Written by Stephanie Kiser, MD, MPH

I’ve worked in medicine long enough to remember when burnout wasn’t a word clinicians said out loud. You pushed through. You absorbed it. And you suffered in silence.

That silence has cost us. It has cost clinicians their careers, their health, and in too many cases, their lives. It has cost patients, who deserve providers who are present, not just physically, but emotionally and cognitively. And it has cost health systems that are now scrambling to recruit and retain a workforce that is leaving in numbers we’ve never seen before.

Burnout among physicians has reached crisis levels in high-income, middle-income, and low-income countries alike. The drivers in a rural Kenyan clinic differ from those in a tertiary academic medical center in Boston — but the outcome is consistent. Clinicians around the world are depleted, and the systems they work within are struggling to respond in meaningful ways.

The Particular Weight of Serious Illness Care

Burnout is affecting clinicians across all specialties, but there is a disproportionate toll on those who care for patients with serious illness. Oncologists, palliative care physicians, intensivists, geriatricians, nurses in the ICU and the inpatient unit, the clinicians who hold the most difficult conversations and sit with the most profound suffering. This work is both meaningful and relentless in ways that are hard to articulate to anyone who hasn’t done it.

Caring for patients at the end of life, or navigating the long and uncertain arc of serious illness, carries a specific kind of weight. Clinicians in this space absorb grief, repeatedly and often, without adequate space to process it. They navigate family dynamics in crisis. They hold complexity, clinical and emotional and ethical, that rarely resolves cleanly. They are asked to be present with suffering in a way that most professions are not, and they are often doing this while managing clinical documentation, administrative demands, and staffing constraints.

The result is a workforce that is particularly vulnerable to moral distress and compassion fatigue. It isn’t simply that the workload is high, though it often is. It’s that the emotional and ethical demands of the work, when unsupported, accumulate in ways that become unsustainable.

If we are serious about building sustainable care systems for patients with serious illness, we have to be equally serious about building sustainable conditions for the clinicians providing that care. The two are inseparable.

Where Current Interventions Fall Short

For years, the dominant response to burnout has been to ask clinicians to be more resilient: meditate more, set better boundaries, practice gratitude. That framing places the burden squarely on people who are already most depleted. It mistakes a structural problem for a personal one.

Current interventions — mindfulness programs, resilience training, peer support, coaching models, schedule restructuring — show only modest effects because they address the individual without addressing the root cause. They don’t change the system that caused the depletion in the first place. And when something does work in one context, scaling it is nearly impossible. A well-facilitated peer program in a single hospital can be transformative. The same model implemented across three campuses with different cultures, staffing, and constraints often fails.

This is especially acute in serious illness care, where teams are often small, specialized, and already stretched.

The evidence shows that the solution can’t be either-or. Systems need to change, and clinicians need skills and support to navigate those systems while the change happens, which is always slower than we’d like. The challenge is holding both simultaneously.

System-Level Change for System-Level Problems

At Ariadne Labs, we’re exploring what system changes can actually help clinicians in serious illness care sustain their work. And it starts with a concept that’s well-established in some fields but almost absent in medicine: clinical supervision.

Clinical supervision isn’t therapy or performance management. It’s structured, protected time with someone trained to help you process the work itself. This is essential for clinicians in serious illness care who are absorbing suffering repeatedly, who hold complexity that requires space to think through, not just time to push through.

When done well, clinical supervision creates the psychological safety to be honest about what’s hard. It helps clinicians develop moral resilience by processing the weight they’re carrying with someone who understands the work. Over time, it changes how they experience the work and whether they can sustain it.

We’re now exploring and understanding how clinical supervision works in practice for clinicians in serious illness care. We’re asking: how does this support translate into the ability to keep doing this work, not just for a few years but for the length of entire careers?

Toward a Sustainable Future

Clinicians entered this field because they wanted to do something meaningful. The goal isn’t to make them more resilient or better at accepting unsustainable conditions. The goal is to make it possible for them to keep doing this work, for careers that span decades, not just for a few years until the tank runs empty.

That’s not idealism. That’s what good systems design looks like. And it’s what our patients deserve.

Stephanie Kiser, MD, MPH is Clinical Director of the Division of Palliative Care and Geriatric Medicine at Massachusetts General Hospital, Interim Section Head for Palliative Care across Mass General Brigham, and Associate Faculty at Ariadne Labs. Her work focuses on clinician wellbeing, peer coaching, and building sustainable palliative care programs.

By: Ami Karlage and Namita Seth Mohta, MD

Rita didn’t like feeling “sick.” Sure, she had hypertension and diabetes, but she was a capable teacher putting in long days with her students and a busy wife and mom taking care of her family. She sometimes forgot or didn’t have time to take all her medications. Also, Rita hated the way the meds constantly reminded her that she wasn’t 100% healthy. After avoiding it for months, she’d finally made an appointment with her primary care physician (PCP) during her spring break.

A few days before the appointment, she got an email from the PCP’s office:

We’re trying something new, would you like to speak to the AI digital assistant to help prepare your PCP and the office staff for what you want to talk about in the appointment?

Though she was a little dubious about AI (her school kept changing its policies, and she spent quite some time making sure students followed the rules), she agreed to try it.

Unsure what to expect, Rita was surprised when the digital assistant asked about her goals and purpose, about the things that bring meaning and joy to her life, and about her experiences with healthcare in the past. She found herself actually rambling a bit: about teaching and her family, about adding an extra stop in the mornings to treat herself to the good coffee from her favorite cafe, about hating taking so much medication. She wasn’t sure what good it did, but she didn’t mind doing it. The conversation felt natural and leisurely rather than hurried, structured, and focused on what the clinical team wanted to know.

What is Relational Care?

Most patients are like Rita: they’re people with complex, busy lives for whom being a patient takes up only a small part of their time and attention. But too often, the bigger picture of who they are and what matters to them outside of an exam room gets lost. With short appointment times and ever-increasing responsibilities, especially in primary care, care team members rarely have time to get to know their patients the way they want to.

In order to holistically promote patients’ well-being (rather than just treating specific discrete problems), primary care teams must provide relational care.

Relational care means making a patient feel known, understood, and cared for as a person. It means primary care teams and patients working together (mutuality) to set and accomplish a shared purpose, and it requires building a deep trust on both sides of the relationship. Every team member must have a meaningful role in developing and maintaining these relationships each time a person encounters their care team.

