INDIANAPOLIS — A panel of six national and local health care experts have completed an external review of the case of Dr. Susan Moore, who died from COVID-19 in December 2020 after she said IU Health doctors provided inadequate care because she was a Black woman.
Following her death, IU Health CEO Dennis Murphy called for an independent review to focus on three issues:
- Clinical care
- Patient communication
- Potential bias
After reviewing medical records, interviewing personnel and going over policies and procedures, the review panel found the medical care Moore received did not contribute to her death, but there was a lack of compassion and empathy in her care. The panel also noted not all health care providers practiced cultural competency and lacked awareness of their implicit biases.
"As a seasoned healthcare leader who is committed to compassionate care and to operating a premier institution focused on providing high-quality care, it is clear to me that Dr. Moore deserved to be listened to and for her concerns to be understood," Murphy said in a statement. "We have more to do to become a more diverse, inclusive and anti-racist health system," he went on to say.
The panel made recommendations for the health system that fall into two categories:
- Enhancing the delivery of appropriate, compassionate and evidence-based care
- Enhancing cultural competency and awareness of implicit racial bias among IU Health personnel
These are the panel's recommendations related to compassionate care and patient advocacy:
- Improve procedures for helping patients and team members voice concerns, escalate issues and access clinicians and other professionals with greater expertise (including social workers, chaplains, etc.) when needed.
- Conduct training for all team members to enhance compassion, encourage empathy and facilitate an optimal patient experience.
- Hire more patient care advocates to improve our system-wide patient care advocacy process.
- Improve patient care coordination and assure communication among all team members and caregivers throughout hospitals.
- Improve team member reporting about the patients in their care and the use of huddling, incident analyses and debriefing.
- Increase support for team members who experience poor patient outcomes and burnout.
- Mitigate the burden of issues like COVID-19 on patients and team members by enhancing different forms of communication.
These are the panel's recommendations related to diversity, equity and inclusion (DE&I):
- Require more comprehensive DE&I learning and training for all team members, with a focus on mitigation, unconscious bias, microaggressions and anti-racism to foster an inclusive culture.
- Establish a response team trained in mitigation for complex DE&I issues.
- Leverage the diverse experiences and best practices of more seasoned team members to help mitigate incidents involving racial tensions and function better as a team.
- Establish an assessment of DE&I efforts as part of required annual performance evaluations for all team members to support a culture of accountability.
- Standardize onboarding and required training so that both employed and independent physicians receive needed information.
- Engage with community stakeholders to publicly acknowledge the history of racism in health care and Indiana, and how IU Health will work toward reconciliation and change.
- Hire a DE&I consultant who can formally assess the organizational culture and climate of IU Health hospitals through an anti-racist lens.
Murphy said the health system has already begun planning a timeline and accountability structure to meet the recommendations. IU Health will publicly report data and track improvements on its website.
On Monday, May 17, the Indianapolis NAACP issued a statement on the review conducted by IU Health.
“We are pleased to see IU Health has completed such a thorough investigation into the care of Dr. Susan Moore and is now committed to an action plan for improvement. We look forward to seeing their progress in becoming a more inclusive, anti-racist organization and plan to hold them accountable to their word," said Chrystal Ratcliffe, president of the Greater Indianapolis Branch of the NAACP.