Diversity in Health Care Task Force Annual Report 2021

Effective January 1, 2020, newly enacted state legislation established the Diversity in Health Care Professions Task Force (Task Force), with administrative support to be provided by the Illinois Department of Public Health (IDPH). Public Act 101-0273 set forth the mission of the Task Force to work towards specified objectives that achieve greater diversity within the health care workforce (newly cited as 20 ILCS 2310-213).

The task force consists of the following professional categories, licensed within Illinois, to practice in their respective field: two dentists, two medical doctors, two nurses, two optometrists, two pharmacists, two physician assistants, two podiatrists, and two public health practitioners.

• Gloria E. Barrera, MSN, RN, PEL-CSN
  
• Lisa Charles-Fields, PhD, PA-C
• Martin Cortez, PharmD, BCPS
• Sodabeh Etminan DMD, MPH
• Christina Morettin, OD, FAAO
• Karona Mason, DPM, MA
• Melissa Martin, MPH
• Ziemowit Mazur, Ed.M, MS, PA-C
• Len Meyer, MHSA
• Erik Mothersbaugh, OD, FAAO
• Vidhya Prakash, MD, FACP, FIDSA, FAMWA (Chair)
• Bryan Richardson, MD

The Task Force elected to use the following framework to generate a list of key recommendations.

Purpose/Goal: To diversify the health care workforce by engaging students, parents, and the community to build an infrastructure that assists students in developing the skills necessary for careers in health care.

Minority students pursuing medicine or health care as a career option.

• Establishing a mentee/mentor relationship with current health care professionals and students by:
  • Utilizing social media to communicate important messages and success stories
    
  • Holding a conference related to diversity and to inclusion in health care professions
    
• Early employment and support by:
  
  • Researching and leveraging best practices, including recruitment, retention, orientation, workplace diversity, and inclusion training
    
  • Identifying barriers to inclusion and retention and proposing solutions
    
• Health care leadership and succession planning including:
  
  • Providing education, resources, and tool kits
    
  • Developing health work environments; leadership training on culture, diversity, and inclusion
    
  • Obtaining workforce development concentrated on graduate and post-graduate education and succession planning
    
• Collaborate with the following to achieve greater diversity in medicine and the health professions
  
  • policy makers
    
  • medical and specialty societies
    
  • national underrepresented minority organizations
    
  • other groups
    

• Affirmative action programs should be designed
• Recruitment activities should support and advocate for the full spectrum of racial, ethnic, and cultural diversity
  
• Recruitment and academic preparations of underrepresented minority students should start in elementary school
  
• Financial incentives should be increased to underrepresented minority students
  
• Staff should be hired in all academic organizations who are accountable to the organizational leadership and should implement and measure the effectiveness of their activities
  
• Establish a formal program or mechanism to ensure that underrepresented minority students have the opportunity to rise to leadership positions at all levels
  
• Organizations with a stake in enhancing workforce diversity should implement systems to track data and information on race, ethnicity, and other cultural attributes
  

What does the data tell us about the existing disparities?

What local, regional, and national think tanks can help us with the data?

What does the literature tell us about solutions at scale?

How should we prioritize our initial list of recommendations/action items?

Who are the key stakeholders and experts we need to bring to the table?

The task force convened June 26, 2020. Members discussed the purpose and goals of the task force, objectives, and priorities. The task force elected Dr. Vidhya Prakash as its chair. A decision was made to organize into three working groups – Education, Leadership, and Collaboration – and select chairs for each.

Working group leaders met with their teams to further discuss existing data, literature, and key stakeholders that would help the task force meet its goals. The task force met again September 11, 2020, and working groups shared their insights. When the task force met November 1, 2020, each working group had generated a list of salient articles and key recommendations. The task force met December 3, 2020, to solidify its recommendations.