Unfortunately, when the system is stacked against patients and care teams, relational care seems impossible, no matter how much patients and clinicians want it. And technology like AI threatens to be one more “layer” between the care team and the patient.

Leveraging Technology to Support Relational Care

At Ariadne Labs, we’re exploring how AI can actually strengthen connections between people in healthcare rather than disrupt them. It sounds paradoxical. How can AI-enabled tools — often criticized for replacing people with technology — actually make health care more relational, more human?

We are designing and testing AI tools for clinical practices to do what AI can do best: listen to patients and summarize, integrate, and present information customized to the care team member’s role. More importantly, we’re figuring out how to design these AI tools to support care team members in doing what they do best: connect with people, explore people’s goals and purpose, and successfully accomplish the tasks they perform and solve the problems they face everyday.

Using AI in this supportive, not displacing, way will improve the patients’ and care teams’ experience, enrich interactions, and give care teams more time to connect with their patients as people, building a strong foundation for relational care. As a first step toward understanding how to make AI tools more supportive and connective, with generous funding from the Healing Works Foundation, we are building a prototype of an AI-enabled digital assistant like the one Rita interacted with.

Forming Deeper Connections

When Rita arrived for her appointment, the receptionist had already seen the output from her conversation with the digital assistant and greeted her by commenting on her week off from teaching. The medical assistant chatted with her while showing her to the exam room and taking Rita’s blood pressure, sharing that her niece attends Rita’s school. She was excited to learn about Rita’s favorite coffee shop in the neighborhood.

When Rita’s PCP arrived, he thanked her for speaking with the digital assistant, saying that he and the staff found it very useful when people took the time to do so. Then, “the digital assistant’s summary mentioned that you dislike taking medications. Can you tell me more about that?” Their conversation covered the difficulties of her schedule (she can’t always take her noon medications because there is some crisis with a student or last minute grading to do) and her dislike of feeling “sick.”

By the end of the conversation, they agreed to streamline her medication: get rid of her lunch dose and combine two of her morning medications into one. Rita was thrilled with the outcome of her appointment and happy to speak to the friendly receptionist about scheduling a follow-up appointment for the summer when she would have more flexibility.

With the right tools, it’s possible to deliver relational care, even in the time- and resource-constrained context of primary care. Ariadne Labs’ prototype focuses on eliciting a person’s story in their own words and translating that story into organized, digestible information customized to each team member’s needs. This information allows each team member (the front desk staff, the medical assistant, the nurse, the primary care physician, and others) to more fully understand and connect to the patient in front of them as they go about their work.

Far from making care cold and distant, this prototype sets up the care team to build better relationships with the people they serve and provide care that sees them as the whole, complex people they are.

This prototype is only the first step in our work. Based on what we learn from testing our prototype, we will develop technical and implementation guidelines for all healthcare systems and IT vendors seeking to use or build AI tools in primary care. The use of AI is already expanding through medicine in many different ways, changing care for patients and care teams. We have an opportunity to ensure that at its core, AI-enabled tools deepen connection and drive stronger relational care for every patient, every time.

Ami Karlage is the Senior Specialist for Writing at Ariadne Labs. As a member of the Science & Technology Platform, she works with program and project teams to strengthen the interpretation and contextualization of scientific results and to improve the scientific manuscripts and knowledge products that result from Ariadne’s work. For more than fourteen years, Ami worked with Dr. Atul Gawande as a Research Assistant, performing background research, fact checking, and editing for his writing projects, and she currently serves as a consultant on complex literature reviews for teams across Ariadne. Using her experience as a teacher, mentor, and tutor, Ami also provides professional development and coaching to staff and faculty around scientific writing, writing for popular audiences, and background research. Ami’s background is in the history of science and medicine, including a B.A. in History and Science from Harvard University.

Namita Seth Mohta, MD, is a physician executive with expertise in health care delivery transformation. At Ariadne Labs, a health system innovation center at the Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Dr Mohta is part of the leadership team for the Navigating Aging and Illness portfolio. She serves as the principal investigator on various research projects related to whole person care, relational care, caregiving, and dementia. Prior to this role, Dr. Mohta served as Director of the Serious Illness Care Program.

At NEJM Catalyst Innovations in Care Delivery, she serves as Executive Editor with responsibility for content strategy and quality and is part of the founding leadership team.

She was part of the founding Population Health and ACO leadership teams as Medical Director at MassGeneral Brigham. Her responsibilities have included designing and implementing value-based care with a focus on scaling tailored clinical interventions and leading systemwide change management. Prior to medical school, Dr. Mohta was an associate with The Boston Consulting Group. Dr. Mohta has worked with multiple digital health start-ups and often consults with organizations to provide strategic and technical expertise and leadership, currently with Ianacare. She practices internal medicine as a hospitalist at the Brigham and Women’s Hospital, where she also completed her internal medicine and primary care training. She is Assistant Professor in the Department of Medicine at Harvard Medical School. Dr Mohta is a graduate of Yale College and Yale School of Medicine.

This blog was originally published by the USAID MOMENTUM Knowledge Accelerator in December 2023

Author: Adam Lindsley, Senior Project Manager, MOMENTUM Knowledge Accelerator

Why is it that up to 60% of innovations introduced in health care are never implemented or cannot be sustained?(1,2,3)

Understanding and including context is key to the success of efforts to adapt and improve health care. With an increase in health care quality improvement (QI) projects globally, consideration of context including hard-to-measure elements such as leadership, staff motivation, and quality improvement experience must not be overlooked.

Dr. Anuradha Pichumani, an obstetrician-gynecologist in Tamil Nadu, India, was determined to understand the unique context of each facility she was supporting with the rollout of the World Health Organization’s (WHO) Safe Childbirth Checklist. Starting in late 2021, Dr. Anuradha led a collaboration among nine hospitals in southern India to scale the Checklist to reduce maternal and neonatal mortality and morbidity. To enable this work, Dr. Anuradha used the Context Assessment Toolkit, a MOMENTUM-revised series of surveys and supportive resources designed to help health care practitioners understand and adjust for the context in which an intervention is implemented. Dr. Anuradha’s experience offers important lessons that can help guide other implementers in successfully assessing the context of their facilities and enhancing their results.

