Written by: Center for Care Innovations

Tosan Boyo shares practical next steps for organizations of any size and at any stage of their equity journey.

Boyo — who was recently chief operating officer of Zuckerberg San Francisco General Hospital and now serves as senior vice president of hospital operations at John Muir Health — asks: “Are we providing the tools and resources for staff to do equity work? Then we are creating an inclusive environment for everyone to belong and to thrive?”

Listen and subscribe to our podcast on Apple Podcasts, Spotify, and elsewhere. Below is a transcript of the episode, edited for readability.

CCI: We are here today to talk about achieving health equity, as we care for patients against the backdrop of COVID-19 and systemic racism. Given the many ways to describe this important work, Tosan how do you define health equity?

TOSAN BOYO: Health equity to me means that we and health services need to do everything we can to make sure that those with the least resources get the most opportunities and even more interventions to make sure that they have just as good outcomes through our system. So that means that we need to understand the story of the people that show up for care. We need to make sure that their stories influence the care that we provide. And we need to constantly build a bridge of empathy. I love asking people, “If I say I treat every patient the same way and they get the same care, is that the right thing? Raise your hands.” And it’s always fascinating to me to watch people hesitate to raise their hands and the people that do. Because the reality is, we don’t want to treat every patient the same. We want to live in a world where care is tailored. And care is personalized. And care is precise. And equity to me is how we get there because there are decisions that we make and are there decisions that impact us every day, that those of us in health care need to understand, to make sure that when patients present and when even when health care staff show up to work that they are empowered to get the best care possible and to give the best care possible. But that’s what health equity means to me.

CCI: So, given the way you’ve described health equity, how do you know when you have it?

TOSAN BOYO: So, my test is I want to create an organization where every person, regardless of their background, regardless of this story, regardless of their income feels, it’s the best place to be. It’s the safest place to be. It’s the most caring place to be. So, this means that the most disenfranchised person, so the poor Black trans person experiencing homelessness would feel that when they come to a health care facility, it is the best place they could come to get what they need. And for context, when you think about the fact that the two places people never want to be are prison and hospitals. And when you work in health care, you’re choosing to dedicate the third of your life to a place that most people never want to be. So, this means that when people present to us, they’re coming because they are afraid. They’re coming because they are vulnerable. They’re coming because they are in pain, and a highly equitable organization makes sure that everyone will view their time in this facility as the best place they could be. This means that they are not experiencing bias. They’re not experiencing microaggressions. Their staff is doing everything they can to build empathy. There’s staff that look like them. There’s staff that speaks the same language that they do. There is staff that understands or is trying to understand what they’ve gone through before presenting for care. So, when I said the example of the person with lower income, who happens to be Black, happens to be trans, and happens to be experiencing homelessness, I want to make sure the facility is the best place for them because through every lens that they have, we will provide everything that they need for them to feel safe. They will not feel “other” through any of their lenses when they present for care.

CCI: I hear you talking about a sense of belonging, even if it’s that people don’t really want to have to belong. So, is there a short story or example you can give of a time where you saw that happening?

TOSAN BOYO: Well, the first thing I would say is that no health system that I know of has it mastered the concept or strategy of health equity. The first thing is that we are all on a journey together to understand how to be equitable, and the journey doesn’t end. So that’s the first thing I would say. So, an example of that would give is, at San Francisco General, I am very proud of the fact that we do everything we can to make sure that when patients present, we meet them where they are, and this means that, you know, if English is not their first language, we have an interpreter available for them. If they need some type of family support, we provide that for them. And an example I would give is our social medicine program at San Francisco General, where we had a patient that had been living on BART. BART was their home, where they live, and this patient had been in and out of the hospital multiple times. And so, this is a person experiencing homelessness. This is a person of color, and this is someone that English was not their first language. And our social medicine team, they didn’t automatically go to, “How can we get you off of BART?” That was not the first thing that they did when they presented to the hospital. Our social medicine team upon providing care was, “What are the things that you currently do not have? And how would getting those things, get you to a place where when we provide care for you, you would be able to keep coming to us and you’ll be able to stick with the regimen that we provide?” And, part of health equity is moving from, “what is wrong with you” to “what has happened to you.” Those are two very different things. And, “How do we care for you based on what are the things that you need to make it through the day-to-day?” And with this one patient and the social medicine team, spending time with them, we understood that there is a set of parameters that they needed to want to be able to come for care. They really want to trust. They really wanted to know that it will be the same person. They really wanted to know that we will do everything we can to make sure we’ve maintained a relationship with them. And we were able to successfully place this patient in housing and to get them off of BART. And to me, that was an intentional equity-based program to get someone that many people would label as a frequent flyer, and we’re able to meet them where they were based on what they wanted and not just what they needed.

