Permanente Medical Groups have been recognized as innovators in promoting wellness and helping patients stay healthy. For family physician T. Ruth Chang, MD, MPH, these efforts extend to her colleagues and staff as well.

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Dr. Chang is the chief people officer and vice president at Northwest Permanente (NWP), a member of the AMA Health System Program. NWP has been recognized as an “Oregon Healthiest Employer” for six straight years by the Portland Business Journal.

Ruth T. Chang, MD, MPH
Northwest Permanente Chief People Officer T. Ruth Chang, MD, MPH.

In addition to promoting well-being, Dr. Chang has been a leading force in the Kaiser Permanente organization’s advocacy for equity and diversity. She has actively promoted “financial health literacy” to help patients navigate the nation’s complex health care system and educate physicians on how patients’ finances can be a barrier to their treatment.

Dr. Chang recently spoke with the AMA about these programs.

AMA: Please define your position and tell us how the post of “chief people officer” came to be.

Dr. Chang: I will give the credit to our president and CEO, Dr. Imelda Dacones. When she came into her role, she was really thinking about what we can do to help support the people of our organization and best take care of them—so, taking care of the people who take care of our patients.

She really reimagined that VP of human resources role—thinking beyond the traditional HR functions—which is still part of my team, but thinking broader and about what do we really need to support our people. She created this people strategy with four pillars, focusing on wellness and resilience; equity, inclusion and diversity; talent acquisition; and leadership development.

AMA: Please describe the work of the Inter-Permanente Medical Group work group for equity, inclusion and diversity and your role in the council?

Dr. Chang: The eight different Permanente Medical Groups across the country are the medical groups that work with the local Kaiser Foundation Health Plans, and “inter PMGs” is how we refer to ourselves.

The Inter-PMG equity inclusion, diversity work group is comprised of the leaders from each Permanente Medical Group. We meet regularly to collaborate, share best practices and then, ultimately, to hold each other accountable to make sure we're moving this work forward. And obviously, we're also there to support and find strength in each other.

This year, we have three top priorities that we all agreed upon:

  • Pushing out the “Belong @ KP” curriculum.
  • Following up on our inclusive climate assessment.
  • Partnering with the health plan and the national equity inclusion, diversity office, to plan the 44th annual national equity inclusion diversity conference that's hosted for Kaiser Permanente across the nation.

“Belong @ KP” is curriculum that's been developed by the national EID office with a third-party vendor called NeuroLeadership Institute. Our Permanente Medical Group leaders have been at the table as well for the content development.

I'm super excited about this curriculum. We are going to be rolling out the first section, which is three modules around breaking bias:

  • Examining our own bias.
  • Recognizing when it happens.
  • Seeing it in others, in situations, and then how to interrupt it.

These sessions will be then followed by another three modules on dismantling racism. And we're rolling this out to everyone who works at Kaiser Permanente across the whole nation.

The second focus is around the inclusive climate assessment. This is a survey instrument developed by Diversity Science and almost all the PMGs have participated in this survey to really take a deep dive and look at our climate of inclusion within each medical group. Together we're doing action planning about what are we going to do.

Thirdly, Kaiser Foundation Health Plans’ national equity, inclusion and diversity office plans and executes a large national conference in collaboration with the Permanente Medical Groups. This year will be the 44th year. I think it’s amazing how long we've been thought leaders in this space.

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AMA: Can you speak to how the focus on health equity has intensified?

Dr. Chang: It's always been something that we have worked on internally. We’ve been measuring disparities in health across populations and working to improve that. In the past year, ever since the murder of George Floyd and then the subsequent demonstrations for social and racial justice, I think the importance, the urgency has really increased. We can build on that momentum to continue this important work and Kaiser Permanente has been walking down this path for many years.

Regarding the AMA health equity strategy, in the past, equity and disparities have been addressed through specific funding and initiatives. We identify one problem and then we put some resources towards it. But this new future that we're imagining, has financial structures that we build into the equity and disparities work. It becomes part of our quality plan. It's no longer this aside—it is central and core to how we think about it and it's completely folded into quality and cost. I love that. It's a complete shift of thinking. I applaud the AMA for really putting that out there.

