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Dr. Susan Moore's son hopes his mother’s legacy brings about a fair health care system

Indianapolis Star - 5/14/2021

Dr. Susan Moore did not set out to be a game changer. All she wanted was to be treated for a severe case of COVID-19 with the same dignity she gave her own patients.

But in a searing video that went viral last December, she charged Indiana University Health providers with allowing their racial bias to taint the treatment she received.

Six months after her eventual death from COVID-19, IU Health on Wednesday released the findings of an external investigation into a case that thrust the hospital into an unwelcome spotlight. The report concluded that while her medical care did not contribute to her untimely death, Moore suffered from a lack of cultural competence on the part of those treating her at IU Health North in Carmel.

More: What investigation says about death of Dr. Susan Moore, who alleged racism

The review by a panel of six outside experts — four of whom are Black — concluded Moore received adequate health care after examining documents related to her treatment and conducting interviews with those involved. But they laid out a series of recommendations for how the hospital system can to address implicit racial bias, weave Diversity, Equity & Inclusion training into staff education, and create more opportunities for all patients to have a voice.

Community leaders and Moore’s family Wednesday welcomed the report as a good start to improving cultural competence at IU Health that could prove to be a model for all of health care. But some think IU Health could have gone further, perhaps detailing consequences for bad actors and seeking input from the general public.

IU Health President and CEO Dennis Murphy said in an interview with IndyStar Wednesday that the external review confirmed an internal review’s conclusion that there were gaps of communication and compassion in the treatment Moore received at IU Health Carmel.

“I was disappointed in the findings that we didn’t provide the best possible care to Dr. Moore in terms of whole person care and how you treat the whole person,” he said. “Overall it still quite honestly was painful to see.”

Dr. Susan Moore: What we know about the Black doctor who alleged racism before she died

In the aftermath of Moore's viral video, several Black physicians and other advocates said that Moore's story was all too familiar and reflects pervasive systemic racism in the world of health care. The fact that Moore herself was a trained physician emphasized that even her medical degree could not protect her from such experiences.

Moore herself was an advocate for providing all her patients with compassionate care, her family said in a statement they released to IndyStar through the law firm of Langer & Langer, which was retained to represent her estate in a wrongful death claim.

"Dr. Susan Moore’s lifelong dream to serve patients and her community as a physician lives on — even after her death. She believed that all patients, regardless of their background, had a right to receive reasonable and compassionate care," the statement read. "She let the world know when she, herself, felt that she was denied that care."

The statement went on to say that Moore's teenage son welcomed IU Health's willingness to try to change its culture to ensure that other people do not have similar experiences.

"Dr. Moore’s son, Henry, appreciates the genuine thoughtfulness and commitment to change that IU Health has promised to pursue," the statement went on to say. "It is his greatest hope that his mother’s legacy brings about a fair, culturally accountable health care system."

Dr. Moore dies: Black doctor dies of coronavirus after alleging racist treatment at Carmel hospital

Panel's findings, recommendations

Comprised of four health care providers and two health care professionals who were not caregivers, the external review panel delved deep into Moore’s case, Murphy said.

They interviewed more than 30 people directly involved or connected to her care and reviewed all of the medical documents relating to her case.

The end result was a series of recommendations that Murphy said would serve IU Health as “a good road map to become significantly better as an organization.”

Among those suggestions:

Conducting a thorough assessment of its care models, including how both patients and employees can voice concerns. Providing all staff members with training designed to enhance their compassion and empathy. Hiring additional patient care advocates and improve the way staff talk about patients in their care.

IU Health also promised to expand its DEI initiatives by:

Having all staff members undergo comprehensive DEI training that includes a focus on unconscious bias, microaggressions, anti-racism and mitigation. Making DEI efforts a part of all performance evaluations. Establishing a response team with diverse, seasoned employees who will intervene to help mitigate racially charged incidents. Hiring a DEI consultant to evaluate the hospital system's organizational culture and climate through "an anti-racist lens.”

Moore’s hospitalization fell at the height of the COVID-19 fall surge. While Murphy said the time was a stressful period for health care providers, he added that he did not want to diminish the core issue of systemic racism, which is a pervasive problem throughout the country.

But in a nod to the stress some health care providers may have been experiencing, the recommendations include increasing support for burned out staff members.

After the incident a small number of staffers were put on administrative leave pending the findings of the review, Murphy said. No one has lost his or her job but these individuals will need to undergo additional training and monitoring as they return to work.

"We believe the findings and recommendations of this external review will drive forward a plan of action for IU Health to become a more inclusive, equitable and respectful healthcare system for all,” Murphy said.

