Hi, my name is Dr. Jacqueline Moss Feldman, and it's my privilege and honor to be facilitating today's session. In response to a reinvigorated national dialogue around structural racism, the American Association for Community Psychiatry, or AACP, aimed to create a tool or a roadmap for community behavioral health providers that would, one, provide metrics specific to disparity and inequity issues in community behavioral health, two, extend beyond cultural competency and linguistic appropriateness to incorporate structural inequity, and three, promote a stepwise quality improvement process that could be adapted for self-directed use in community behavioral health settings. This session today will introduce the Self-Assessment for Modification of Anti-Racism tool, otherwise known as SMART, a quality improvement tool that aims to meet the AACP's need in facilitating organizational change in community behavioral health care. In this session, attendees will review previously described health inequity frameworks highlighting their strengths and their limitations as it relates to addressing structural racism in community behavioral health practice. Our speakers will then introduce the key components of the SMART, describing the process and developing this organizational tool based on key inequity issues that are most relevant to community mental health practice. Lastly, they'll use a case example to illustrate the process for using the SMART and describe future directions for piloting this framework. Let me briefly introduce this very fine panel. Our first speaker today is Rachel Melissa Talley, M.D. She's an Assistant Professor of Clinical Psychiatry at the University of Pennsylvania, where she directs the Fellowship in Community Psychiatry. She works clinically in community psychiatry as a staff attending at Horizon House, Inc. Dr. Talley received her B.A. from Harvard, her M.D. from Stanford, and completed both her adult residency training and public psychiatry fellowship at Columbia University New York State Psychiatric Institute. She's an Early Career Psychiatrist Board Representative for the AACP. Our second speaker is my dear friend Ken Minkoff. He's a Board Certified Psychiatrist with a Certificate of Additional Qualifications in Addiction Psychiatry, a dedicated community psychiatrist who serves currently as a Clinical Assistant Professor of Psychiatry at Harvard Medical School, and is a Senior System Consultant for Zia Partners, who provides support and consultation on the development and maintenance of recovery-oriented mental health services literally across the globe. And our last speaker is Dr. Sosin Molu-Shoyinka, who serves as the Chief Medical Officer for the Department of Behavioral Health for the City of Philadelphia, excuse me, the Department of Behavioral Health and Intellectual Disability Services. Prior to this, he served as Medical Director for the Home, State, and Sunflower Health Plans and is Director for the Missouri Behavioral Pharmacy Management Program. He's Triple Board Certified and holds an MBA from Kelly Business School. He teaches at the University of Pennsylvania, serves on the Board of American Association of Community Psychiatry, and has been recognized as a Black Leader Shaping the Future of Psychiatry. It's my pleasure to now have us move forward with this incredibly important session. Rachel? All right, well, thank you so much, Jackie, for that introduction, and it is such a pleasure to be here today to discuss this tool. I think the only things I'll add as far as myself and the background that I bring to this as far as my passion for this topic is that, of course, as a Black female psychiatrist myself, this is a topic that is near and dear to my heart as far as what I consider important in mental health practice. And secondly, as somebody who is primarily on the front lines, I direct a community psychiatry fellowship, but I spend most of my week working frontline in community psychiatry. And so that is a lot of the passion that I bring to this topic as far as considering this to be such an important effort. And so it is so exciting to be here to share this with the audience. So to start out, we have no conflicts or disclosures to make. And again, essentially summarizing some of the points that Jackie already raised, our hope is to, our learning objectives today are to share a little bit about how structural racism manifests, describe the five domains of the SMART tool, and talk a bit about how this new quality improvement tool can be used in the community mental health organizational setting to facilitate change. So just to start out, as was so wonderfully framed by Jackie, what really brought us as individual psychiatrists, as members of the American Association for Community Psychiatry, and as members of the board to this effort was, of course, this important reinvigorated national dialogue that has occurred over the past year and a half around the issue of structural racism, kicked off by, of course, by the horrible and highly publicized death of Mr. George Floyd. So following this, as this dialogue came into national prominence, the American Association for Community Psychiatry, and we as board members, I think like many of us in society, found ourselves grappling with what is our role in addressing these systemic issues? And for us in particular, the question arose of how do we serve as leaders to guide community psychiatrists towards addressing structural racism and really being proactive in making change to help to address the needs of our most marginalized patients and make sure that we are providing care in an equitable manner? So here on this first slide, I have a list of four commitments that were part of a statement that the American Association for Community Psychiatry released last summer at the time of Mr. George Floyd's death. Basically, in addition in the statement, in addition to decrying police brutality, our board aimed to go a step further in articulating four commitments that we felt we as a board needed to reach for in terms of addressing structural inequity and racism and four commitments that we hoped to guide our membership in addressing in their daily work and daily lives. And so this is part of a statement that we released at the time of these events. Following this statement, I think the question really arose for us of what next? We have we have stated commitments, but how do we really move towards walking the walk in addition to talking the talk? And I think perhaps more importantly, as an organization charged with being a source of leadership and guidance for community and public psychiatrists across the country, how how could we go about finding a concrete way to support our frontline providers who are part of our membership in addressing structural racism on the ground in their community organizations? So as as was already articulated very well by Jackie, basically in our next steps as board members, we found ourselves centering around three key goals as