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Background
In their ‘Call for papers: Leadership, EDI, and social justice in times of crisis’, the editors of BMJ note the impact of the COVID-19 pandemic, racism, climate change, economic instability and geo-social-political conflicts on healthcare systems globally.1 While these external events have been destabilising to healthcare systems, they have also sharply focused the lens on ways in which health systems could more effectively be a counterforce to destabilisation in times of adversity.
Despite these external threats, it is critically important that healthcare systems not only see themselves as the victims of adversity, but with unsparing self-reflection, see the ways in which they may inadvertently be contributing to the perpetuation of these crises.2–4 When viewed within the framework of constructive remediation—finding a balance between repairing harms done while ensuring that they are not repeated—pathways to effective change can be defined and implemented. The area in which healthcare systems can most effectively leverage their strengths for positive change is in reducing the impact of racism in health and healthcare.5 6 Racism in healthcare has influenced all aspects of global health and healthcare, including but not limited to equity in direct care, access to new therapies, development of an effective inclusive healthcare workforce, health outcomes by population and community groups, research agendas and the education of next-generation healthcare workers. Our purpose was to consider how we, as a healthcare system, could take actions at this point in time to support equity in health and healthcare. With thoughtful self-analysis, healthcare organisations and systems can become impactful agents for positive change in reducing the damages of racism in health and healthcare. Improvement in the quality and quantity of human life, health equity across all borders and social justice worldwide are the overarching goals. System-by-system change is the path forward.7 8
Academic health systems have unique strengths positioning them to powerfully counter racism-driven disparities in global health and healthcare. The most common configuration of academic health centres in the USA includes universities and clinical systems.9 Regardless of the nature of the relationship between these two entities (separate collaborative organisations or integrated organisations), they shape every aspect of health and healthcare by means of research that spans molecular mechanisms to population-based, socioeconomic and environmental determinants of health; by innovative education, including curricular material and training methods by being intentionally inclusive in the creation of a diverse workforce; and by providing extraordinary healthcare options to all patients and populations. Academic health centres are also among the largest employers in the USA, impacting local economies.9 These systems can be closely connected to the priorities of individual communities because they impact many key domains determining health equity within communities. They thus have the capacity to implement a broad array of changes that are of high relevance. Organisational self-reflection and actions at this defining moment must be focused on the elimination of racism from all aspects of our work. We need to consider all factors that contribute to disparities in healthcare and health outcomes; to consider whether current educational paradigms adequately disseminate racism-free principles; to assess how to broaden our research on mechanisms of disease that address biological, socioeconomic and environmental factors; and finally, how to apply new knowledge in ways that provide equal benefit across all populations. Collaboration across the health system allows addressing the breadth and heterogeneity of challenges required to achieve equity in health and healthcare.
We present a process and plan developed by the Columbia University Irving Medical Center (CUIMC), comprising the Vagelos College of Physicians and Surgeons (VP&S), the School of Nursing (SoN), the Mailman School of Public Health and the College of Dental Medicine (CDM) in collaboration with the NewYork-Presbyterian Hospital (NYP) group to counter the impact of racism in every aspect of our work.
CUIMC is a large, research-intensive and clinical academic health system in northern Manhattan, serving multiracial and multiethnic communities in New York City (NYC) and beyond. Thus, we provide care for our neighbouring communities made up of populations who are of predominately African American and Hispanic/Latino descent, as well as for a wide range of patients from all demographics and geographical locations requiring advanced specialty healthcare. The students, trainees, faculty and scholars making up our internal university community come from highly diverse national and international populations.
NYC was the site of one of the very earliest cases of COVID-19 in the USA and saw a very early and rapid spread of the disease, compared with other cities and states. It was at the epicentre of the COVID-19 outbreak in the USA,10 likely due to population density and a new, highly transmissible pathogen. NYC is also one of the most diverse cities in the USA and so the race, ethnicity and socioeconomic-based disparities in COVID-19 outcomes became evident quite early in the pandemic.11 The CUIMC-NYP system serves the northern Manhattan and Bronx communities that had the highest death rate in the NYC area.10 The shock of pandemic-related disparities in morbidity and mortality, as well as resurgent race-based violence directed towards multiple racial, ethnic and religious groups, generated a powerful call to action. In July 2020, a Task Force for Addressing Structural Racism in Healthcare and the Health Sciences was convened to guide us in steps to reduce racism in health and healthcare. The task force was charged with assessing our institutional practices, policies, culture and climate, and with making recommendations, determined by consensus-driven conversations, that would be impactful, actionable and have measurable outcomes. Moreover, institutional leadership was tasked with providing resources for implementation and tracking progress over time. We report the initial process and selected outcomes at 2 years. We hope that this report will encourage other healthcare systems and health-focused institutions to define and implement specific actions that reflect the priorities and capacities of their communities to reduce racism from health and healthcare.