Single Approach Led to Inconsistent Results from WHO’s Safe Childbirth Checklist

The Context Assessment Toolkit was developed by MOMENTUM Knowledge Accelerator (MKA) partner Ariadne Labs after their experience with the WHO Safe Childbirth Checklist during the BetterBirth trial. When the Checklist was introduced in 60 health care facilities in Uttar Pradesh, India using a highly standardized implementation strategy, there was significant variation in uptake by the sites. And when uptake data were examined, there was no single explanation that accounted for the mixed results. Instead, it was found that multiple factors including a lack of provider knowledge and unclear communication among staff were unique contributing factors to the success of the interventions. But had these factors been analyzed and included as part of the initial assessment, implementation strategies could have been adapted to meet facility-specific needs and improve uptake.

Uptake and Revision of the Context Assessment Toolkit Increases Innovation Uptake and Streamlines Resource Use

While administering the Context Assessment Toolkit, Dr. Anuradha and her team conducted 79 interviews and surveys to identify contextual strengths, challenges, and staff/leadership discrepancies in implementation of the Safe Childbirth Checklist. Action plans for each facility were developed that identified steps to build on assessment results. With this context-specific support, the project reported 97% sustainability of the Checklist, a vast improvement from previous uptake.

Experiences like Dr. Anuradha’s provide useful guidance for those seeking to use the Context Assessment Toolkit. In 2021–22 and in collaboration with MOMENTUM Country and Global Leadership (MCGL) in Indonesia and Lifebox’s Clean Cut Program in Ethiopia, MOMENTUM Knowledge Accelerator evaluated the Context Assessment Toolkit for feasibility and acceptability in low-resource environments. The evaluation revealed that participants thought the Context Assessment Toolkit led to productive communication and helped identify potential challenges. As a result of the MOMENTUM-led evaluation, the Toolkit was revised to ease translation into different languages, and to augment resources for results interpretation. Building on MKA’s evaluation, here are some additional learnings for those considering using the Context Assessment Toolkit:

• Leadership matters. In order for an intervention to succeed and sustain, high-level buy-in is needed, not only from the implementer but also from participating facilities. For example, Dr. Anuradha was able to champion using the assessment results for decision making.
• Timing must be considered. To get the most use out of the Toolkit, it should be incorporated early into work plans and given a corresponding budget. Resources and strategic thinking about when to use the Toolkit help maximize its utility. MOMENTUM Country and Global Leadership and Clean Cut started the assessments prior to the start of their intervention, allowing them to change course based on results rather than duplicate efforts.
• “Fit” is critical. “Fit” means that the people conducting the Context Assessment can influence change within the facility and are well-positioned to work on any challenges identified, and that suggested pivots align with the facility’s work at the time.
• Communication strategies. Context Assessment results can often expose uncomfortable interpersonal dynamics that should be communicated delicately. Building on “fit,” Assessment results should be delivered in a collaborative manner by trusted individuals who have strong working relationships with facilities. Dr. Anuradha, leveraging her quality intervention experience, was able to have difficult conversations with facility leaders and staff about improvements needed for the intervention to be effective.

What are the next steps for Context Assessment?

The Context Assessment Toolkit is continually being refined for ease of use and efficacy. It is currently being used in a number of facilities around the globe, which offers ongoing opportunity for improvement.

References

1. Burnes B. Emergent change and planned change — competitors or allies? Int Jrnl of Op & Prod Management 2004;24(9):886–902.
2. Sorensen JL, Hall SM, Loeb P, Allen T, Glaser EM, Greenberg PD. Dissemination of a Job Seekers’ Workshop to drug treatment programs. Behav Ther 1988;19(2):143–55.
3. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q 2013;91(3):459–90.

Change doesn’t come out of nowhere

Authors: Meagan Elam, Mackenzie Stratton, Francine Maloney

A lot goes into getting people the health care they need. There are the people providing care, the processes they follow, the physical spaces they work in, the digital tools they use, and more. This web of people, things, and systems creates context.

At Ariadne Labs, it’s our job to think about context. We work to improve the health care system by helping health care organizations make practical, positive changes. To do this, we help organizations understand their unique context, which includes factors like:

• How well different team members work together
• How committed and motivated staff and leaders are to making change
• How supplies, equipment, and data are integrated into the process of providing care
• Whether change is possible with current staff conditions

Imagine you work at a hospital. You read about the U.S. maternal mortality crisis, and you want to start a program to make childbirth safe, respectful, and empowering. It will involve new tools and procedure changes to give the patient more of a voice in their care. The program has a lot of potential to make a positive impact, but context will influence whether it reaches that potential.

• Do people think there’s a problem that requires change?
• Do people think the program is a helpful way to address the problem?
• Is the program something people can adapt into their day-to-day work?
• Does the hospital’s culture make it safe for everyone to speak up?
• Is the hospital committed to supporting the program long-term? (yes, this means money)

Asking all these questions — and they’re hard questions — will help you make a game plan. You might need data to make the case that there is a problem. You might need to adjust hiring and schedules so people have the capacity to make changes. Then, as you start the program, you can keep asking these questions to figure out how things are working.

By considering the whole system and its context, you can figure out how to introduce the right change at the right time in the right way.

Meagan Elam, DrPH, MS, Senior Clinical Implementation Specialist and Francine Maloney, MPH co-lead the Atlas Initiative at Ariadne Labs. The Atlas Initiative uses context assessment to help health care facilities of all types implement successful quality improvement projects.

Interested in bringing context assessment to your health facility? The Atlas Toolkit can help.

By: Justin Sanders and Catherine Schofield

Racial disparities in health care begin before birth and are compounded by inequitable care across the lifespan. Upon facing serious illness and the end of life, people of color and others from marginalized communities already have significant mistrust in the health care system. Patients’ racialized experiences in health care, due to systemic factors or real or perceived bias and discrimination, can erode trust and infiltrate clinical encounters.

Mr. Jones* was a Black man in his mid-forties with multiple complications of late onset type I diabetes. In the years since his diagnosis, his heart had begun to fail, and nerve damage throughout his body left him with numbness, tingling, and pain that made every day difficult. Like too many others, he had severe asthma from living in a neighborhood colored by past redlining and present pollution. These conditions meant that, despite his young age, he was at high risk of dying.

Advance care planning was an essential task, and yet his primary care doctor (an author of this post) struggled to engage him in discussions about the future, specifically about what treatments might not help him. It always felt like the system (and the doctor as its representative) was trying to do one more thing to take something away from him. In the face of significant challenges, I observed how much his family had to fight for access to every treatment that he had received. He died in intensive care, pneumonia wreaking havoc on his asthma-weakened lungs. After his death his family and I regretted not having a chance to talk about what he’d want when he became critically ill. In light of all his experiences, it felt like a bridge that couldn’t be crossed.

