What does enacting commitments to Health Equity imply in a Rural Community Health Team?

Autumn leavesAn interview with Sara Dalo, Executive Director Tilbury District Family Health Team 

Interview by: Will Chukra, MD Candidate
Schulich School of Medicine & Dentistry 


Sara Dalo is the executive director for the Tilbury District Family Health Team (FHT) located in Tilbury, Ontario, Canada, approximately 26 kilometres southwest of Chatham-Kent. Sara is also the vice president of the Association of Family Health Teams of Ontario (AFHTO). Sara’s position often requires collaborating with Public Health Ontario, Health Quality Ontario, Windsor- Essex County Health Unit, Erie St. Clair Local Health Integration Network, and several other health teams to ensure the healthcare provided to patients is equitable. I interviewed Sara to get her input on the health inequities that the Tilbury District FHT must work around as a rural community health clinic, and how she advocates and implements changes to help overcome these inequities.  

Will: “Please tell me a bit about your role as executive director of the Tibury District FHT.” 

Sara: “Maybe I could start off with how I support quality improvement. There are different aspects to this, but one of them is trying to gather evidence on how we are currently performing. Usually what we do is leverage data in our EMR (Electronic Medical Records). I work specifically with our analyst to do that. I also have people in specific roles that I support to gather information, make informed decisions, engage team members so that they can speak to the information, provide better insight on maybe what's not captured through the data so that we can collectively make shared informed decisions. Usually though, there is a very specific goal that we're working towards, and if it's vague, we look at what we can take to have a more defined goal that is specific to improving patient care. So that goal is based on something operationally that would translate into improved patient care outcomes based on what we know from research, from recommendations that come from the ministry, people we report our data to, or even from information we know through lived experiences, depending on what it is. 

I also am responsible for working with my board (Tilbury District FHT’s board), so I provide to them how we are working towards our shared goals or fulfilling our strategic plan. So my board from a governance level will wonder how we are meeting expectations. What are we doing to achieve X, Y, Z, and then I give them updates throughout the year. But all of those, again, even though they're not specific patient examples, they're all intended to organize and structure the organization so that we’re fulfilling our strategic objectives, which ultimately result in improved patient outcomes. 

I work with partners throughout the OHT (Ontario Health Team). So that's focused on community, acute care, and what primary care does to play a role in improving patient experience in the system. I also work with people across the province involved in family health teams. So I work with people across the province in different levels of care, such as ministry reps or even just other healthcare political representatives that would guide our work in the right direction. Oftentimes this work is anchored in the quadruple aim: patient experience, patient wellbeing, provider wellbeing cost, and affordability. There is even the quintuple aim that includes an equity dimension, and even though that’s not necessarily the model that the ministry is using to guide healthcare, we also take that into consideration through offering some training opportunities, education for staff, leadership across the region, and we talk about how we can train ourselves or bring in certain concepts and adapt it to our organization so that we're addressing equity, diversity and inclusion from the organizational perspective. So if it’s primary care or another community care partner or hospital, we look at what we can do within our organizations.” 

Sara and I go on to discuss her work involving outside facilitators, municipalities, and larger public health organizations in regards to achieving health equity in Tilbury, and what changes she thinks could be made.  

Sara: “One thing that I think there's an opportunity for me and even my partners to work on is just having the foundation established. So I think that a lot of people that are key to the solution of addressing equity, barriers, or just anything to do with equity, inclusion, and diversity, they need a level of understanding that makes sense to them in their work and in their available training so that they can really digest it and retain it and adapt it to their work. It's difficult to have a meaningful conversation when maybe I'm using terminology that they're not so familiar or comfortable with, or they think “well, it's not really related to my role so I don't really play a part in this”. These concepts are sometimes very abstract or complex. So I think that if we really want to make sure that we're addressing it in healthcare, offering even just a foundation of what is equity, diversity, inclusion, what are the takeaways, what are the goals for the year. Then my role as a leader is to say which ones are realistic for us, and then what do we take from that and adapt to our organization because it's very specific to our needs and our patients. There's really not much of that. So what I find is sometimes training is very specific to one aspect of health equity. It might be about LGBTQIA2S+, or it might be very specific to racism, which are all important, but there's no foundational setting so that we can then say, there's a reason why we're doing specific training. So then it's like I'm working backwards trying to explain to them (the team) how this all ties in, making it difficult at times. They're also doing their clinical work or their administrative work, so you can only limit how many times you meet as a group for education. So it's also being really strategic about what to say, how to say it. You only have so much time. So I think that's just part of it too.” 

