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Management in Practice

How a Time Out Can Help Address Bias

To counter the sometimes-deadly effects of bias in healthcare, hospital executive Gina Calder ’22, Dr. Cecelia Calhoun ’21, and other leaders in the field developed a tool to help teams spot and address bias in real time. The Bias Time Out draws on a system that has successfully reduced other kinds of medical errors.

  • Cecelia Calhoun
    Assistant Professor of Medicine & Assistant Professor of Pediatrics, Yale School of Medicine; Director, Adolescent-Young Adult Sickle Cell Program, Yale Cancer Center
  • Gina Calder
    President, St. Charles County, BJC Healthcare

Q: You are two of the co-authors of a paper, “The Bias Time Out: A Practical Tool for Advancing DEIB in the Healthcare Space” that proposes a real-time process for reducing errors and negative outcomes due to bias. How did you develop this tool?

Dr. Cecelia Calhoun: Five of us came together as clinical and administrative healthcare leaders. We shared stories about our work in care delivery, hospital management, workforce development, and academic medicine. We talked about how we show up as advocates, allies, and sponsors to create equitable spaces. In doing that, we noticed patterns both in the bias that occurs throughout the system and in the concrete steps we already take to counter it.

Gina Calder: We are in the business of saving and healing and birthing lives. If at any point there’s any systematic error that we’re introducing into that work, it puts lives at risk. And many times, if we’ve not done the work to actually identify what our biases are, bias is unconsciously a systematic error. That’s the burning platform for us: in the healthcare space, bias is deadly.

Encouraging everyone on the team to partner with each other in this effort, that’s impactful. That’s a direct connection to equity. That’s going to help our systems and the way we deliver care be better long term.

Across the healthcare industry, many organizations have been engaging in unconscious bias training to begin to bring those biases to the forefront, allow people to identify them, and to think about ways in which they might adversely impact outcomes.

Calhoun: In the places where it’s done, that training creates a foundation of awareness and education. It’s essential, but sometimes it ends there. What we really want is to change practice.

Calder: That’s it exactly. We’re aiming to drive change as deep into organizations as we possibly can.

Calhoun: So the question became, “How do we, in a just culture, in a kind and non-punitive way, mitigate unconscious bias?”

We need to have space to have uncomfortable conversations in a productive way. We need to make them routine. That’s the way that we grow. That’s productive discomfort. It’s John Lewis’ “good trouble.”

Encouraging everyone on the team to partner with each other in this effort, that’s impactful. That’s a direct connection to equity. That’s going to help our systems and the way we deliver care be better long term.

Q: The Bias Time Out is designed to both do something new and fit into a familiar process. Would you give that context for readers who might not be familiar with how healthcare already uses time outs to reduce errors in a clinical setting?

Calhoun: We took inspiration from the Institute for Healthcare Improvement (IHI) and the clinical time out developed by Don Berwick.

Before minor procedures and major surgeries, we stop, gather ourselves, and go through a checklist that unambiguously confirms that we have the right patient, are moving ahead with the right procedure, and will be performing it on the correct side of the body.

The tool exists to address errors that have happened too often. Nobody wanted to make those errors. They weren’t aware they were making them. They happened because we’re humans; we make mistakes.

Using the clinical time out is now so routine that it’s built into our culture. Anyone can start a time out—it doesn’t have to be the most senior person. That creates an equitable space and makes everyone responsible for reducing errors.

Calder: The IHI clinical time out has been a wild success. It’s now part of the National Patient Safety Goals and healthcare’s regulatory and accrediting bodies agree it’s a proven method to reduce error. If we don’t consistently practice and document use of the clinical time out, we’re in a world of trouble with respect to regulatory compliance, maintaining accreditation, and eligibility for reimbursement from the Centers for Medicare and Medicaid Services. The tool is a big deal.

Given the clinical time out’s impact and proliferation, we designed the Bias Time Out as a six-step checklist that would be familiar to healthcare practitioners. But because we know that bias unfortunately shows up broadly, we wanted the tool to be agile and adaptable enough that it can be used in a range of settings.

Frontline teams can implement the Bias Time Out in the course of caring for a patient. Executives can use it in evaluating where to open their organization’s next access point for care. Hiring committees can use it to address bias in their processes and decision points.

One of our co-authors, Dr. Cynthia Boyd, is a dean of admissions at Rush Medical College. She is thinking about how to leverage a tool like this in the face of the recent SCOTUS reversal of affirmative action.

Q: What would the Bias Time Out look like in practice?

Calder: We have lots of examples in the paper we published in Management in Healthcare, but I think a patient care case study really gets to the deadly nature of how bias works.

Here’s a scenario. At the end of a shift, a clinician is signing their patients over to their colleague. They report one patient is an elderly man, who happens to be Black, who arrived in the emergency department (ED) complaining of dizziness. He’s being treated for uncontrolled hypertension and Type 2 diabetes.

The clinician making the report says the goal is to release the patient, but he is non-compliant with respect to his medications and does not follow up as he should with his doctor. The patient’s lab results, health status, and non-compliance have been documented in the electronic medical record (EMR).

Someone asks, “Is there potential for bias?” If there are people involved, the answer should always be yes. So that’s kind of a gimme. The team pauses. It’s a chance to recognize that with the shift change there’s a desire to hand over care quickly. That increases the likelihood that assumptions may be thrown in.

What biases might be at work? There’s a subjective judgment that the patient is not cooperative, not interested in his own care. It may be implied that it’s his fault that he’s sick.