When caring for patients of color, how can clinicians integrate an understanding of patients’ past experiences of racism to improve their experience of care? What words and behaviors might build trust and relationships rather than reinforce patterns of interaction that tend to do the opposite?

The Healing Potential of Race Dialogues

Race dialogues are conversations about race and racism among individuals holding different racial identities. They have been used in education and psychotherapy spaces to foster positive relationships. In health care settings, these conversations have the potential to cultivate meaningful, authentic healing relationships between patients of color and their clinicians. Such dialogues can support participants in exploring social identities and experiences relative to other people, which could translate into greater empathy, understanding, and anti-racist dialogues and action.

Introducing these conversations in clinical spaces has the potential to improve health care experiences and outcomes for people of color. Building stronger clinician-patient relationships can lead to higher-quality care and encourage engagement in important processes, such as advance care planning to prepare for their future with a serious illness.

Engaging in Difficult Conversations

Ariadne Labs’ Serious Illness Care Program developed the Serious Illness Conversation Guide, to help clinicians navigate difficult conversations with patients about their goals, values and priorities to inform their future care. With the vision of every patient affected by serious illness feeling known and cared for on their own terms, the Guide provides clinicians with structure and language to learn and honor what matters most to patients. Building on this idea and recognizing the way in which people’s experience of racism can undermine trust, we recently sought to develop a tool to support clinicians in having race dialogues with their patients.

Designing and Iterating a Tool Prototype

To co-design a tool prototype, our research team brought together Black patients, White clinicians, patient advocates, and an interprofessional, racially diverse advisory board.

Interviews with clinicians and patients revealed perceived or anticipated challenges and benefits in having these conversations. Patients and caregivers affected by serious illness who identified as Black or African-American shared stories of overt and subtle experiences of racism in health care settings. Their remarks expressed hopes for high quality and equitable health care in the context of caring interactions with clinicians. White physicians experienced in treating patients affected by serious illness revealed their worries about ‘getting it wrong’ or disrupting relationships by addressing racism. They also demonstrated curiosity and willingness to learn how to have these conversations as a way of improving health equity.

Using interview data and advisory board input, as well as human-centered design principles we developed a conversational tool prototype to promote race dialogues. After several cycles of iteration and improvement, we put our early prototype in front of patients and caregivers. We partnered with the Patient Insight Institute through the National Patient Advocate Foundation to recruit and interview 15 patients and caregivers, predominantly identifying as Black, with personal or family experience of serious illness. Their feedback informed a final prototype.

Talking about Racism to Advance Care Equity: The TRACE Tool

The Talking about Racism to Advance Care Equity (TRACE) tool offers clinicians structure and patient-tested language to support race dialogues in health care settings. Beyond the tool’s potential utility in supporting advance care planning, we anticipate the tool enhancing care at other critical moments in health care when experiences of racism may impact decision making and care, such as maternity or surgical care. Tracing patients’ experiences in the health care system and bringing them into the open can be therapeutic and cultivate compassion.

The tool is organized into three parts:

Reflection: Clinicians are encouraged to reflect upon a patient’s past health care experiences and the role that racism may have played in shaping them.

Action: Clinicians are given language to normalize the conversation and to invite patients to share their experiences.

Compassion: Provides language to acknowledge these experiences and affirm a commitment to providing the best possible care.

To educate clinicians about the tool, we developed an illustrative whiteboard video. We acknowledge the importance of training clinicians in how to facilitate these race dialogue conversations so they can be carried out skillfully and meaningfully and not cause further harm.

Next Steps

Before moving forward with dissemination and implementation of the TRACE tool in health systems, we are currently seeking funding to support its further testing in real world situations. Many questions remain about whether and how to integrate such a tool to meet its intended aims within the realities of clinical practice.

Other Initiatives Promoting Equitable Care

Our team is not alone in innovating to advance care equity through enhanced, high quality patient-clinician communication. At Stanford University, the Presence 5 team for racial justice offers recommendations to improve clinical communication and empower Black patients as they navigate getting care. They are working to develop medical education curriculum and piloting with patients and community partners. They are also exploring adaptations in pediatric settings and evaluating an allyship training program to support academic physicians of color.

For clinicians who want to address racism with their patients and improve health equity and outcomes, but struggle to find the words to do so, new communication tools offer innovative solutions. In a world in which racism has remarkable public health consequences, we are hopeful about the role that authentic, meaningful, compassionate relationships between clinicians and patients can play in healing. We hope to share more evidence about the benefit of the TRACE tool in the months and years to come.

*Not the patient’s real name to protect identity

By Oloruntobi Dare

Across many industries, the question of how to design tools and products people will want and use is critical. While a product might sound helpful in theory, if it’s too difficult to use, too expensive, or requires too much time and effort to start using, it’s unlikely to be widely adopted.

Solutions in public health and health care are no exception. While things like follow-up appointments after concerning test results or open communication among care teams during labor and delivery may seem simple, putting systems in place to ensure those things happen is more complicated.

To solve this problem, involving end-users of the tool or product from the beginning of the design process is critical. Through a process known as human-centered design, product designers can put the needs, wants, and behaviors of people at the center of the design process. This process is further strengthened when the tool or product’s intended end-users can co-design the solution, whether by giving guidance as subject matter experts, through interviews and focus groups, or as patient advisors.

So, what does co-design look like? At Ariadne Labs, a joint center for health system innovation at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, we apply human-centered design to our work to design, test, and spread solutions to some of health care’s most pressing issues. Since 2012, Ariadne Labs has been able to to develop and disseminate hundreds of tools and solutions, touching more than 97 million lives around the world in 2022 alone. We’ll look at a few examples of how co-design has played a role across Ariadne Labs’ work.

Convening an Expert Advisory Board to Support Conversations about Racism in Health Care

According to a survey study by the Pew Research Center, when asked about their own health care experiences, 56% of Black Americans said they’ve had at least one of several negative experiences, including having to speak up to get the proper care and being treated with less respect than other patients.