far as this effort that we hope to develop to address structural racism and just to dig in a little bit more to these three goals. So the first was to ideally create something that would provide metrics specific to disparity and inequity issues in community mental health to guide our providers on the on the ground. In other words, we knew, of course, coming into this effort that we are by far not the first to think about inequity in health care, to develop frameworks or tools to address racism and inequity. But our hope is that we could develop something that would be really specific to the community mental health provider and would ideally highlight issues that are uniquely important to the populations that we serve. So some particularly clinical issues that are disproportionately relevant to people in the public system, to people with severe mental illness, issues that we felt our providers might be encountering at higher frequency than people in the general health landscape. So that was our first goal, to have a tool that would really drill down to these specific issues that are most relevant in the community or public mental health setting. Secondly, our hope was that this in creating a tool that could be used by community mental health providers that we would ideally extend beyond cultural competency and linguistic appropriateness to incorporate issues of larger structural inequity. As I'm going to allude to in a slide or two, of course, there are some wonderful prior frameworks and guidance out there around addressing inequity in health care, many of which focus on the important issues of cultural competency and linguistic appropriateness, which are key parts of providing equitable care to diverse populations. But our hope was that we could create a tool that addressed those issues, but also extended beyond to really look at structural and systemic issues that are relevant to the in the community mental health landscape. Lastly, we hope this tool would provide a would provide a stepwise, concrete quality improvement process that could be adapted for self-directed use in the community mental health setting. So knowing I speaking for myself, being on the front lines of community mental health, of course, something that was in my mind as we went to create this tool is that that is a busy landscape, that there is plenty going on in terms of providing direct services, adhering to various regulations, all of the daily work that comes in a busy community mental health setting. And so our mindset was that the average community mental health provider or leader of community mental health organization could be very committed and passionate about addressing structural racism, but might simply feel overwhelmed by the scope of the problem and not feel that they have the bandwidth necessarily to move towards a process addressing these issues. So our goal in creating this tool was to create something that kind of breaks down the issue of structural racism into a set of very concrete, stepwise issues with an easy to use tool that could be implemented ideally for self-directed use. Just to say an additional word about that, something that we were commonly seeing and experiencing last summer at being in community mental health was finding that many organizations, upon feeling overwhelmed by these issues of structural inequity, would often feel the need to turn to consultants or other sorts of professionals, potentially beyond the financial bandwidth, say, of your average community mental health organization to address these issues. And so our hope in creating this tool is that we would formulate a well-structured, easy to use, freely available resource that a community mental health setting could self apply, leveraging the expertise of people within the organization who know it best, who potentially actually have the most in-depth understanding of the ways in which the organization functions and the areas where inequity might be relevant. So to say a little bit about our process in developing this tool, so last summer at the time of this reinvigorated dialogue, we held a membership town hall. This town hall wasn't intended specifically for the SMART tool, but ended up being an important sort of ground for mining ideas and mining the thought process of our membership as far as what issues felt most relevant to those who are members of the AACP, who are on the ground across the nation working in community mental health, and what ideas our leaders and providers in community mental health had around what the key topic areas could be that would be most relevant in a community mental health setting to the issue of inequity, areas where inequity might be most commonly apparent in community mental health. The American Association for Community Psychiatry Board is divided into four subcommittees, and so members from two of those subcommittees, our advocacy subcommittee and our subcommittee that is involved in the creation of products and documents, met together again to draw on the expertise that we mined from the membership town hall, as well as the expertise of the board to start to formulate what might be key topic areas to include in a tool like this. And from there, basically drawing on that expertise, as well as a review of the literature to wrap our minds around some of the most relevant issues of inequity from an evidence based standpoint, we developed a list of key target organizational issues where inequity might be most relevant for a community mental health organization. As part of that literature review, we also, of course, considered prior frameworks that, again, creating frameworks and quality improvement tools to address inequity in the health care setting certainly is not a new thing. And so we felt it was very important to review prior frameworks in part to gather, gain understanding of what could be most important to include in our own framework, naturally to make sure we weren't reinventing the wheel and to confirm that there wasn't a tool already out there serving the purpose that we had in mind. And so that was our process in developing this tool. So I'm going to say a little bit about some of those prior existing frameworks. Again, I'm not going to go through our full exhaustive literature review, but just to highlight some key examples of prior frameworks that we found helpful in developing this tool, but that we also felt it maybe perhaps didn't fully fit the unique need that we were trying to fill and sort of fueled our passion to continue in developing something unique to community mental health. I've highlighted a few examples here of some of the prior inequity frameworks or guidance that we considered in putting together the SMART tool. So first, structural competency from doctors Helena Hansen and Jonathan Metzl. This is a very important set of a very important framework that is basically looks at seeing medical care through the lens of structural inequity. There are a range of wonderful training materials and