Over the past year, the Task Force recognized the importance of acquiring data to understand existing disparities in medical education and to inform solutions at scale. The Task Force designed a comprehensive survey tool to collect data on equity, diversity, and inclusion policies and practices. The survey was sent to all statewide medical institutions September 28, 2021, with a request for responses within one month. At the time of this annual report, the task force is in the process of analyzing the data.

“The business case for inclusion and diversity (I&D) is stronger than ever. Taking a closer look at diversity winners reveals what can drive real progress,” begins McKinsey and Company’s 2020 diversity report. The company’s 2019 analysis revealed that “companies in the top quartile for gender diversity on executive teams were 25% more likely to have above average profitability than companies in the fourth quartile.” Further, top quartile companies in ethnic and cultural diversity consistently outperformed lower quartile companies. While this data makes for quite a compelling case for diversifying the workforce, companies represented in the United States and United Kingdom in the McKinsey study are making little progress overall; more than one third of these companies have no women on executive teams and the representation of ethnic minorities in executive teams only rose 7% over five years.

How does the McKinsey business experience and analysis pertain to our health care system? In an umbrella review, Gomez et al found a positive association between diversity, quality, and financial performance in health care. Patient outcomes improved when cared for by diverse teams, and there was a direct correlation between increased diversity and financial performance. According to Dr. Yele Aulko, EY Americas chief medical officer, “COVID-19 has demonstrated the direct correlation between the health of a workforce and the resiliency of the business.”

The Centers for Disease Control and Prevention (CDC) emphasizes that race and ethnicity are markers for social determinants of health including income, education, housing, access to health care, and occupations that puts individuals at risk for COVID-19 (frontline, essential, and critical infrastructure workers). Compared to White persons, Black or African American persons are 2.6 times more likely to be hospitalized due to COVID-19 and 1.9 times at higher risk of death due to COVID-19. As a result of disparities in health care in Black, Latin X, and Native American populations, in particular, the projected economic burden of these very disparities will cost the United States $353 billion by 2050 if no changes are made to the current system.

In order to bridge these health disparities, to promote health equity for all populations, and to reduce the economic burden of these disparities, the health care workforce must be diversified. As discussed in the Task Force’s 2020 report, a culturally competent workforce is imperative to optimize patient satisfaction and to provide the highest quality of care for an increasingly diverse patient population. Further, a diverse health care workforce is required to enhance access and excellent patient care in underserved communities. More data reveals that physicians who are Black, Hispanic, and Native American practice in underserved communities, and that racial concordance between patient and provider leads to improved patient satisfaction. A diverse health care workforce will also help broaden a narrow research agenda to one that addresses the very disparities in health care unearthed by COVID-19.

What progress have we made in bringing diversity, equity, and inclusion to the health care workforce? As discussed in the Task Force’s 2020 annual report, according to data from the Association of American Medical Colleges (AAMC), in 2018 only 5% of practicing U.S. physicians were Black, and 5.8% of practicing U.S. physicians were Hispanic. These figures stand in stark contrast to Blacks or African American representing 13.4% and Hispanics or Latinx representing 18.5% of the U.S. population, respectively. In addition, in 2018, 64.1% of physicians were male and only 35.8% were female. Further, the AAMC’s “Exploring Faculty Salary Equity at U.S. Medical Schools by Gender and Race/Ethnicity, published in 2021, highlighted gender disparities among faculty in medicine, including the fact that White men are more highly compensated than men of other races and women of all races and ethnicities, and that men make more than women of the same race and ethnicity. Transgender and gender non-binary medical students and physicians continue to witness and to experience stigma and discrimination, having to hide their identities.

What are the barriers to achieving diversity, equity, and inclusion in the health care workforce? As a result of decisions that end taking race into account for admissions policies in schools, medical school enrollment of underrepresented minority groups is on the decline. Since 2017, women have outnumbered men in matriculation to U.S. medical schools, but women continue to struggle with career advancement in medicine. The COVID-19 pandemic has brought with it even more barriers as women bear a disproportionate burden of child care responsibilities, having to choose between work and home and ultimately, leaving the health care workforce.