Ariadne Labs’ Serious Illness Care Program launched the Race Dialogues project to explore an evidence-informed approach to talking about racism in health care settings, particularly for people affected by serious illness. Their goal is to develop and pilot a novel tool to promote authentic healing relationships and address inequities in health care experiences that result from poor clinician-patient communication with people affected by both racism and serious illness.

Co-design plays a critical role in this project by sourcing perspectives from a broad range of stakeholders at an early stage. Thus far, the project team has conducted individual interviews with white clinicians, completed five focus groups of patients and clinicians, and convened an interdisciplinary advisory board with varied backgrounds in social work, religious leadership, psychology, geriatric medicine, and more. The ethnic identities represented on the boards include Native Americans, Asian, and Latino Americans, and there are plans to keep them engaged and involved as the project progresses. Though the project is in its early stages, assembling these participants is informing the creation of specific tools and language for clinicians to have conversations about race and promote understanding. The diverse perspectives represented provide the team with context of how to design race dialogue tools such as conversation guides and trainings.

Partnering with Patient and Family Advisors to Improve Cancer Screening

Currently in its 18-month pilot phase, the Ambulatory Safety Net Collaborative project team continues to partner with patients and families through their engagement. Ambulatory Safety Nets are person-centered programs that provide a backup system for following up on abnormal test results when the standard follow-up process fails. When successful, safety nets offer a reliable and effective approach to connecting patients to the right care at the right time. Before launching this pilot, the team at Ariadne Labs took the time to understand why medical errors happen, and they found that communication failures were a big part of the problem. That’s why it was only fitting that the team co-created with key stakeholders, including patients, families, and hospital leadership.

The team authored a Patient Safety Adoption Framework, with contributions from a diverse group of patient and family advisors to make the program with vulnerable populations in mind and account for differences in cultural context and potential barriers in the development and implementation phase. For example, patients face barriers in health literacy, access to services, and mistrust in the health care system. In the context of the Safety Net, the participating clinical sites are encouraged to document health equity metrics to see if a population is overrepresented, which may signal issues with contacting, scheduling, and completion. Patient level barriers such as insurance plans and personal scheduling issues are other factors that trained patient navigators take note of during outreach.

When these equity metrics are reviewed monthly, sites can use the data to make steps forward to determine where in the process the breakdown is occurring and work to ensure patients receive the appropriate follow-up care within an acceptable timeframe. Patient and Family Advisors continue to stay involved in the initiative through in-person learning sessions and facilitate discussions on how to handle challenging patient conversations and closure criteria. The Framework informed the Ambulatory Safety Net Implementation Guide, which is being used by seven health systems in the Boston area since 2022. Programs at these health systems have identified patients who are currently receiving follow-ups for colorectal cancer and behavioral health.

Conducting Interviews and Focus Groups to Improve Communication and Teamwork in Childbirth

TeamBirth is a process innovation to improve communication and teamwork in childbirth pioneered by Ariadne Labs’ Delivery Decision Initiative (DDI). TeamBirth ensures people giving birth and the clinicians who are caring for them have shared input and understanding into decisions during and after labor and delivery. TeamBirth has been adopted in close to 90 hospitals across the U.S.

The success of TeamBirth stems from its thoughtful design and testing process, which incorporated numerous stakeholders. To understand the acceptability and feasibility of TeamBirth, the team conducted in-depth, semi-structured interviews of 103 (58 nurses, 37 obstetricians, and 8 midwives) clinicians and 16 focus group discussions with 52 implementers between June 2018 and October 2019. The clinicians also came from diverse facilities like midwifery care, hospitalist care, and private practice, which brought in a unique perspective for the design for scalability early in the development of our solution. Prototypes representing the “minimum viable product” of TeamBirth materials were developed and refined based on the feedback from the aforementioned diverse clinician group, to show that the initiative could work across multiple contexts and clinical care environments.

Conclusion

Why is it crucial to include patients, family advisors, and other stakeholders in the design process of public health interventions? It’s because when we work together, we can create interventions that are tailored to meet the needs and preferences of the people who will actually use them. When patients and health care providers collaborate, it builds trust and engagement, which leads to better health outcomes and overall satisfaction with care. The result? Uptake is increased, new knowledge is discovered, approaches are refined, disparities are addressed, and more innovative solutions and well-informed products ultimately improve patient safety and the overall patient experience.

Oloruntobi Dare, MPH, is a public health technical professional who previously served as an Implementation Specialist at Ariadne Labs. Currently, she holds the role of Consultant for the Veterans Health Administration (VHA), contributing her M&E expertise to enhance healthcare initiatives.

By Catherine Givens, LICSW, ACHP-SW

Teresa, a hospital social worker, was dismayed. “Even though we planned for it, I don’t think I can have that Serious Illness Conversation with my patient, Marcella*,” she told her supervisor. The attending physician had made it clear that the social worker shouldn’t talk with Marcella or her family about health-related goals and priorities, even though Marcella was seriously ill; he even seemed to suggest that the social worker should “stay in her lane.”

“He suggested that I complete a Health Care Proxy with Marcella instead,” Teresa said.

The situation was not only distressing for Teresa as a member of the interprofessional care team, but she also believed it was not in her patient’s best interest to place limits on the patient’s right to explore goals and preferences. Rather than “staying in their lane,” social workers can and should play a major role in serious illness conversations so that patients and families are more likely to experience patient-centered and goal-concordant care and social workers can effectively communicate influencing factors to the providers working on the case.

This approach has long been part of Ariadne Labs’ Serious Illness Care Program. The lab has hosted multiple trainings around the U.S. for a broad range of health care professionals on how to use the lab’s landmark Serious Illness Conversation Guide to ensure seriously ill patients communicate their preferences, priorities, and goals to facilitate shared decision-making. The Guide, a structured communication tool based on best practices in person-centered communication, has been used for training more than 121,000 clinicians nationally and globally.

The Guide is designed to be used by all members of the interprofessional care team. From June 13 to 14, 2023, Ariadne Labs will host a virtual summit on “Driving Equity in Serious Illness Communication and Care” that will bring together a community of serious illness care practitioners.

Social workers are key members of that community. In fact, many of the skills that are prioritized in social work education and training are the very skills essential to sound and effective palliative care practice.