resources out there under the under the lens of structural competency that aim to guide health care providers and the training of health care providers towards a lens that considers structural factors as relates to health disparity. This was this is an important and wonderful resource for us to consider. But what we found as far as we could find in the literature, we couldn't find a quality and improvement tool, an organizational quality improvement tool specifically that had been developed under the lens of structural competency. What we primarily found were training materials for health provider education. Next, I want to highlight the national standards for culturally and linguistically appropriate services in health and health care or the class standards from the Office of Minority Health. Again, these provide important guidance and important metrics for health care organizations to aim to meet as far as ensuring that their services are culturally and linguistically appropriate. Again, an important framework to guide this key facet of inequity. But our feeling in reviewing these standards, as well as the literature, some of the literature around them, was that we wanted to be we didn't feel this quite fit the bill of what we were trying to create and that we certainly wanted to address cultural and linguistic appropriateness, but ideally wanted our tool for the double ACP to extend beyond just those issues to include other issues of structural inequity. Next, I want to highlight the roadmap to reduce disparities out of funding from the Robert Wood Johnson Foundation. This framework, I think, is a key guidepost as far as the process, the sort of process that we were aiming ideally to create for community mental health. Basically, a set of standards as what this resource includes a set of standards as well as a set of concrete quality improvement resources that a health care organization can implement in their setting to sort of guide them through a quality improvement process, as well as a database of key literature that a health care organization can review to identify inequity issues most relevant to their setting. I think that this this framework was tremendously useful in terms of guiding our thinking and how we would ideally create a framework that can be most useful to the community mental health provider. The one area where we still felt that there was room for our group to develop something new was that we found that the roadmap to reduce disparities, which covers it was a broad range of health care issues, doesn't necessarily target things that are so unique to community mental health. So while one could certainly apply many of the resources that are part of the roadmap to reduce disparities to the community mental health setting, we still felt that there was a space for us to create something that could be applied a little bit more easily rather than trying to pull this resource that wasn't specifically designed for community mental health. As an example, we found in the literature database from the roadmap to reduce disparities, the key some of the key clinical issues most relevant to community mental health. We didn't find as much literature. And then lastly, I want to highlight the research to equip primary care for equity or equip framework, which comes out of Canada, a framework specifically around inequity in the primary care setting, which has some positive self-report data as far as the experience of providers who who have utilized this framework. But again, just again, highlighting where we felt there was still space for us to create something new, as much as we found this tremendously useful as a framework that has been applied in a public clinical setting. This is a research that was not specific to community mental health and also involved the use of consultant consultants, whereas we ideally wanted our tool to be a self-directed quality improvement process. So with that, I'm going to hand it over to my colleague, Ken. Thanks, Rachel. That was a wonderful introduction, and I think everyone listening can appreciate how much your energy and content knowledge helped to drive our ability to turn this idea into a real product. And we're very appreciative of the way you've helped us all do that. My contribution to this effort came from two background areas. One is I am the person who chairs the product subcommittee that Rachel referenced so that one of my jobs within the AACP board and the organization generally is helping to shepherd good ideas into real products. So that's one area in which I was helpful. But another area which is important is, as Jackie indicated, I work, I have a small consulting company with my wife and partner called Zia Partners in Tucson. And we do large scale system change consultation for people to help systems be better organized to meet the needs of people in the community. People help systems be better organized to meet the needs of people who have all kinds of complicated challenges. And we've been doing this for decades. And a lot of our work has involved teaching organizations to use quality improvement strategies to improve their ability to organize the way they respond to the people who need the right response. And doing that as not a training thing, but as an organizational change thing. And so experience with that informed the way we approach this. And that's what I want to talk about here. So one thing I also want to add is as both a mental health person and an addiction person and someone who does a lot on delivering integrated services, mental health, substance health and behavioral health and all that, we're hoping that this tool is not just for mental health organizations. As it says on the top, we're using that kind of. But the intent is that this tool can be applied for organizations or programs delivering mental health care, substance care, adults, kids, services that are organized to deliver behavioral health needs and specialty settings, whether they're homeless settings or criminal justice settings and school settings and all of that kind of thing. One of the important underlying principles of what we're trying to do, well, there are two. One is that we didn't say this in the original learning objectives, but I want to underscore it here. The reason that we're doing this presentation is because we want you guys to use this tool to make change in your own organizations. This is not for us an academic exercise. We want you to turn your good intentions into meaningful action. At your own level. So part of what we observed inside AACP, when we were having the focus groups and the forums and the discussions in the aftermath of what happened to George Floyd and so forth, is that everybody wanted to do something. And so there's a lot of discussion about all the things that we in AACP were going to change. And some of that was self-directed at our organization, you know, as a small but mighty professional organization. But a lot of it was directed at, you know, everybody