better."
The Global Health Leadership Initiative, which is comprised of faculty and staff with expertise on a range of specialty areas, takes a multidisciplinary approach in tackling a host of complex global health challenges. That includes sepsis, a life-threatening systemic reaction to an infection. Sepsis affects about 1.7 million U.S. adults each year and is one of the leading causes of death. Black and Latinx people with sepsis experience higher rates of complications and hospital readmissions compared with the non-Hispanic white population.
"Sepsis influences a lot of people in the United States," Linnader said. "It's a major driver of morbidity and mortality, meaning a lot of people die of it, and even if you survive sepsis, it can have lifelong implications for your health."
Through a multi-year effort called Champions Advancing Racial Equity in Sepsis (CARES), Linnader and collaborators are currently working to address racial disparities in sepsis care through leadership development and cross-sector partnership. The initiative includes three health systems across the country working to rethink their organizational cultures as it relates to sepsis care.
In an interview, Linnader explains the disparities in sepsis care, how CARES is addressing those gaps, and how society might advance more equitable sepsis care in the future.
The interview has been edited for length and clarity.
How do systemic inequities influence the care and outcomes of sepsis patients?
Linnander: We can trace a patient with sepsis all the way from early risk and prevention through to post-discharge care, and you see ways that structural racism shows up along that whole pathway. In terms of early risk and prevention, we see that Black and brown patients are less likely to receive certain immunizations. They're more likely to have certain comorbidities that put them at greater risk for sepsis. In terms of early care, those patients experience more barriers to accessing care like financial barriers or geographic barriers. When we talk about early recognition and treatment, implicit bias plays a role there. A lot of algorithms are also race blind. In terms of post-hospital care, Black and brown patients tend to have less access to corporate insurance plans or commercial insurance plans that allow for really good follow-up care. So, there's this interplay between race and ethnicity, plus financial disadvantage and geographic access. All these things are compounded because racism in the U.S. is a structural problem.
Why is a collaborative approach necessary to advance equitable sepsis care?
Linnander: So little is known about sepsis and equity. All of the participating health systems came to the CARES collaborative saying we have an ethical commitment to equity. From the top of the organization, there was a commitment to providing equitable care, but, generally, health systems across the U.S. don't always know exactly how to operationalize that. We believe this thing is important, but how do we make it tangible? How do we implement that? A collaborative allows us to bring our scholarship, but it also allows the sites [the health systems the Yale initiative has partnered with] to bring their experience and expertise. Putting together the scholarship and the practice is where you get really meaningful learning.
One of the big goals of CARES is to reimagine the organizational culture within health systems. What have you learned about that through the CARES collaborative so far?
Linnander: There's not a playbook or a formula that we can give hospitals to say, "Hey, do these four things and you will have great sepsis outcomes for all your patients." Instead, we've got to build these capacities that allow health systems to get curious about inequities, to look at their data, and to have safe conversations and generate hypotheses about where gaps might exist. So, it's kind of building those aspects of organizational culture that allow for this continuous self-exploration and then having hard conversations.
What we saw over time is that sites were able to get curious. They were able to take a step back and say, "Let's talk about how racism might show up here. Let's come up with some hypotheses. Let's check those out. Let's iterate on this." We saw this shift toward curiosity, which is just so powerful in these health systems.
What other interventions might help address inequities in sepsis care?
Linnander: Some of our sites have been focusing more on language barriers than race-ethnicity barriers given the populations they were working with. They found that they had some equity gaps related to language. For example, they need to make sure interpretation services are top notch and easily accessible. We have other folks spreading awareness about implicit bias, looking at the data and delivering feedback to make sure we're always having these conversations to help bring it to front of mind. It's the kind of thing where as soon as you shine a light on it, it starts to fix itself.
The other thing that sites are showing us is the value of baking an equity lens into a health system's quality improvement [QI] infrastructure. Most high-performing hospitals have a robust quality improvement infrastructure [to measure and improve outcomes at their hospital]. Disaggregating data and proactively, continuously looking for gaps within the data will help from an equity standpoint. Because once you identify a gap, most health systems are chomping at the bit to address the gap. They love to improve their performance.