Social Work Skills and Strengths in Serious Illness Communication and Care

Social workers usually develop trust with both the patient and family, friends, or loved ones, and are skilled in supporting patients’ articulated goals and preferences. They may be able to ease unnecessary tension between the family and members of the care teams. Social workers often have a solid knowledge of community resources, as well as behavioral health diagnostic and intervention skills. They are able to identify cultural, ethnic, and spiritual factors that influence patients’ experiences and abilities to take full advantage of treatment plans available to them. Importantly, social workers are adept at interpreting the relationship between many psychosocial factors and medical decisions that influence patients’ outcomes regarding client-driven care and the commitment to goal-concordant care.

Yet there remain significant misunderstandings about social workers’ skill sets, and there are barriers to optimizing their roles in interprofessional, team-based serious illness communication, both early in an illness trajectory as well as at the end-of-life.

For example, in the scenario described above, the attending physician mistakenly assumed that Teresa was planning to talk with their patient about a change in the care plan, possibly even suggesting a transition to comfort care, whereas Teresa’s hope was to engage Marcella and her family in an exploration of Marcella’s goals and preference as her illness trajectory continued to decline. This misunderstanding of the social work perspective led the physician to suggest Teresa “stay in her lane” and help the patient complete a Health Care Proxy.

The irony in this suggestion cannot be overlooked. While many medical providers see the completion of a Health Care Proxy as merely “administrative paperwork,” for social workers, it is also an opportunity to explore hopes and worries in the context of future medical decisions before such decisions need to be made. Some of the richest information available to the interprofessional team comes from these social work-led discussions with patients, often when there is nothing immediately riding on the conversation other than the sharing of goals and worries.

Beyond the completion of the Health Care Proxy, the social worker is able to engage their patients in the exploration of their preferences and worries before their health trajectory worsens. Either conjointly with other team members, or alone with their patients, the social worker can assess the patients’ illness understanding, prognostic awareness, and their information preferences.

Social workers prioritize cultural humility when working with their patients and support persons, assessing the impact of the patients’ cultural, racial, ethnic, and spiritual alignment on their experiences moving forward. So often, medical providers do not have the information that can profoundly impact the success of the treatment plan because they do not understand the effect of culture, race, ethnicity, or religion/spirituality on the patient’s and family’s experiences and motives.

A clear example of this is demonstrated during a subsequent conversation between the social worker, Teresa, her patient Marcella, and Marcella’s family. With Marcella nearing the end of life, the team broached the subject of hospice; in response, the family recoiled, saying, “When someone goes on hospice, they always die.” One family member said, “I heard that they give them extra pain medication to hasten their death. That happened to our aunt when she had cancer.”

The social worker explained that this was more a matter of the patient’s imminent death, regardless of hospice support or not. One of the family members asked, “But what if she gets better?” as they worried that hospice would just “let her die anyway.” Teresa responded, “Then we will have a huge party to celebrate.”

Through the building of trust, the family became more open to transitioning to hospice. With the help of the social worker, the team was also able to come to see the impact of historical racism on Marcella and her family’s views on hospice and was better able to approach the family’s reluctance with understanding and reassurance. Ultimately the family agreed to hospice and their mother was able to die at home, which was her hope.

Thus, a crucial role for a social worker is communication with the medical team. The social worker can provide context for a patient’s preferences, helping interprofessional team members understand why the patient may decide on one course of treatment versus another, or why a family member may have expressed resistance to a certain proposed course of action. This can reduce tension between the family and members of the care team.

Using the Serious Illness Conversation Guide in Social Work Practice

Social workers can and should use Ariadne Labs’ Serious Illness Conversation Guide, and health systems should be open to training in the use of the guide for interprofessional teams that include physicians, nurses, social workers and other clinical staff.

While it is out of the social worker’s scope of practice to provide time-based prognostic information, a social worker may express feelings of uncertainty about a patient’s future, perhaps saying, “While I hope that this isn’t the case, it is hard to predict when another significant medical crisis might occur.” This is often referred to as anticipatory guidance, helping the patient and/or loved ones think ahead and develop Plan B and perhaps even Plan C in preparation should Plan A not go as intended. In situations where a patient and/or support person asks a direct question about a time-based prognosis, the social worker is able to provide reassurance that the medical team can be consulted and the social worker can request that the team returns to the patient with more detailed information.

When exploring patients’ goals, values and priorities, social workers are especially attuned to the psychosocial factors that frequently impact their treatment decisions and the ways they, themselves, can and do communicate such significant information to their interprofessional colleagues. Relying on the skills that are at the foundation of their practice, social workers can ensure that patients and families are far more likely to experience supportive, client-centered, and goal-concordant care, and their interprofessional colleagues will engage in effective communication in treating and interacting with serious illnesses.

Catherine Givens, LICSW, currently works at Brigham and Women’s Hospital in Boston as a Social Work Manager and the Manager for Social Work Education and Professional Development. She has been practicing palliative care for more than 15 years, including training interprofessional medical providers in using Ariadne Labs’ Serious Illness Conversation Guide for nearly nine years.

During the June 13–14th, 2023 Serious Illness Care Program Summit on Driving Equity in Serious Illness Communication and Care, Catherine will be speaking on “Collaborative Conversations: Can Teamwork Really Make the Dream Work?” Register for the CME-eligible virtual Summit to hear from Catherine and our exciting line-up of speakers.

*Note: All patient scenarios are fictionalized. While based on real-life situations, they do not reflect the care of any specific patient.

By Anupama Murthy, MD; Mary Brindle, MD, MPH; Alex B. Haynes, MD, MPH; and George Molina, MD, MPH

Twelve years ago, the World Health Organization’s Surgical Safety Checklist was introduced in a publication in The New England Journal of Medicine, sparking a worldwide movement to improve the culture of surgical safety. A major study in Scotland subsequently indicated that the use of a checklist significantly improved outcomes after surgery.

Not all studies, however, paint such a positive picture. A study in Ontario, Canada, found that implementation of the Surgical Safety Checklist was not associated with significant improvements in surgical outcomes. Moreover, its impact fluctuates among high and low-resource settings.

What explains these differences? Answering this question may help us identify effective Checklist implementation strategies and pinpoint how the Checklist can have a more effective impact on surgical outcomes, particularly in low-resource settings. We explore examples of how the Checklist has been modified and implemented in different settings, analyze what led to successes and failures, and offer recommendations on how it can be more effectively implemented.

History of the Checklist

The WHO Surgical Safety Checklist, a 19-item list of prompts divided into three critical pause points, was created to prevent “never-events” (mistakes that should never happen in surgery), to promote safe administration of anesthesia, reduce surgical site infections, and improve teamwork and communication in the operating room. A decade after its launch, facilities in 70% of the world’s countries attested to using the Checklist, according to the report “Checking in on the Checklist,” released in January 2020.