else on the planet that we want to influence. But what we have to come to terms with and what this tool represents for us is that that we in community behavioral health have to recognize that even though we're all wonderful people with great values, trying to do good things, it doesn't mean that structural racism is not as embedded in community behavioral health settings as it is in every other setting in our society. And we have to be honest enough to acknowledge that and be willing to do something to change that because that's the, of all the things we can advocate outside of ourselves, but honestly, we have to be able to do our own part to create change. So one of the things that I think is really important about the concept of structural racism, if you sort of take it out of the abstraction that sometimes people get lost in, it actually is tied very directly to the organizational dynamics literature and the organizational change literature that's connected to quality improvement. The thing about structural racism is not that there are racist people running around doing racist things. It's that organizationally at different levels of a system, the structures in place produce inequity, produce results that are inequitable based on race, even though everybody is doing the very best they can and totally convinced that they themselves are not racist at all. And this fits together with the organizational literature. The underpinning of quality improvement is this wonderful organizational motto, which says every organization is perfectly designed to achieve the results that it gets. So if inside a behavioral health organization, lots of good people are trying really hard, but they're producing results that demonstrate inequity as we know they do, then that is a marker for structural racism. And the good news is you don't have to change everybody's minds and attitudes. You have to change the organizational process that produces that result in your own organization, which is something that presumably you have more control of than anything else on the planet is your own organization. And if you change those processes that are directly connected to structurally inequitable outcomes, then you yourself are contributing to positive change in your world. Now, in my work, I tend to call this kind of inspiring organizational process for anything, not just for structural racism. A recovery process for organizations because it requires organizational change that's sustainable because it's built into the policies, procedures, and practices of the organization to produce better results for both the people the organization serves, its community partners, and the people who work inside of it. And in the spirit of that, the organizing motto for this, which is the starting place on this slide, is what you probably are all familiar with the idea that there is a recovery processes through things like 12-step programs like AA, and they have the serenity prayer. And so we have this thing called the serenity prayer of system change, which is that, and this is what we're inviting all of you to join in, the serenity to accept the things you cannot change, which is everybody else, the courage to change the things you can in the domain of structural racism, in your own work, in your own program, in your own team, in your own agency, whatever your span of control is with you and your colleagues. And the wisdom to know the difference. And you can spend a lot of time talking about how you wanna change Congress and Washington and your governor and blah, blah, blah. But it's real important to step into this first and say, if I'm honestly gonna be an effective advocate, I have to demonstrate my ability and willingness, my organization's ability and willingness to make change within our serenity prayer of change, what we actually can do something about. Now, the second part of this that is really important, which we're gonna talk about in more detail through this presentation, is that there are things that community behavioral health organizations experience that are any organization experiences that have to do with hiring and recruitment and organizational culture. But there are things that are very unique to community behavioral health, where there are literally differential clinical outcomes that have been collected in data where black people and other minorities may have different access to the best possible assessment and treatment services compared to non-minority counterparts. Even though nobody has consciously decided that that's what's gonna happen. And those impacts have to do with how people are diagnosed. It's their access to the best, quote unquote, gold standard medication interventions like Clozapine for treatment resistance or treatment refractory schizophrenia. Who receives involuntary treatment versus who successfully engaged. Prevalence of people with behavioral health needs in your local jail. All of those things are directly connected to structural racism in community behavioral health. And they're all things that flow into this that we hope to address. Okay. So the next piece of how to address it is once you get out of the ether of, there's some vague, amorphous thing that's being talked about as opposed to actual data-driven inequities that are coming out of organizational processes in your organization. Well, you're immediately in the land of the organizational change best practice that we call continuous quality improvement. Or what I like to call customer oriented continuous quality improvement because you're always looking to improve the experience of your customers, not to improve your internal organizational experience by getting rid of the customers. You don't like. So one of the, there's lots of different fancy models of doing continuous quality improvement, but the one that is most easy, the one most people have heard about the most generic is this thing called focus PDCA or focus PDSA. And it involves a fairly simple set of structures for creating a framework for change and then engaging in data-driven rapid change cycles to continuously improve. It's not like we find one thing and then we fix it. It's a process of continuous improvement. And we don't expect to go from wherever we are to perfection in one go round. We expect that our ultimate goal is to eliminate structural racism and to have no demonstration of inequity, but we're not there. And it's gonna take a while to get there and we're gonna proceed in slow steps, but we're gonna be very organized about doing it. And the purpose of the smart tool is to contribute to a piece of structure that organizations can use within a quality improvement process to get where they're going. So focus PDCA means it's an acronym, find a process to change in this instance, structural racism organize a team to use the tool. And it's very important because as I like to say, quality improvement is a team sport and we'll talk more about that. Clarify the baseline with the tool. So clarifying