CCI: I really love the, what are the things you need that you currently don’t have approach. Thanks for that. Tell us why equity matters to you personally and professionally.

TOSAN BOYO: So personally, equity matters to me because I look at the world through the lens of someone who has lived in multiple different places. So, I’ve lived in Nigeria, I’ve lived in the U.S., and I know what it’s like to live in different worlds. I know what it’s like to live in a world where everyone looks like me. And then I’ve lived in places where most don’t look like me. And a story for me is when I first moved to the U.S. I was involved in a car accident. I was a skateboarder at the time and doing one of my tricks. I got hit by a car and broke my wrist, and I remember trying to hide it. And then, when the pain was just excruciating, getting home, and telling my mom that I think my arm was broken. So, keep in mind, we’ve just moved to a new country. We’ve never navigated the health system before. And when my mother spoke to, you know, in classic immigrant mentality, she spoke to another person that looked like her that had her experience. She just spoke to another Black man and was like, “Hey, where’s the best place for us to go?” Based on knowing that trust is necessary. Based on knowing that you want to feel welcomed. Based on knowing that you want to make sure that I’m going to go to a place where they understand you. And the person recommended the public hospital. And that was my introduction to public hospitals in the U.S. system. And I will never forget that it was through a referral that we decided on what hospital we were going to go to, to get care. So that always stuck with me. So that’s one. Number two really ties into why I believe in health care is a sacred calling. Growing up in Nigeria. So, on June 12th, 1993, Nigeria was going through its very first democratic elections. And I will never forget that when the winner was announced, the winner of the election, his name was Abiola. He ended up essentially getting picked up and disappeared. No one heard from him again until he died. And riots broke out in the streets. And my father owns and runs a community hospital in the city that we lived in called Legos. And when riots were breaking out and violence is going across the streets. When different people from different camps came into this hospital, they knew that in this space, they were not allowed to engage in violence because this community hospitals would take care of everyone, regardless of what you believed. And that moment for me in 1993, realizing that there is a sacred space that takes care of people in times of strife, resonated with me. So that’s why I’ve stayed in health care. And to your question about why equity means that to me, that’s why I chose health care. But then I realized that the life expectancy for people is not the same, especially when we consider how culture impacts them, but then the treatments they get when they present for care. And when I think about the stories like Shalon Irving or different stories of people who have experienced poor outcomes, or the fact that if you are a Black woman with a master’s degree, you are more likely to have a miscarriage if you’re pregnant than a white woman without a GED. You know, that says a lot, especially when you think about how the day-to-day stresses and the day-to-day impacts of racism can influence and drive poor outcomes. So, after traveling the world, after immigrating, after looking at, reflecting on the lens that I see the world, and I’ve always viewed it as something that I have a responsibility to address because if I don’t do it, who will? And I’ve looked at it as my calling.

CCI: I think you’ve given new meaning to the word, safe space for a health care, for many of us with your story. If you were just starting on this journey toward health equity, where would you begin?