Yet the Checklist is not routinely used in many operating rooms, particularly in low-resource settings. In 2016, the GlobalSurg Collaborative reported that countries with a low human development index had a mean unadjusted rate of checklist use of 35.9% compared to 64.6%, 91.2%, and 88.5% for countries with a medium, high, or very high human development index, respectively.

Furthermore, often when it is used, compliance and fidelity, and specifically to all of the Checklist components, are variable and frequently low. Therefore, effective implementation should not only center on making sure the Checklist is being used, but that it is being used with a focus on compliance with process measures and conversation prompts that are included.

The Checklist is not meant to be a rigid document; rather it is encouraged that systems adapt it according to their needs. Even the process of adapting the Checklist allows health care providers to recognize and potentially address the obstacles to safe surgery that are unique to that hospital system. Adaption, however, can produce challenges. For example, it can become considerably longer even to the point of being burdensome to the teams using it. A study of 155 checklists found that while several items from the original WHO Checklist were removed, most of the checklists grew in length.

More troubling, is how many systems removed checklist sections related to teamwork and communication. This finding is unfortunate since these “conversation prompts” may provide the greatest value of the Checklist in improving team function and culture of safety.

Effective Ways to Implement the Checklist

Effective implementation should not only center on making sure the Checklist is being used, but that it is being used effectively. For example:

• Checklist implementation programs should engage all stakeholders including not just the checklist users but also hospital leadership.
• Local Checklist champions can play a key role.
• Early in the pilot period, infrastructure or resource barriers to adoption should be identified; this is particularly important in low- and middle-income countries.
• Customize the Checklist to fit local context, culture, workflow, and needs. A non-tailored checklist may not reflect the local context and needs. Do this before a larger rollout is undertaken.
• Use a multidisciplinary training approach.
• Include regular feedback after implementation.

Even with attention to these processes, a lack of resources may pose barriers. A 2014 study in the Democratic Republic of Congo found that participants in the operating rooms or recovery rooms lacked pulse oximeters, a critical requirement for surgical safety emphasized in the Checklist; and nurses did not have training in how to count needles, surgical instruments, and sponges. Lack of essential technology and baseline training in quality and safety measures in the operating room may complicate effective implementation of the Checklist.

Mandated Versus Voluntary Checklists

While some Checklist adopters have opted for a voluntary implementation approach, others have used mandates and have tied reimbursement to compliance. A study in Ontario, Canada, in 2010 of systems where the Checklist was mandated found little evidence that these hospitals engaged in a robust implementation strategy that included tailoring the Checklist for the needs of their institution. Rather 90% just used the unaltered WHO Checklist or the Canadian Patient Institute version. Despite hospitals reporting high rates of Checklist compliance the mandate was not associated with reductions in adjusted operative mortality, surgical complications, postoperative emergency department visits, or postoperative hospital readmissions 30 days after discharge.

By contrast a study of voluntary Checklist implementation in South Carolina found that after implementation of the Checklist, the 14 out of 58 hospitals involved were associated with a 21.9% relative reduction in postoperative mortality compared to the ones that did not. Although these 14 hospitals only represented 24.1% of the hospitals included in the study, they performed about 40% of the operations included in the pre- and post-implementation analysis.

Thus, a quality improvement program mandated by regulatory authorities might not have the same grassroots buy-in and support as a program that is led and implemented by front-line healthcare providers who have support from leadership.

Best Strategy for Implementation

Implementation must be a dedicated strategy with buy-in and support from an institution’s clinicians and stakeholders, highlighting their readiness to commit to patient safety. Implementation is most effective when it involves local checklist champions, checklist customization and/or adaptation to meet local needs and workflow, and team trainings and simulations before a larger rollout is undertaken. A dedicated training period can build a sense of community and promote sustainable compliance with the checklist.

Through a comprehensive and flexible implementation model, the promise of the Surgical Safety Checklist can be achieved, leading to better outcomes for surgery patients in all socioeconomic strata and geographic locations.

Now, 12 years after the introduction of the Surgical Safety Checklist, it is essential that we focus on effective implementation strategies that strengthen how teams use the Checklist.

Mary Brindle, MD, MPH, a pediatric surgeon and health systems researcher, is the Director of the Safe Surgery Safe Systems Program at Ariadne Labs.

Alex B. Haynes, MD, MPH, is Associate Professor and Associate Chair for Investigation and Discovery at the Department of Surgery and Perioperative Care, Dell Medical School / University of Texas at Austin.

George Molina, MD, MPH, Core Faculty for Safe Surgery/Safe Systems at Ariadne Labs and a surgeon at the Department of Surgery at Brigham and Women’s Hospital in the Division of Surgical Oncology.

Anupama Murthy, MD, is a general surgery resident at Montefiore Medical Center / Albert Einstein College of Medicine in New York.

By Stephanie Schorow for the Global Mass Vaccination Site Collaborative

Barely a year ago, the first vaccines against COVID-19 rolled out, raising hopes and posing challenges for efforts to halt the spread of the pandemic. To say it’s been a rollercoaster for vaccination professionals would be putting it mildly. Yet the scramble to get shots into arms in diverse populations around the world has produced insights and learnings that will inform vaccination efforts in the coming decades.

The final May 13, 2022, online meeting of the Global Mass Vaccination Site Collaboration, an initiative by Ariadne Labs and the Sabin Vaccine Institute’s Boost Community, focused on “Best Practices, Lessons Learned, and the Path Forward” in the continuing push to support and promote COVID-19 vaccinations worldwide. The lively, highly interactive meeting attracted more than 60 representatives from around the globe including from India, Afghanistan, Nigeria, Israel, Kenya, Democratic Republic of the Congo, the Philippines, and the United States.

Posing the first question to three panelists was Eric Goralnick, MD, MS, Principal Investigator of the collaborative and Associate Faculty at Ariadne Labs. He asked: “Mass vaccination sites have played a critical role in COVID-19 vaccine delivery strategies. What are some of the major successes we’ve seen in this time? What best practices stick out to you?”

Responding first was panelist Anna Rapp, Senior Program Officer, Bill & Melinda Gates Foundation, who praised the rapid set up, globally and locally, of vaccination efforts. “That has meant a mobilization of all kinds of resources: robust planning, staffing, funding, sometimes in modalities never had been used before …That galvanization has been a tremendous success,” she said.