The task force comprised over 100 faculty, staff and students from across the four health science schools, as well as members from NYP. Membership of the committee was broadly representative across the institutions. Faculty members from each school of all ranks, areas of specialty and demographic backgrounds were invited to participate. Each health science school dean nominated two students to attend. Senior staff members in roles related to human resources were also invited to participate. The task force was led by three faculty co-chairs (RAL, ALT, OAW) who are senior faculty and leaders. The task force was charged with developing recommendations for change in six academic mission-related domains described below and working groups for each domain were appointed. Each school focuses on a different aspect of health and healthcare. In order to cover all of our domains, including direct clinical care; educational programmes; workforce development; and organisational culture, community engagement and health research, it was essential to leverage the expertise of each of the four health science schools. Working group co-chairs included two to three faculty members from different academic ranks, disciplines and schools who were able to lead productive discussions that included diverse perspectives. All groups were asked to provide their top three agreed upon recommendations, and additional recommendations were assessed by the entire task force. The working groups developed the detailed recommendations that would become the CUIMC Roadmap for Anti-Racism in Health Care and the Health Sciences (see online supplemental file I). Recommendations were required to be specific, actionable, durable and with measurable outcomes in six discrete but inter-related domains:
Supplemental material
Faculty recruitment, retention, advancement and leadership
Examine current recruitment, retention and career advancement processes for unintended bias that might be exclusionary for faculty from groups under-represented in the health sciences.
Address ways to increase recruitment, retention and academic advancement of faculty from groups who have been historically under-represented in the health sciences based on racially discriminatory practices. Also, particular attention should be paid to inclusive leadership opportunities.
Education, training and curricular change
Identify what is needed to educate/train our faculty, staff, researchers, trainees and students to develop a racism-free approach to health and healthcare.
Recommend the creation of sustainable structures for addressing anti-racism training for faculty, staff and students on an ongoing basis.
Healthcare disparities, social justice and solutions research
Recommendations for the development of a CUIMC comprehensive research programme in health disparities that would encourage meaningful short, medium and long-term solutions.
Recommendations for the development of a CUIMC research mentoring network for faculty, students, trainees and others interested in healthcare disparities, solutions and social justice research.
Clinical care
Develop a set of principles to promote bias-free patient care as well as an institutional position on racism in the delivery of healthcare.
Make recommendations for the development of structures to foster equity and minimise bias in all aspects of patient care that include an operational collaborative framework for working on these issues.
Community and public service
Add to current CUIMC-wide approaches to sustainable participatory community outreach efforts that build trust and enable dissemination of health and healthcare knowledge in our local communities.
Make recommendations for leveraging and enhancing CUIMC-wide resources for addressing social determinants of health including their intersection with structural racism in our local communities.
Civility and professionalism
Formulate principles of professionalism and behavioural expectations with attention to respect across race, ethnicity, sexuality, gender orientation and religious beliefs.
Create structures that promote the awareness of these principles and opportunities for education and training across CUIMC.
Development of reporting structures and training that are constructive, fair, equitable and transparent and that minimise risk of retaliation by those who report.12
Each working group met weekly over an 8-week period and working group co-chairs had additional meetings. The co-chairs provided additional resources and tools to inform the members of their groups. Organisational resources, tools and templates were provided and organised by the CUIMC Office of Faculty Professional Development, Diversity, and Inclusion to support the working groups and the co-chairs. After a task force report meeting, recommendations were presented to the larger committee for review and input. Once finalised, the recommendations were widely disseminated to faculty, researchers, students and staff for comment. Following the comment period, the recommendations were submitted to each school for approval. The four CUIMC health science school deans and their faculty governance bodies accepted the recommendations in full. Budget proposals for implementing the work were also developed in tandem by central units and approved to begin the work.
This set of recommendations provided the scaffolding for a complex set of action plans that will be advanced over time. Contemporaneously, each school, most departments, centres and institutes developed their own diversity, equity, inclusion and belonging (DEIB) strategic plans that were specific to their units. Because each school had individual plans relevant to their particular disciplines, those specific recommendations were handled at the school levels. For example, a mobile dental van to increase community access to oral healthcare was part of the CDM’s individual plan. Enhancement of a nurse practitioner-staffed primary care practice was part of the SoN’s individual plan. These are examples of discipline-specific actions that may not have been recommendations of the centre-wide group but were essential to the health equity priorities of the individual schools.