TOSAN BOYO: The first thing I would do is taking a step back to understand what equity means. And that goes back to our earlier conversation. What does equity mean in health care? And knowing there’s difference between equity and equality? They are not the same. So, first of understanding, determine what it means to your organization. The second is making sure your team understands what it means and why it has to be important to your organization. So, what is the “why” to the CEO. And what is the “why” to the patient population. So, your executive team and your staff needs to understand that. After that, I would say every high-functioning clinic. I mean, especially since after the Affordable Care Act, every clinic, every FQHC, every safety net care facility has quality metrics that they’re looking at. Be it hemoglobin A1C greater than eight, hypertension under control. There are key quality metrics at every system. My ask to the group would be, let’s lay out our quality metrics. Maybe look at the top three and stratify it by race over the past year. So, upon doing that, what did you learn from it? Right. So, if you stratify hypertension under control, if it says that, okay, your indigenous population or your Latino population isn’t close to the average of everyone else, or is an outlier, that tells a story. Stratify your data is the most important thing to understand the impact you are making when it comes to disparities. So, upon doing that the next thing I’d recommend is what is your hypothesis based on what the data is telling you. And then what do you want to test out to try and address this? During this point in time, it can become, and this is something that happens for every organization, regardless of how much funding you have, there’s going to be this tension of, “Is this something we can afford to do? Is this something that we can do? And is this a priority?” And my challenge always to this tension that is natural is, “What are the reasons for you to not do this?” So, yes, you’re going to have those feelings, but when you’re having those feelings or when you present the information and you’re the leader of your physicians has feelings of, “I don’t know if this can be a priority right now,” list out the reasons why it shouldn’t be a priority. What are the reasons to not make sure that your patients are having the same outcomes? Or having the best outcomes possible? Why is it okay for some patients to have better outcomes than others? And you’re going to find that it is very hard to do that, especially once, you know.

CCI: I want to drill down just back to one piece, and we’ll keep it short. When you talked about where to begin, you said, take one, one metric and stratify it. Can you get specific?

TOSAN BOYO: Yeah. Yeah. So, working in San Francisco General, when I came on board a key theme, because we’re, we’re a level one trauma center. So, we see a lot of violence in the hospital. We see a lot of aftermath of violence. So, while we are providing trauma care, people are experiencing trauma. So I’m using that to say that, due to the kind of organization we are, we partner very closely with law enforcement. And when I started my role, I would look at the use of force that had been taking place in the hospital. In the beginning of my tenure, because of my natural inclination, I wanted to say, “Hey, let’s look at the stratify to use of force by race.” And when we did that, we found out that almost 50 percent of every use of force on a patient was on a Black patient. Almost 50 percent. Despite the fact that Black patients only make up 17 percent of the entire population, right? So that’s almost three times representation. So, by drilling into this, it really compelled myself, our CEO, and our chief quality officer to understand, “What are the drivers here? What is causing this to happen?” And one of the assumptions was, “Why is it that law enforcement is reacting and this way?” And the reality in time that we found out very recently is that it’s not solely law enforcement reacting this way to patients. We found out that the number one driver for this is staff calling law enforcement on Black patients and not just exclusively law enforcement reacting this way to Black patients. So that’s an example of a metric we drilled into that we thought we wanted to look at one intervention, and then the reality was we needed more intervention upstream. Why is it that staff who are not going enforcement are more likely to call law enforcement on their own patients? And then the question is, “How do you care for a patient when you are afraid of them?”

CCI: You outlined three parts to the equity journey: One, understanding your patients or your customers. Two, eliminating disparities in your care or your service. And three, developing your workforce. Tell us a little bit more about how those all work together. Can you do just one and then move on? Or is it sequential?