the baseline with the tool is has a couple of different layers. One is the tool itself will outline your current state around across a number of issues. But within each issue, the tool will prompt you to look at your own data, such as it is or isn't to what extent is there actual inequity around this issue in our organization. And if you haven't ever looked at it, well, that's a good beginning. Okay, because just because you didn't look at it doesn't mean it isn't there and you won't be able to address it without data. So it's helpful to start looking. One areas where there may be deviance, if you will, between what you're hoping for and what you've got, okay? Then you do a deeper dive to understand the variance. Why is our baseline the way it is? What are the organizational processes that directly or indirectly contribute to this variance? So for example, if we find that there's a disparity between the number of people who are white who have access to clozapine who have treatment refractory schizophrenia versus the percentage of people who are black with treatment refractory schizophrenia who are given clozapine, what do we know about why that happens? And there are usually multiple different reasons that you wanna dig into. And of those things, you say, well, what are things that maybe we can modify by creating new processes, whatever they happen to be? And we select one or more of those issues in our team and we implement a piloting activity to see if something is helpful. And we call that a plan, do, check, act cycle where we create a plan, do the plan pretty quickly, measure again to see if it's making any progress. And based on our measurement, we do the next thing. We keep it going, make it bigger, make a change, drop it because it doesn't work, start something else. And we do that in regular cycles, moving quickly. This is not research, it's quality improvement and we're making change and we're acting using organizational best practice. Next slide. Next slide. So in this process with the FOCUS PDCA, the use of the smart tool answers a very important question because what we've discovered, talking with our colleagues and as we've been promoting the use of the tool is there's tremendous willingness and readiness to do something. But where people get stuck is like, what do I do? And one of the things in all fields, but for some reason, from my perspective, we get more caught up and stuck with this in behavioral health than anywhere else, maybe because of some of the reasons Rachel mentioned about all the nonsense paperwork we're always filling out and all the things that were made to do by the external world. But we find that it's very difficult for most organizations to get started until they know the answer. So if you tell me exactly what the answer is and then you make sure that you tell me how to do it perfectly and it isn't gonna cost me too much energy, then I'll do something. Which is really, it's not how we work with our clients and it's not the best practice for organizational change. So the goal of providing the smart to the world is say, if you're wondering what to do, read the tool, organize your team and then help use the tool to help you get started with identifying some things you can take action on. So what does the tool do? It replaces subjective impression with actionable information. In other words, you can have very broad, open-ended conversations in your behavioral health organization about why you think racism may or may not be there. But the tool is designed to point you and say, let's look at some useful and practical data elements that can tell us where the pain points may actually be in our organization. The second bullet is we wanna create safety for these discussions. And one important way to do it is to make this about the organizational process, not about people. We're not pointing any fingers at anybody saying you're racist, you're not racist, you're more evolved, you're less evolved, okay? Everybody's a very good person trying to do the very best they can within the organizational structure that they live in. Let's look at that organizational structure. Does it help us to be our best or does it get us off track in ways that we're often not even aware of? Okay, let's look at data. We're not asking for research quality data. If you start thinking you need to hire a full-time research assistant to do this, you're thinking wrong, okay? Let's find out what practical actionable data we have for any of these items. And if we don't have it, like I said earlier, well, let's figure out easy ways to collect it, even if only by sampling. We're just trying to get data that helps us to understand where the bigger issues are and where we may have some success that we didn't even realize we had. And then the tool is intended to be done in a conversation. So for a lot of places that Rachel said, you hire a consultant to help facilitate your conversation so you can talk about race because everybody's terrified. One of the things the tool does is it says, well, okay, we can all get sit in the room and talk about this together much more safely across different staff boundaries and backgrounds because we're not pointing fingers at each other, but we're talking about our organization and how well it does or doesn't do based on objective data and analysis of policies and procedures and processes within our organization. But in the process of having these discussions, we are actually directly training the people who participate in what structural racism means because it stops being an abstract concept and it becomes about, well, how is it that, oh my goodness, half the percentage of black people get close of penis white people. How the heck did that happen? None of us were doing that on purpose. Is that structural racism? Better damn well believe it. So what are we gonna do about it? And then everybody has to talk to each other to create consensus scoring. That's how you use the tool. And the purpose of the consensus is not that the number means a great thing, but in order to get consensus, everybody has to talk. And it's the talking that's actually part of the best practice of starting out a quality improvement process of any kind. Next slide. So, Sosamol is gonna go into like showing you examples of each of these things, but when we kind of sat together, we looked at some major areas where we thought there were some reasonable amount of evidence of structural racism within the community behavioral health space. So one thing is within the hiring, recruitment, retention, promotion thing, which is not, as I said earlier, unique to behavioral health, but it's no less relevant in terms of the internal dynamics for people who work there and the ability of the workforce to reflect the population being served. But very important is the clinical care domain. Basically, what are our organizational processes in relationship to the people we're serving? Adults, kids, medication processes, diagnostic processes, et