Will: “In terms of what barriers you’ve seen in the past at Tilbury district FHT, and how you and your team have overcome them, could you tell me a bit about that? Maybe with an example?” 

Sara: “So because we are an interprofessional team, one of the challenges, which can also be a strength, is that we have people with different capacity, different education, different lived experience, which all have their pros and cons. And sometimes when it comes to specific matters, like equity, diversity inclusion, some have had no formal training around this. How do you relate it back to your work? And with all of just the needs right now in healthcare and the strain, how do you fit it in when you're talking about a million other things, and there are a bunch of other priorities. So, I think that the overcoming it is mostly like looking at optimizing our team meetings so that there's some education in there. But also, there are fees associated with that, and so it's just trying to find things that are cost effective, affordable, but also digestible for a broad group of learners with different capacities, lived experiences, and understandings, because their takeaway needs to be enough that I can then build on that for them. And if someone comes in with a very specific teaching and it's very specific to a group, it's not really in a foundational setting. It's just very specific to a community, which is great, but I can't really anchor it in something if the foundation (of equity, diversity, and inclusion; EDI) hasn’t been established. So what I'm trying to do is look at something that's a little bit broader in terms of what is EDI and what does it mean for us? So that then I can bring more specific training and say this is why we pursue training in LGBTQIA2S+, this is why we're pursue training with X, Y, Z, because it helps us build our understanding in these domains. And I think if you're going to do the training, the idea is that you're changing the way you work. So then that means you're building different functionality in your EMR or asking different questions, and all of that needs to be rooted in why we're doing that. So they really need to understand the ‘Why’? Because it is a change.” 

Will: “As one final point here, in terms of some difficulties that you and your team face when collaborating, such as not seeing eye to eye for wanting to go in one direction or building towards a specific goal, how do you meet common ground?” 

Sara: “So when I've experienced it within the organization, oftentimes I try to get the staff to try to anchor it in some kind of credible source. So, is it because you're hearing this message from a credible source, like the ministry or an organization like the OHT where is it coming from? Because often times there may be competing priorities. So if we can substantiate it in something, it's not just emotionally driven, it’s also because there's a need that's expressed across the province, or we know that our demographic happens to be representative of our specific population. So even if there are things coming from the province, it may not really be specific to us and our demographic. We really need to think about the people we serve, you can justify that because you're using data or other sources of evidence. So just making informed decisions or having informed conversations is one thing I really, really push because, not to dismiss, but sometimes based on that information we need make difficult decisions about what's priority now, or what are our resources allowing us to do now, but what do we want to work towards? Then we start building a case for why we need different training or resources, and I partner strategically so that we can address this other identified need. So that's one way we overcome a challenge and maybe if there's some disagreement, how we compromise so that we're still not ignoring or dismissing something that's important, but working towards a solution in a more strategic, methodical way. 

The other thing is just making sure that if there is a gap that it’s identified. So the one that I shared with you is a big one, right? Like there are all of these trainings that are very specific to EDI initiative, but there's nothing to root it in. So how do we know that we're not missing the ball? If somebody says to me I've done all this training, but we only serve, maybe 3% of our population that happens to fall in this community, what about the 50% that happened to be missed based on our data. How do we use that data? How do we let people know that we're not dismissing this important initiative, but that we need to focus our efforts on something else because we're neglecting a big part of the demographic we serve if we don't focus our training on XYZ. That may be inconsistent with what maybe our partners are doing. How do you have informed conversations so people don't think you're being dismissive, but you're being mindful of the need. So most of the time, it comes down to using evidence and having that support on the conversation.” 


Photo Credit: ooyoo, Getty Images