TOSAN BOYO: So, understanding your patients, knowing the demographics of your population. So, taking a step back and saying, if you are a FQHC with 10,000 patients, what are the demographics? Race, ethnicity, and language spoken by your patient population. And you can also include sexual orientation and gender identity. So, you want to know who are the people you are taking care of? What are these characteristics for them? So that’s understanding that patient. The first part is really the data so that you can actually do work. The eliminating disparities is once you have that data, being able to say, okay, so we’re looking at our quality metric, now that we have those pieces — we know that of the 10,000 patients, 9,900, we can tell how many are Black, how many Latino, how many are Native American, how many Asian. You know, eliminating disparities. Once you have that data infrastructure, you take it, your number one quality metric. You have the ability to stratify. And it tells you where patients are supposed to be on a quality metric. The other piece of eliminating disparities is once you’ve stratified, like I mentioned earlier, you have the hypothesis and then you’re testing things to see like, “Hey, is the work that we’re doing, actually having an impact on closing the disparity?” So that’s the actual interventions after stratifying. And then the third strategy is developing the workforce. So here is really focused on, “Are we providing the tools and resources for staff to do equity work? Then are we creating an inclusive environment for everyone to belong and to thrive?” Those are the three strategies. I would say understanding your patients has to come first because without that you can’t really do any interventions. And then the workforce piece is really critical because I’ve come to believe that my new hypothesis is, when you understand your workforce, when you know what your workforce looks like, once you’re making sure you have the resources and tools that they need, you are also setting yourself up to be more successful in impacting disparities. You are also setting yourself up to be more successful with the business because you’re able to retain and recruit more employees.

CCI: Many health care organizations we work with have chosen to focus their first work on equity on reducing disparities among their Black and African-American patients. What are some best practices you’ve seen? And especially for engaging the Black community, help inform those solutions.

TOSAN BOYO: Number one is listen to the patients. Hopefully the organization has a patient advisory council. So, listen to your patient advisory council, the Black patients. Listen to the community that you’re serving, engage in town halls, engage in community meetings. And then talk to your Black employees. And again, going back to my hypothesis that you shouldn’t work solely on patient outcomes without looking at the workforce. Talk to your Black employees and ask yourself to be honest about the organization for them. So, the number one thing is listening. The number two thing would be okay, then going back to the three steps I mentioned with — What is the data that you currently have? What does it look like? You know, quality metrics. And then how are you engaging the workforce in that piece? But the number one thing you can be doing is listening and partnering with the patient, the advisory council, the community, and the Black staff to truly understand how to make an impact. Because the reality is because of the history in the U.S., there are cases where some people just won’t want to go to a hospital or a clinic, if they don’t see themselves there. You know, there are some institutions where if they realize that no one on the leadership team looks like them, they’re not going to feel welcome. They will only come to you when they have to. And we all know, since the Affordable Care Act, we don’t want people to only show up when they have to show up. They want people to have a relationship with their care team where they know like, “Hey, I want to do this. Not because I have to, or because I want to.” So, building that relationship with the care team is going to be an outcome that you want. And that starts with building relationship with the patient population.

CCI: What’s the advice you wish someone had given you when you started your journey toward equity at your organization?

TOSAN BOYO: Oh yeah. That’s very simple. The journey is hard. The journey is painful. The journey doesn’t end. The journey is so rewarding. What’s been fascinating for me is that I’m leaving San Francisco General and heading to John Muir, and the most breathtaking moments for me have been people writing letters to me about how they had been working in the organization for a while and hadn’t felt seen them for who they were — not just a role, but like felt seen. Felt heard. And those moments are invaluable. And to me that that is worth the work. And going back, people spend most of their time at work, right? So, you work eight hours a day. You come home, spend a couple of hours and then you go to sleep, and then you go back to work. So nowadays people are at work more often than they are at home. And the equity work means that you are making a place where people spend most of their time feel like home. And a place when people are in pain, they come to a place where they know that the pain will go away, and the fear doesn’t have to be there. So, for me, it makes the work really rewarding. So, I wish somebody said, “Hey, Tosan, you’ve picked up this journey, you’re going to experience a lot of frustration. You’re going to experience a lot of emotional pain, but it is extraordinarily rewarding. And the impact will last long after you.”

CCI: I think you pointed out something really important, which is that you started this equity journey for the patients in many ways, but the way that you knew it, it had landed also with what you’ve heard from the fact about that sense of being seen. And I mean, I got goosebumps. Who doesn’t want that?



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