cetera. And we have data as Sosamol will talk about that show us where these inequities are. And let's take a look. And let's start, clinical care means looking at our own internal clinical processes for our clients. Okay, things that are fully within our space. The third issue has to do with the workplace culture, which has to do with the degree to which people can have conversations and be aware of racial issues and be able to discuss and address them in a way that's safe. It's connected to, it's based on the connection between trauma, race, microaggressions, and all of that. And it's designed to create objective information that you can use for culture improvement. And that's within your existing environment of staff and clients. It's separate from just hiring, recruitment, retention, promotion things. Community advocacy has to do with how the community behavioral health organization participates with other partners in that community, addressing issues where inequities are, responsibility for addressing inequities requires that kind of shared commitment. And the easiest examples have to do with things like who's being incarcerated, as I said, or who's being, which children are being removed from their homes and placed in residential or foster care environments versus receiving family support to remain in the home, all of that kind of thing. And then the role of the behavioral health organization in helping to address those with its partners. And then the final one has to do with what are we measuring as overall population health outcomes? Are we looking at all the things we know about health equity and inequity inside what we do and what we measure in terms of our own global performance? And how do we do that? And what do we do to do it better? And so forth and so on. So those are the five major domains, but each item within the domain is a prompt for a group discussion, looking at what level of data do we have about where we are, and then using that baseline information to identify priorities of all the questions, which are the ones we wanna work on first. And let's designate some plan-do-check-act cycles to get busy identifying things that we can do, and then bring it back to our team, see how we've done, keep going, using the tool sequentially over time. So I'm gonna hand over to Sosin Molu, who's gonna take you for a bit of a deeper dive into the specific, oh, no, I'm not. I'm going to do this slide. Okay, so the way you do the tool, sorry about that, is that, as I said earlier, it's a group conversation. If you hand the tool out to everybody individually and ask them to score it separately, you're missing the point and the opportunity. Your team needs to include a diverse group that represents different components of the organization. Now, you can do this across a big organization, but it's also helpful, and sometimes more helpful, because different parts of the organization may be different to focus on different programs within the organization. So for example, in Horizon House, where Rachel works, there's lots and lots of different programs. There's residential programs, and there's recovery-oriented rehabilitation services, and there's case management services, and all this kind of stuff. And each of those teams will have similarities in some of the things, but they also have their own particular dynamics, and sometimes it's very helpful for a diverse group of staff from each program to get together and then compare notes at a higher level within the organization as a whole. And diverse means diverse racially, culturally, and so forth, but also diverse hierarchically, diverse in terms of people's clinical backgrounds, because all of that affects people's perception of the organizational whole. Are you a nurse? Are you a doctor? Are you a peer? Are you a case manager? Okay, are you older, younger, more senior, less senior, Black, White, Hispanic, et cetera? And the challenge is to get a representative group. So if you have a staff of 100 people, you don't want all of them in the room. You want to pick 10, 12 representative people to engage in a conversation. But if this opens the door for a broader conversation, and you want to keep a flow between whoever's participating and the rest of their team members who may not be participating, so it's a transparent process. As I said, each item is scored on a Likert scale from one, we've barely done anything about this, to five, we're super cool and somewhere in between. And the idea of the consensus is to get everybody's perspectives on the item. And it's very interesting how in a diverse group in the same program, people can respond to the same question with very different ideas. And it's in the process of the consensus discussion that actually a lot of learning takes place. And it's important to identify not only the score, but also to make notes that say, as we're talking, this became a priority for us to address. And here are some ideas that were generated. You don't solve the problem while you're sitting there, you'll never get done with the tool, but you don't wanna lose track of your conversation, because otherwise it gets really... And then you plan to do some work for a while and reassess and keep using the tool over and over again as you grow. Now it's Osamolo's turn. Well, thank you, Ken and Rachel, for absolutely outstanding introduction and explanation of the rationale for the SMART tool. As very often is the case in my day job, my task is to explain and translate the concepts discussed into implementation, where the rubber meets the road, basically. Let me say one quick comment about just to riff off of what Ken and Rachel have said already. Disparity really is driven by discretion. It really occurs at points where discretionary judgments and decisions are made. And if you look at every one of the sections that have been discussed, you will see that that thread runs right through. So for example, decisions about who gets hired, who gets promoted are on the surface, would appear to be based on objective data. But when you apply a tool like this, that actually requires a closer examination of data and facts, particularly through the lens of structural racism, then certain things begin to become more apparent. So we know, for example, that an organization, in terms of its quality, in terms of its culture, in terms of its leadership, really is driven by who gets hired. We also know from the business literature that persons with, say for example, African-American names or minority names receive callbacks less frequently than folks who are non-minority. And so the disparity really begins to take shape, take form at that very early stage. And so the first step or the first domain in addressing structural racism is taking a look at who comes into the organization, how those people move through the organization, who gets opportunities and who doesn't. Of necessity, this process is, of course, retroactive or retrospective, but nonetheless, that offers the opportunity