Who or what might be affected by the bias? First and foremost, the patient, clearly. Medical care and treatment might be suboptimal as a result of the bias. He may not receive additional testing; may not be made aware of other conditions that he could be at risk for given his uncontrolled hypertension and diabetes.

Beyond the patient, the providers may be impacted. The new treating team arriving for their shift may wonder if it’s worth making referrals if the patient is not going to follow up. In future episodes of care, a non-compliant label in the medical record may impact how people think about, interact with, and care for this patient.

Those experiences will likely worsen his outcomes, put him at greater risk for other complications, and provide a poor experience in general, which may lead him to become frustrated and noncompliant.

What actions can be taken? The team might say, “You know what, let’s not label the patient. Let’s talk with him. Let’s try to understand whether there are underlying circumstances that could be addressed by partnering with the patient rather than perpetuating this idea of non-compliance.”

Taking action, a team member is tasked with getting a more thorough history. What led the patient to the ED? Are there challenges in his life, in his current environment, that played in? Does he live alone? Does he have family or friends who can help? Where does he live? Does he have safety concerns? Does he have a way to get to healthcare appointments? To pick up medications?

With a clearer understanding, it may be possible to come up with a feasible plan. The record is updated, not to talk about noncompliance, but to include the barriers and challenges facing the patient and how providers and patient are working together to address those issues to make sure that he can meet his care goals.

Finally, the team will debrief because this is an opportunity for learning. We want that continuous feedback and improvement loop. Many of the biases that we experience in the healthcare space are not one-off. In that reflection, they can decide, could this happen again? Does it happen often? And if so, is there something that we can do so that the pattern is stopped in a systematic way?

Calhoun: Our intention with this tool is to mitigate bias, but with this example, we’re really pushing forward better care. Opening up the space to communicate about biases becomes an opportunity for quality to emerge too.

One of the action items was talking to the patient. I recently had a patient who had gone years without care before pain associated with his sickle cell disease forced him into the ED.

Initially, he was very closed off. But by taking time to talk with him, we learned he didn’t have insurance coverage and was scared of getting a bill. He hadn’t applied for Medicare because he didn’t know how. The Bias Time Out allowed us to really leverage the knowledge and expertise on our team. It let us provide necessary ongoing care to a patient who had been just surviving.

Q: You noted that the tool works in many settings. Would you offer some examples from an administrative context?

Calder: The Bias Time Out has forced me to challenge my own thinking. When the executive team is having discussions and making decisions, the Bias Time Out is causing us to question whether certain policies and procedures have been underpinning implicit bias and maybe no longer are best positioning us. It has led us to question which strategic next steps are most important and who we need to tap into to get that work done.

For example, when I first joined our organization, I had an opportunity to review equity in compensation. Given past experience, I knew it would be a sticky issue. That could have been reason enough to put it off until I had made some progress on a few of the many other issues I needed to advance.

Instead, taking a Bias Time Out, I prioritized it right away. We made significant changes. Those changes impacted not only leadership but everyone hired into the organization. They shaped who is advanced. They brought greater equity into compensation. Now those changes are trickling through the whole organization, including the point of care.

Focusing on bias of all kinds let us understand just how pervasive it is. It revealed how many different opportunities we have to increase equity, which in turn drives the organization to deliver the highest, safest, and best care for our patients.

I have found using the Bias Time Out to be extraordinarily impactful in helping us to advance our mission. In fact, it would be a scary proposition to try to do what I’m doing today without this tool.

Calhoun: It’s my job to keep my patients healthy and safe. To do that requires making space for accountability, for evaluating our processes, for learning and iterating to keep getting better, and for doing the right thing.

The Bias Time Out tool is simply recognizing our humanity. We will make mistakes, so what systems can we put in place to minimize that? In addition to cutting down errors, by going through the checklist we’re working together to understand a situation more deeply. It becomes a great opportunity for knowledge exchange within the team, which I think is really valuable. I get great enjoyment from learning from the people around me. Again, this is not a punitive thing. It’s saying, we are a part of this community; we share the same goals; we understand that we’re imperfect. How do we work together to do better?

Calder: The five of us who came together to develop the Bias Time Out are all committed to equity in healthcare to ensure that people can live the lives that they deserve to live. We believe this can be a valuable tool. Is it all the work there is to do on bias? Of course not, but we think that this will get us further than where we’ve been.

Calhoun: Bias affects every area of our lives. So it’s potentially transformative to consistently,
consciously be aware of bias, how it may be playing into different decision-making points, and how it can be mitigated. We know culture change can be slow. Regularly getting space to be reflective is a way to move it forward.

Q: What’s next?

Calhoun: Several organizations across the country, including Gina’s, are incorporating the Bias Time Out into their work.

Calder: One of our co-authors, Gayle Capozzalo, is the executive director of The Equity Collaborative, a learning and doing community made up of leading healthcare organizations. A cohort of collaborative members have taken on piloting the Bias Time Out. We’re learning from their experiences so that we can continue to refine the tool for a range of healthcare settings and decision points.

We’ve also had folks reaching out to us to say, “This sounds like a great quality improvement tool. We want to use it in our organization. How do we do it?” We welcome the chance to collaborate, and the Bias Time Out tool is easy; it’s user-friendly. Anyone can use it. We’d like to hear about your experiences when you do.

Calhoun: We’ve launched the Bias Time Out within healthcare because it’s the space that we’re privileged to work in, but the tool can be adapted to any industry. Yale Insights readers and the Yale SOM community touch many sectors. And they know leadership doesn’t just come from a title; it comes from how you show up in the spaces in which you have influence. As Gina said, try using the tool, then share your experiences. Give us feedback so we can make it better. That’s the work.