AMA: How do you get to be recognized as Oregon's healthiest employer?

Dr. Chang: The short answer is: By design, by intentional work in this space—that does not happen by accident. We have been putting resources into developing our Northwest Permanente wellness program. We have a dedicated consultant for that area. We have a physician director of wellness.

Our model of wellness is based off of the Stanford WellMD that we've customized. With a culture of wellness, we've built a big group of people who have self-identified as wellness guides. Across departments, hospitals and different medical office building locations, we have local folks who are really promoting this cause and encouraging their colleagues to be thinking about wellness, encouraging colleagues to take care of themselves.

We've also stood up a peer-support program recognizing that when physicians and clinicians have patients that suffer an unexpected adverse outcome, we can really be victimized by that. It's that second-victim phenomenon. Talking to a peer can be most healing for us, to help process those emotions and to think about what it means to be  a human being when we witness the pain of our patients.

We have invested significantly around optimizing our practice and looking at how we help our physicians and clinicians be more efficient.

Certainly, the electronic medical record is a big part of how we practice medicine now and it's a lot to learn. We've invested in a program called “Pathways to Proficiency” that's developed by our own medical informatics team. Pre-COVID, we sent clinicians to a three-day offsite retreat to just focus on learning the efficient tips for operating the EMR. During COVID, we’ve had to shift and turn to courses online, but that's the type of investment that we've made in our people.

The final component is around personal resilience and wellness. We offer courses, we put out incentive programs for people to take care of themselves, and then we also have our own in-house employee assistance program called Permanente Advocate Resource. This is confidential counseling that we offer to, not only our physicians and administrators, but also to any family member—recognizing that, when our families are not doing well, it  impacts our clinicians and administrative staff.

Those are the programs we've built around the model. Ultimately, the target is that we experience more joy at work.

AMA: Health professionals, including doctors, are often criticized as being bad patients. What does it take to get health professionals to practice wellness?

Dr. Chang: Yes, health professionals are sometimes bad patients. What does it take to get us to walk the talk? One way is that we’ve got to make it easy and accessible. Physicians and health professionals are super busy. We put a lot of our offerings online, anything from a quick tip on recipes, cooking classes, podcasts on tips to tools on how to improve your practice and your own wellness.

We've also put in this incentive program, that's very creative called the Wellness Passport and we have high engagement in this. It comes out quarterly and the program encourages people to practice self-care and earn a reward. You earn a bonus or a prize for completing a specific number of those activities. It's been a very successful program for us.

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AMA: AMA policy encourages efforts to educate patients, medical students and residents in health economics’ literacy. Could you address the connection between financial literacy and health, particularly as it pertains to adherence to treatment and prescription regimens?

Dr. Chang: Why is financial health so critically important? I would frame this as, what's in this for the patient, what's in it for the clinician, what's in it for the organization?”

For our patients, there’s a sad-but-true statistic that only half of American families have even $400 in a rainy-day fund. That's shocking. But that’s the financial reality of our patients.

Our own internal research shows that a quarter of patients have reported delaying their care because of cost concerns. We also know that a quarter of prescriptions don't get refilled or don't get picked up. All physicians, at some point in their career, have heard a patient say to them, “Oh yeah, Doc. I'll pick up my blood-pressure medicine next Friday.”

That's a comment that’s so easy to just let slip by. I never really thought about it, even though I heard it fairly often. However, once I woke up to this idea of financial health impacting patient care, I realized, “Oh, they don't have money and next Friday's payday.” Patients are often choosing between paying for groceries and paying for medications.

What’s in it for the physician? It's really about physician burnout. We all want to be effective because we're in medicine to make a difference in people's lives. When we put all this effort out to take care of patients and then they can't follow through, that doesn't feel professionally satisfying.

For the organization, when there’s a delay of care or an inability to follow the treatment plan, patients end up in our ERs or hospitals way sicker than if we had been able to tackle these issues up front.

For these reasons, it’s important for the physician to be a partner in the patient’s care. By asking something as simple as, “Do you have any concerns about being able to follow your treatment plan?” we can better understand a patient’s barriers to care and help address them together.

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