In 2021, more than a billion doses were distributed in low-income countries. Sites have been able to pull in large swaths of the population that had never been a focus for vaccination as well as general health services.

However, mass vaccination sites “are not a long-term delivery strategy,” said Vidya Sampath, Director and Team Lead, Data Analytics, VillageReach, which creates people-centered health solutions that improve equity and access to care. “They have a very specific moment in time when they can be effective and that is related to demand for vaccines.” Unlike campaigns that seek out people, these sites are for those who want the vaccines and who are coming to get them, thus it should be clear when and where to go.

Sampath’s other points include a recommendation for conducting exit surveys that “ask specific questions of how the community is feeling that day.” Using that data, VillageReach has been able to tweak its strategies, she said.

Mass sites are “very good for urban, highly populated areas,” said Imran Mirza, Health Specialist, UNICEF. “We don’t need a 5-star vaccination site. We need a site where people can come, they don’t have to pay, they don’t have to face any problems. They get the vaccine and they go home.”

Rapp addressed some of the gaps remaining, particularly the decreased sense of urgency. “We are far from done with this pandemic unfortunately,” she said. “One of things that is concerning me is a loss of momentum, especially as restrictions are easing and there is an eagerness in all countries, but particularly in high-income settings, to be past the end of the pandemic. There needs to be attention to reach everyone who needs a vaccine.”

COVID-19 fatigue is setting in across so many domains, Goralnick agreed.

Vaccination needs to be as convenient as possible, panelists said. “We have shifted from a deep constraint of vaccine supply to really having an ample vaccine supply at a global level, but we are not reaching local and global targets,” Rapp said. Mirza noted that about 30 counties have less than 20 percent of their population fully vaccinated.

Sampath said that VillageReach has found that the truly vaccine hesitant are just a small minority. “Large swaths of the community are generally supportive of vaccines and they trust the process.” The solution is to double down on access and communication.

“Our clear message is to leverage our mission and advance it, not just for COVID-19 but other vaccination efforts,” said Goralnick.

Key Takeaways

• Establish collaborations to share what works and what doesn’t.
• Supply and demand will fluctuate, so vaccine strategies must be nimble.
• Bi-directional learning can provide insight. “Practices in low and middle income countries are influencing what is happening in high income countries and vice versa,” Rapp said.
• Cross-sharing partnerships are vital for keeping costs down, particularly in set-up, staffing and maintenance costs.
• Mass vaccination sites are not standalone concepts; they need to work in tandem with all other delivery points in a locality. Think in terms of a “suite” of interventions.

The Global Mass Vaccination Site Collaborative was launched as a way for stakeholders directing vaccination campaigns around the world to come together and learn from each other’s efforts. This blog series was created to record and share the learning and insights gained from this collaboration. Read blogs from our previous meetings here.

By Stephanie Schorow for the Global Mass Vaccination Site Collaborative

March 11, 2022

The need for COVID-19 vaccinations is universal, but ways of effectively administering those vaccines can vary dramatically from country to country.

In Brazil, for example, the population is accustomed to mass vaccination campaigns and generally feels comfortable going to mass vaccination sites. In Haiti, many people are leery of the COVID-19 vaccine and need privacy to get their shots. In India, mobile vaccination units that can travel into the countryside proved essential for reaching the population.

These were among the lessons that nonprofit Community Organized Relief Effort (CORE) learned as they launched efforts with partners to get shots in as many arms as possible as quickly as possible once the vaccines were released.

“The process of CORE is to explore where are the gaps in the community and how we can best serve (to fill) those gaps,” said Matthew McCoy, a health science specialist and a program manager at CORE, during a March 11, 2022, presentation to the Global Mass Vaccination Site Collaboration, an initiative by Ariadne Labs and the Sabin Vaccine Institute’s Boost Community.

McCoy outlined the similarities and dissimilarities in CORE’s COVID-19 vaccination efforts in Haiti, Brazil, India, and the United States.

CORE began promoting testing in the early days of the pandemic in Haiti. This work eventually shifted to vaccination, but many of the lessons of organization and outreach still applied. As in all of its work, CORE seeks to partner with local institutions, and this ranged from partnering with fire-fighting departments in Los Angeles to public health centers in Brazil.

McCoy said mass vaccination sites proved to be very important in Rio de Janeiro

Brazil, which has a history of large vaccine campaigns. Establishing mass vaccination sites allowed local health clinics to maintain their focus on other health and medical issues. “We built a mass vaccination center next to a local clinic and that really helped,” he said.

Since many Rio residents commute long distances for work, mass sites were more effective than mobile sites because so many residents were not home during the day.

In India, at first vaccines could only be administered at hospitals, which proved to be a barrier for many residents. When this rule changed, CORE was able to organize mobile units that could reach directly to those who had concerns or hesitancy.

The infrastructure in Haiti remains very weakened by earthquakes and political unrest, and CORE found Haitians hesitant about getting vaccines in public. The use of screens and one-on-one consultation made the vaccination process more intimate and thus more acceptable.

McCoy’s March 11 presentation produced a host of questions and comments from participants who checked in from various places around the globe.

“I’m interested in your comment about Brazil’s history of mass vaccination campaigns leading to less vaccine hesitancy. What can we learn from this history to help with hesitancy challenges elsewhere and drive demand?” was one question.

“That’s not to say there is no hesitancy in Brazil. You’re going to encounter hesitancy everywhere,” McCoy responded. But through Brazil’s universal health care system, traditional vaccines are free and accessible. Everyone (gets shots) from children to adults — this creates a culture where you get your shot and you don’t really think about it.”

Key takeaways:

• Know the local culture when creating a vaccine campaign.
• Build knowledge and trust by working with local partners.
• Stay flexible. One day only a few will show up for shots; the next day the line will go out the door.
• Learn from doing. CORE experienced some trial and effort moments.
• Proximity is important — try to provide vaccinations where the public is likely to be, either a home or in a center like a soccer stadium.
• Health professionals may need training in administering vaccines; not all EMTs, for example, know how to give shots.

The Global Mass Vaccination Site Collaborative was launched as a way for stakeholders directing vaccination campaigns around the world to come together and learn from each other’s efforts. This blog series was created to record and share the learning and insights gained from this collaboration. Read blogs from our previous meetings here.