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External review of Black doctor’s death concludes IU Health employees showed “lack of empathy and compassion”

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IU Health North has released the findings of an external review of the circumstances leading to the December 2020 death of a Black patient who claimed race played a factor in what she deemed inadequate treatment at the Carmel hospital.

Dr. Susan Moore, 52, a licensed physician who succumbed to COVID-19 at a different Carmel hospital, posted a video on Facebook two weeks before her death in which she said her white doctor didn’t take her complaints seriously and declined to prescribe sufficient pain medication until a scan showed evidence of problems in her lungs.

The review, conducted by a panel of six health care experts, determined that the medical and technical care provided at IU Health North “did not contribute to her untimely death; however, there was a lack of empathy and compassion shown in the delivery of her care,” according to a statement by IU Health CEO Dennis Murphy.

The review panel recommended several action items to enhance the delivery of compassionate and evidence-based care and to enhance cultural competency and awareness of implicit racial bias among hospital employees.

Read the full statement below:

“We have already begun taking action around recommendations from the external review panel, which fall into two categories: 1) enhancing the delivery of appropriate, compassionate and evidence-based care; and 2) enhancing cultural competency and awareness of implicit racial bias among IU Health personnel.

The first set of recommendations highlights a need for a thorough assessment of IU Health’s systems and structures related to our care models, patient advocacy system, team members reporting and communication methods, including:

  • Improve our 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 our 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.

The second set of recommendations focuses on training, Diversity, Equity & Inclusion education and interactive hands-on learning to improve the cultural competence among our team members, including:

  • 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 healthcare 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.

On behalf of the entire Indiana University Health team, I want to express my deepest condolences and heartfelt apologies to Dr. Susan Moore’s family and the broader Indiana community for the loss of a valued member of our medical community on Dec. 20, 2020. I called for an independent review into the care of Dr. Moore, a respected physician, who reported her concerns that racial bias was affecting the care she received at one of our hospitals. An external review panel of six leading national and local healthcare experts was established to examine whether Dr. Moore received appropriate, compassionate and evidence-based care, and whether racial bias was present in the delivery and communication of her care.

After a thorough examination of medical records, interviews with IU Health personnel, and a review of organizational policies and procedures, the external review panel has completed its investigation and concluded that:

  • The medical management and technical care Dr. Moore received at IU Health did not contribute to her untimely death; however, there was a lack of empathy and compassion shown in the delivery of her care.
  • Cultural competence was not practiced by all providers and several caregivers lacked empathy, compassion and awareness of implicit racial bias in the delivery and communication of Dr. Moore’s care.
  • 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.

We owe it to our patients to always show up for them, to treat them with dignity and respect, to appreciate their perspectives, and to validate their feelings when they are in our care. We did not live up to these values with Dr. Moore and acknowledge that we have more to do to become a more diverse, inclusive and anti-racist health system.

We have already begun taking action around recommendations from the external review panel, which fall into two categories: 1) enhancing the delivery of appropriate, compassionate and evidence-based care; and 2) enhancing cultural competency and awareness of implicit racial bias among IU Health personnel.

The first set of recommendations highlights a need for a thorough assessment of IU Health’s systems and structures related to our care models, patient advocacy system, team members reporting and communication methods, including:

  • Improve our 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 our 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.

The second set of recommendations focuses on training, Diversity, Equity & Inclusion education and interactive hands-on learning to improve the cultural competence among our team members, including:

  • 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 healthcare 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.

We appreciate and accept the panel’s recommendations and have started to develop a timeline and accountability structure for this work, which will be grounded in our values and aligned to the DE&I commitments we announced last year. We believe the findings and recommendations of this external review will drive forward a plan of action for IU Health to become a more inclusive, equitable and respectful healthcare system for all. We invite you to track our progress as we publicly report our data and improvement on our website.

Again, we express our sincerest condolences to Dr. Moore’s family, friends and loved ones. We also want to thank the highly qualified external review panel for bringing their experience, expertise and thorough work to the review of Dr. Moore’s case, and for providing recommendations on how IU Health can become a better organization and healthcare provider. We look forward to providing regular updates on our progress and ask for the support of our patients, families, team members, board, partners, local communities and allies in helping to hold us accountable for driving change.”


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