for some insights. So there are five areas or six areas under domain number one, promotion, mentorship, recruitment, hiring, retention, and disciplinary action. And the literature is pretty consistently clear on the disparities in each one of these areas. For example, even though African-Americans make up 13% roughly of the population, maybe 6% of top leadership positions or less are occupied by African-American individuals. And that's a consistent finding across every industry across the United States. Similarly, we know that the representation of minorities in medicine is low. In fact, there's some literature that suggests that fewer African-American men have matriculated into medical school in the past decade than did in the 1970s. When you look at that through the lens of more recent findings, that there is a concordance between the ethnicity, race of provider, and the outcomes that the population is being served experience. And this becomes very stark and very concerning. So we'll go to the next slide and just show how this tool is used. So as Ken already walked us through the basic framework of applying the tool, the smart tool. So for example, under domain number one item, the promotion item, that group that sits down together, again, drawn from across the organization from all levels of the organization, all sorts of professional backgrounds, hierarchical diversity, ethnic racial diversity would sit down and consider this question to what extent does the organization track racial disparities in promotion, time to promotion, percentage of employees receiving promotion, and then sit down to discuss whether or not that process has even begun, which would be a score of one, identifying whether or not some tracking could have begun, but disparities identified, but not very much progress being made, and all the way up to consistent tracking processes in place have been put in place to identify the reasons for any disparities and disparities have been eliminated. That would be an example under this domain. Next slide, please. And obviously, as was mentioned earlier, clinical care is really at the heart of community psychiatry. It's really our bread and butter in what we do. And so we know, again, the literature is pretty clear on disparities. Ken mentioned plus being access earlier, but if you look at the literature around coercive treatment at all levels, if you look at who gets sent to residential care treatment, juveniles that get sent to residential treatment, if you look at who the involuntary treatment protocols are applied to, if you look at who gets put in restraints, if you look at who gets diagnosed with schizophrenia, again, as was mentioned earlier, there's clear evidence of disparity. And so we know that some of this is, there are historic reasons for this. So in reviewing the organization in the light of, this particular domain, the group would, for example, pick involuntary treatment or diagnostic disparities. And in fact, this was actually, this exercise was actually performed by a member of the WACP and reported on and with some interesting findings. The next slide. The group would pick one of these areas and then run through, again, the Likert scale to reach, attempt to reach a consensus on whether or not, for example, the organization is tracking racial disparities in the provision of access to Clauseril or pick any one of those areas with a score of one being, we don't track this, we haven't addressed it, we do track this, we have made not much progress at all. Score of three would be tracking fairly well, having identified disparities and starting to make some progress. And again, you'd want this to be based on actual data, looking at medical records, looking at other sources of data. Next slide. Workplace culture. And this is in some ways the invisible air that you breathe in an organization. This is in many ways the keeper and the driver of structural racism where it exists. And we know that it's pervasive throughout all organizations across the country globally. And so we look, picking what makes it difficult to, what makes this particularly challenging is how amorphous it is to define culture, right? And how difficult it is to lay hold on any one item or one part of what constitutes the culture of the organization. But there are specific factors or aspects of how an organization operates that either lend themselves to racism, structural racism, or intentionally begin to combat structural racism. So for example, to what extent the organization is able to have conversations, to able to track experiences of microaggression, shall we say, for example, whether that's between staff members or whether that's between providers and the clients of the organization. To what extent is the organization able and willing to engage in implicit bias training to, for example, apply something like the Harvard implicit bias tests and then actually follow through. Those are some measures, small signals of where the organization is in terms of its approach towards structural racism. So in the next slide, we'll take a look at actually applying the tool to one of these. So an example would be to what extent has your organization explicitly identified a goal of creating a safe space in the workplace for staff and clients to identify and discuss racism and its effects, as well as establishing formal processes that is accountable individuals, structures, and so on to achieve that goal. Score one would be, we have just begun to think about this, but have not taken any action. Score two would be, we have acknowledged that this might be an important goal, but we have not formalized this goal. Score three would be, we have formalized the goal, but haven't really put any structures in place for accountability. And score five would be, we have this figured out, we have a formal goal, we've got a structure and process and are starting to make measurable progress towards this goal. So next slide. Now, again, this was mentioned earlier, but the community advocacy is such an opportunity. It's such an opportunity for community psychiatry because, at least in part, because of the myriad of ways that psychiatry overlaps with other structures in the society. So for example, we know that there's a school-to-prison pipeline, we know that, and we know that the impact of that pipeline is disproportionately experienced by minorities. We know that the literature is pretty clear on that. We know the same about child protective services, that the population that's most impacted, most often reported and gets taken into custody are minorities. We know the same thing with respect to law enforcement. In fact, I will say that during COVID in Philadelphia, when there was a push to move individuals out of congregate settings, namely jails and prisons, there was an observation that the Department of Behavioral Health has multiple programs within the criminal justice system and examined the data. And the representation of minorities in prison, and these