The hospital system promised to provide regular updates on its progress on its website.

Community advocates' response

Advocates for reducing racial disparities in health care said that while the report offers a good start, the proof will come in how well they execute their plans.

IU Health deserves kudos for being honest about how its doctors and nurses failed to provide Moore with culturally competent care, said Tony Gillespie, vice president of public policy and engagement at the Indiana Minority Health Coalition.

“Overall it’s a great response,” Gillespie said. “All of those things were bold for them to put that in writing…. There are other health institutions that might have gotten in the same situation, and I don’t know that some of the others would have gone this far.”

Indiana Rep. Robin Shackleford, D-Indianapolis, chair of the Indiana Black Legislative Caucus, has introduced legislation for several years that would require at least two hours cultural competence training for all health care providers.

This year that bill did not even get a hearing.

So Shackleford was pleased that the IU Health review included such education among its recommendations. She said she will continue to work for such legislation to extend the training across hospital systems in the state and possibly even to other industries.

“I think this is a phenomenal beginning for IU health and other health systems to take heed throughout Indiana,” she said.

What about consequences?

However, some said that IU Health could have gone even farther.

The plan talks about the need for employees to do a better job but does not discuss what consequences might be applied if they fail to do that, said TyJuan Garrett, vice president with the Greater Indianapolis NAACP Branch.

That’s akin to posting speed limit signs but not planning to pull people over who break the speed limit, Garrett said.

“With any action plan, you have a level of accountability that needs to be within the plan and once you have accountability, what corrective actions are you going to take and is there going to be any consequences for not acting on that,” he said. “What I would like to see is what deterrents are they going to put in place so this doesn’t happen again.”

The review also did not include any measures for seeking community voices, Gillespie said. He would have liked IU Health to lay out plans for how to collect input from the general public, through focus groups, listening sessions, or town hall meetings.

And none of this, they all agreed, can bring back Moore, who died at the age of 52, leaving behind a teenage son and elderly parents.

"It was definitely sad that Dr. Moore’s life was taken in such a non-compassionate way," Shackleford said. "However I think this will be a positive step and a positive note that her death will bring such change to our culturally insensitive health system."

Dr. Susan Moore video

News of Moore's death went national after a video she had posted Dec. 4 went viral.

Moore — an oxygen cannula atop her lip and tears in her eyes — looks at the camera and describes her experience at IU Health North, where she sought treatment for COVID-19 in late November.

Moore said the white physician who treated her there did not take seriously the neck pain she described nor her difficulty breathing. He made her feel like a drug addict, she said, and prescribed medicine only after the CT scan he finally ordered confirmed what she had been telling him.

“I put forth and I maintain that if I was white I wouldn’t have to go through that,” she said. “Being Black up in here, this is what happens.”

A few days later, she was discharged from IU Health but within 12 hours her condition had deteriorated and she had to return to the hospital, this time to Ascension St. Vincent in Carmel. Despite receiving what she described as better care there, Moore died of COVID-19 three weeks after she first learned she had the disease.

On May 5, Moore’s estate filed paperwork to lay the groundwork for a wrongful death claim. The estate has asked the court to seal certain records related to that case.

Four months have passed since IU Health convened panel

On Jan. 7, the hospital system announced it was convening the panel to look into Moore's death.

While hospital officials initially said they hoped the investigation would wrap up quickly, four months elapsed before the results were released Wednesday, May 12.

Moore, 52 at the time of her death, became a symbol of pervasive inequities in the healthcare system, disparities that the pandemic had only emphasized.

'The system was complicit in her demise': Dr. Susan Moore's death spotlights racism in health care

While Black people have about the same risk of contracting COVID-19, according to Centers for Disease Control and Prevention statistics, once they have it, they are nearly three times as likely as white people to be hospitalized and twice as likely to die from it.

Four days after Moore’s death, President CEO Dennis Murphy announced that IU Health would conduct full internal and external investigations into the case, saying the health care system is committed to equity.

Diversity effort: IU Health makes 3 appointments to add diversity to leadership

During the intervening months, IU Health added a Black woman to its board of directors and increased diversity representation on its committee of values, ethics, social responsibility and pastoral services.

IndyStar reporter Johnny Magdaleno contributed to this report.

Contact IndyStar reporter Shari Rudavsky at shari.rudavsky@indystar.com. Follow her on Facebook and on Twitter: @srudavsky.

This article originally appeared on Indianapolis Star: Dr. Susan Moore's son hopes his mother’s legacy brings about a fair health care system

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