Michigan’s Plan to Reduce Implicit Bias for Improving Care Outcomes

by Orlene Hawks, Director, Michigan Department of Licensing and Regulatory Affairs

August 20, 2021 - Healthcare is not just science, but science directed by people. The last thing we think might be in the way of healing patients is our own bias. Yet, one of the brutal lessons from the COVID-19 pandemic is that racial disparities and implicit biases persist in our society. In particular, the disproportionate COVID-related death rate among people of color focused a spotlight on the differences in how disease is recognized and treated among people with the same disease but with different racial backgrounds. These disparities often have their root in a caregiver’s implicit biases.

Implicit biases that contribute to disparities are often unconscious, and as former Supreme Court Justice Ruth Bader Ginsburg said, “…unconscious bias is one of the hardest things to get at.”

Recognizing that implicit bias factors into healthcare disparities, Gov. Whitmer charged the Michigan Department of Licensing and Regulatory Affairs (LARA) to develop administrative rules to educate and train healthcare professionals to recognize and address implicit biases. Motivated to quick action by the escalating death rate during the pandemic, my team worked with 86 stakeholder organizations, licensees, health professional boards, and legislative partners, to craft nation-leading rules governing implicit bias training for healthcare professionals. While rulemaking is generally a lengthier process, LARA was able to complete this in less than one year and the rules were enrolled on June 1, 2021.

What is Implicit Bias?

As defined in the rules, implicit bias means an attitude or internalized stereotype affecting an individual’s perception, action, or decision making in an unconscious manner, often contributing to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic. As a Black professional woman, I can tell you that I have often encountered these biases from well-meaning people, from all walks of life, who have made assumptions about me solely based on my race, age, and/or sex.

Everyone can have an implicit bias, and it is important to recognize that implicit biases often exist outside of conscious awareness, and therefore are difficult to control. They can shape behavior, including the behavior of healthcare professionals. One way to reduce disparities in health outcomes is to seek to eliminate the unconscious biases, misconceptions, and stereotypes that can lead to differences in how healthcare is provided.

Administrative Rule Promulgation

The promulgation of administrative rules requiring implicit bias training has its origins in Gov. Whitmer’s Executive Directive 2020-7, issued in July 2020. While implicit bias in practitioners was not unknown prior to the COVID-19 pandemic, racial disparities in health outcomes came into sharp focus during the early stages of the pandemic. Reports that COVID-19 was four times more prevalent among black Michiganders than white Michiganders, coupled with national data from the Centers for Disease Control and Prevention showing higher COVID-19-associated hospitalization rates for non-Hispanic black persons than for white persons, and even higher hospitalization rates for Indigenous populations, were sobering. Death rates exposed more of the grim story with Black and Latino peoples nearly twice as likely to die from the virus as white people.

Sadly, these disparities are not limited to COVID-19, as people of color face disparities in terms of morbidity, mortality, and health status, with black, Hispanic, and indigenous Americans having higher infant mortality rates than white and Asian Americans, and the death rate from heart disease and stroke being highest among black Americans.

Training Standards Take Effect June 1, 2022

Such stark differences in healthcare outcomes compelled the Governor to issue a directive that LARA promulgate rules requiring healthcare professionals to receive training on implicit bias and how it affects delivery of healthcare to improve outcomes for all Michiganders. Starting June 1, 2022, over 440,000 healthcare professionals licensed or registered in Michigan, representing 26 of 27 Article 15 license types, will be required to complete training.

The rules require new license applicants to complete a minimum of two hours of implicit bias training within the 5 years immediately preceding the issuance of a license or registration. For those already licensed, the requirement is one hour of education per cycle year prior to renewing licenses and registrations.

Training must be interactive and include information on:

  • The history and present nature of implicit bias
  • Improving equitable access to healthcare to reduce disparities in care and strengthen healthcare outcomes
  • Strategies to self-identify and address implicit biases

Training can be delivered by:

  • A state or national health-related organization, such as Michigan Academy of Family Physicians
  • A state or federal agency
  • An accredited college or university
  • An organization specializing in diversity, equity, and inclusion issues
  • A board-approved educational program

LARA’s Bureau of Professional Licensing will be sending out reminders and information to stakeholders and licensees about the new requirement as the implementation date gets closer, so be sure to look for those notices.

Michigan is committed to having the best healthcare workforce in the country with the best healthcare for all citizens. Through the collective efforts of our licensees, health professionals, and board members, we took a bold step to improve health outcomes and ensure the highest level of care, access, and equity for every individual.

Not only are we promoting high standards of technical knowledge and clinical skills, but we are also creating an environment where health professionals can better understand the ways in which they view and interact with the communities they serve. While there is more work to do, I am truly proud of the steps that we have taken. With the adoption of these new training standards, Michigan is leading the nation in addressing implicit bias within the practice of healthcare. I am confident that we are laying a strong foundation of systemic change that will improve the delivery of healthcare and lead to better health outcomes.

For more information regarding the new implicit bias training standards, please reach out to BPLHelp@michigan.gov or call the Bureau of Professional Licensing at 517.241.0199.

Orlene Hawks is director of the Michigan Department of Licensing and Regulatory Affairs. Prior to joining LARA, she led the state's Operation Excellence project dealing with Michigan Department of Health and Human Services' Child Protective Services investigations. She previously managed the Quality and Program Services section in the Michigan Department of Community Health (DCH). She also managed the Child, Adolescent and Family Health Services section, directed the Office of Statutory and Legislative Compliance, and served as Legislative Liaison for DCH.