All departments were also asked to appoint faculty members to lead efforts within their departments. Thus, the central process was amplified and synergised across CUIMC. Many of these appointed faculty members had little formal experience in DEIB work and were isolated within their departments. A network of all faculty members leading DEIB initiatives across schools and departments was formed to (1) provide guidance and resources; (2) encourage collaboration; (3) and facilitate the exchange of initiatives, challenges and solutions in tandem with the implementation of the task force’s recommendations. Prior efforts focused on addressing the needs of faculty from groups under-represented in health sciences and had taken place primarily within individual schools. Most were directed at changes in faculty recruitment to result in broader inclusiveness in the composition of the faculty, at professional advancement and support, and at minimising bias in key decision-making processes. While important, they did not have the breadth of focus charged to the task force nor the central oversight to maintain momentum of actions over time. The task force was a CUIMC-wide initiative to develop a comprehensive set of action recommendations for solutions in all domains of healthcare and the health sciences held in common by all four schools. The intentionally highly collaborative nature of this work has required strong partnerships and joint efforts across the CUIMC enterprise, including but not limited to CUIMC central and departmental administrative units, CUIMC clinical and basic science departments, CUIMC human resources, the CUIMC Academy of Community and Public Service, the Columbia University Center for Teaching and Learning, the CUIMC Office of Innovation in Health Professions Education, the Columbia University Irving Institute for Clinical and Translational Research, the VP&S Office of Research, the Academy of Clinical Excellence, all CUIMC offices of education, the Columbia University Department of History, CopeColumbia (a programme developed by the Department of Psychiatry to support members of the CUIMC community) and NYP. The progress made thus far is the result of the dedication of the entire CUIMC community to the work required for an enduring transformation of the academic health system.
Two-year implementation
Task force findings and recommendations were formally shared in a report in October 2020 and adopted by all four schools (see online supplemental file 1 for full report). Implementation began in January 2021. Selected outcomes as of February 2023 in each of the six domains are outlined below in table 1.
Updates regarding our progress have been disseminated broadly to the CUIMC community via the following communication strategies: a monthly implementation group meeting made up of co-chairs of the working groups, leadership and students from CUIMC; presentations from the dean’s office via open forums and messaging to the university leadership. Data collection and reporting have been continuous throughout this process and are regularly shared with CUIMC stakeholders, faculty and leadership.
Although progress has been made in the implementation of the recommendations, it is clear that transformative change requires complex relationships that are sustained over time.
Discussion
The recommendations of the Task Force for Addressing Structural Racism in the Health Sciences at CUIMC have become a blueprint for a catalytic, collective and strategic approach to reducing racism in healthcare and the health sciences. Importantly, it is treated as a living document that is expected to undergo reconsideration and revision over time. Even though there have been transitions in leadership over the 3-year period since the task force was appointed, the task force recommendations have continued to be implemented and held at the highest priority level. The implementation of many of these initiatives has become increasingly integrated into the fabric of the day-to-day organisational policies and procedures. Included are hiring and onboarding of new personnel across all position descriptions; career advancement of faculty, researchers and staff; searches for faculty and staff; curricular change and professional development for students, staff and faculty; clinical operations; research agendas; the ways in which employees, faculty and students interact with one another; service to our surrounding community; and consensus to operate under the lens of anti-racist health equity and social justice.
CUIMC is a matrix organisation, as is common among other academic health centres in the USA. Thus, much of this work still takes place in silos and requires intentional integration and system-wide collaboration across organisational entities (ie, hospital systems and universities). Examples of these complexities include:
(1) Departmental-level change is focused in a single discipline and limited in the type and range of domains in which change can be implemented. For example, a department focused on the delivery of direct care may not be able to impact the science behind health differences and inequities.
By contrast, (2) large-scale changes in clinical care environments require the integration of distinctive hospital and university governance structures on both inpatient or outpatient care. Clinical practice sites have very different volumes and flows of patients, as well as other factors requiring individual approaches specific to specialties that are best determined by individual departments. Clinical departments vary in size, balance of outpatient versus inpatient activities, procedurally based or not, as well as needs for diagnostic equipment, space, etc. Policies and governance procedures for changes in clinical environments require the cooperation of two separate corporate entities, NYP for inpatient settings and Columbia University Faculty Practice Organization for outpatient settings. While our two organisations are in complete agreement about the goal of this work, working within two large complex organisations is challenging and time-consuming.
Under the new leadership of CUIMC, the overall strategic planning process aims to (1) further embed DEIB and anti-racism efforts into all medical centre operations; (2) identify the current structures that are not aligned with those goals and (3) critically examine the ways in which CUIMC engages with the surrounding as well as global communities.
We are encouraged to see fellow academic health centres acknowledging commitment to anti-racist change and urge our colleagues in academic medicine not to lose momentum. Despite the efforts that have been made, there is much left to be done. We remain optimistic about a path to a very different world of health equity.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors would like to thank the 100+ members of the CUIMC Task Force for Addressing Structural Racism in Health Care and the Health Sciences who worked intensely and thoughtfully to create the recommendations found in the Roadmap for Anti-Racism in Health Care and the Health Sciences.
Footnotes
Contributors AKR appointed the Columbia University Irving Medical Center Task Force for Addressing Structural Racism. ALT, RAL and OAW co-chaired the task force. The Office of Academic Affairs team under the leadership of ALT provided administrative support to the committee. KAA provides continued support from the dean’s office. CL, NH and ALT took the lead in writing the manuscript with input from all authors. The members of the Task Force for Addressing Structural Racism worked quickly and thoughtfully to create a Roadmap for Anti-Racism in Health Care and the Health Sciences to guide us to be champions of change.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.