are individuals with severe mental illness oftentimes, actually went up. So everybody else got released and minorities got to stay in prison during COVID. And that, again, to Ken's earlier points and Rachel's earlier points, is likely less of a manifestation of a conscious choice by an organization and maybe more, and actually much more of a manifestation of structural racism, the way processes work for or against a particular segment of the population. Now, why this is relevant to community mental health is that we do have an opportunity to say something about this. For example, if I were an ED physician, a psychiatrist working in the ED, I might choose, or my team and I might choose, for example, to take a look at who gets brought in in cuffs. Who comes in, who walks into the ED for a psych evaluation in crisis versus who gets brought in in cuffs. And that's just one example. So in the next slide, we'll take a look at applications of this idea. Next slide. So to what extent we know that there is unequal representation within the criminal justice system broadly of minorities. We know that to be an impact of the war on drugs, for example, we also know that individuals with mental health needs are disproportionately represented in the criminal justice system. And this intersection of those two facts affects minorities disproportionately. So to what extent does the organization in question work in partnership with law enforcement and the local criminal justice system to eliminate racial disparities in arrest, incarceration, and diversion of people of color who have mental health and substance abuse conditions? A score of one would be we don't participate at all. A score of three would be, yeah, we do have some collaborations. We have identified this as an issue. We have data indicating that we have made some progress. And a score of five would be we work, have processes in place to track this consistently and work on this consistently. Now I'll give an example here of just one way in which this idea was applied again during COVID. So in Philadelphia, we have, as I mentioned, a whole division that focuses on justice, the criminal justice interface with the mental health system. And during that same period of releasing incarcerated individuals to prevent the spread of COVID, a program was put in place. And it turned out that with all the best of intentions, there was disparity. With a little bit of examination of that program, it was discovered that the representation of minorities in that program set up by very well-intended people was less. It was not consistent with the representation of minorities in the population. And so simply tracking that, simply taking a look at those numbers, simply examining the results of this good idea led to a change in policy, which did correct that inequity. Next slide. And the final domain, which is outcomes at a population level, is yet another area in which behavioral health, community mental health can play a part in addressing and advocating for and addressing. So for example, we know that mental health is in and of itself a determinant over the population. It's a determinant of the overall wellbeing. And so for an organization to examine its catchment area, its population for these system level outcomes, mortality rates, morbidity rates, high school graduation rates, that type of, those sorts of things, would be of interest and would be important in gauging the effectiveness of the organization in addressing structural racism within itself. Next slide. So for example, to what extent does the organization track disparities in employment, homelessness, graduation, recidivism, and work to eliminate such disparities? And it becomes a very important area to examine the outcomes of the organization. So for example, the organization is able to track disparities and it might be that the organization has not even thought about it or has just begun to think about it, has not taken any action, which would be a score of one, or has actually discussed, identified this as an issue, discussed, and reached a decision that this should be a formal goal to eliminate, to track and eliminate disparities in population health, but may not yet have begun to take action, which would be a score of three. And then a score of five would be that, yes, there's a formal goal and a well-established structure and process for making progress towards that goal. Next slide. And I will turn this back over to Dr. Talley for a few final thoughts on the next steps with regard to the SMART tool. Next slide. All right, thank you. So I will finish this up here, and then I know we're so excited for questions and discussion that will follow. So just to share a little bit about future directions, as well as places where you can find more information about the SMART tool. So first I have highlighted here that we do have a publication out in the community in Community Mental Health Journal that basically dives a little bit deeper into some of what we've discussed today as far as our process of developing the tool, the rationale behind some of the items and components. And so for those attending this presentation who are interested in reading further, we encourage you to take a look at that article. And lastly, just to, I think, circle back and reemphasize points already made by both Penn and Sosumolu. So the tool is available on the AACP's website. I've included the link here. And I guess just to strongly echo Penn, I would say if there is one thing that we hope you take away from this presentation, it is to please consider using the tool. We are at an early pilot, informal piloting, early adopter phase, where what we are most eager for is to hear from folks on the ground in community mental health organizations in terms of their experience applying this tool. This tool, we made our best effort to develop something drawing on the existing evidence base and prior frameworks, drawing on the experience and expertise of the AACP. But of course, what we think is most important is, is this tool actually effective and does it work? And so please consider taking a look at the tool and trying to apply it in your organization. And if you do so, please give us feedback. We are eager to hear what the experience is like, what works in terms of how we've laid out the instructions to use the tool and the items. Perhaps even more importantly, what doesn't work? So we can think about ways in which we might revise this tool to make it most useful and effective for people working in community mental health organizations. And so with that, here are some of our references and we look forward to questions, comments, and discussion. And thank you so much for attending the presentation today.

Self-Assessment for Modification of Anti-Racism Tool

SMART

American Association for Community Psychiatry

structural racism

disparity and inequity

quality improvement process

community behavioral health settings

Likert scale

equity and inclusivity

AACP's website