The mission of the Task Force is to diversify the health care workforce in Illinois in order to create a culturally competent workforce, optimally care for underserved populations, broaden the research agenda, and ultimately improve patient satisfaction through service of the highest quality of care. The Task Force is committed to leading a collaborative effort among statewide and national stakeholders to achieve its objectives.

1. Launch a statewide survey similar to the 2015 American College of Healthcare Executives (ACHE) survey comparing career attainments and experiences of male and female health care executives by race/ethnicity.
2. Expand the survey to regional organizations, including the Illinois Health and Hospital Association, the Illinois Primary Health Care Association, and academic institutions to ensure a robust data set.
   
3. Sponsor a diverse array of health care professionals in Illinois for national leadership training from entities, including the Presidential Management Fellowship, The Albert Schweitzer Fellowship, ACHE fellowships, and the Robert Wood Johnson Foundation Health Policy Fellows program.
   

The Leadership Committee emphasizes the following key areas as the task force engages with stakeholders:

Individual and Organizational efforts: An increased focus on organizational as well as individual development through an evidence-based approach is essential to build a more culturally competent health care organization. From an organizational perspective, current health care leaders must possess characteristics to lead systemic transformation towards a sustainable delivery system. Previous models of health care are migrating toward a focus on wellness, prevention, primary care, increased patient autonomy, and involvement in decision-making, which requires a more integrated model of care. This, in turn, mandates a more collaborative and transformational leadership style that is achieved by having a more inclusive leadership team. Promotion of diverse health care providers to leadership roles is possible through organizational mentorship, and it is recommended that health care systems pursue the development of human capital systematically by encouraging goals in mentorship and development.

Evolving patient base: From 2011 to 2013, hospitals saw the percentage of underrepresented minority patients grow from 29% to 31%, while racial and ethnic diversity in C-suite positions remained flat at 14%. Recent studies demonstrate that leadership teams that include greater diversity and reflect the patient base are associated with higher performance. Moving forward, the goal will be to bridge the disparity between the diverse patient population and the makeup of our health care leadership teams.

Organizations that promote leadership training to increase diversity in health care leadership: Diversity in C-suite positions has much room for improvement. According to a 2019 survey conducted by the Institute for Diversity and Health Equity (IFDHE), a branch of the American Hospital Association (AHA), more than half of hospital and health system respondents acknowledged having a comprehensive plan for reducing inequities in health care delivery. At the time of the survey, only 16% of all C-suite positions were held by an ethnic/racial minority. Only 40% of respondents indicated their organization had either implemented or achieved an increase in their C-suite positions, 81% of board member positions were held by someone who is White, and 65% of the board seats were held by males.

More than half of respondents reported no concrete plans to diversify their board of trustees. A third of respondents indicated that diversifying their C-suite was not a part of their organization’s strategic plan.

The value of diversity has been well-understood in the corporate world. Diversity in companies has been shown to build relationships, enhance problem-solving skills, better retain employees, and increase profitability. The value of diversity in health care has less research than in business but there is ample data to suggest that diversifying the health care workforce leads to improved patient outcomes. Diversity in health care leadership leads to better understanding of cultures, issues, and needs of local populations which results in better decision-making on how to serve those communities. Researchers estimated that health disparities amount to $93 billion in excess medical care costs and $42 billion in lost productivity per year, and the potential for a gain of $135 billion per year if we are able to eliminate racial disparities in health. In the end, we must diversify our health care workforce to eliminate health disparities and to improve patient outcomes.

1. Appropriate funding to outreach/pipeline building programs for elementary and high school students from underrepresented racial/ethnic minority and/or low-income backgrounds.
2. Develop standardization for pipeline programs, including metrics of success.
   
3. Develop and implement universal guidelines for institutions of higher education as it relates to their institutional commitment to diversity, to equity, and to inclusion, and to justice.
   
4. Call to action for health care professionals in Illinois to volunteer their time, whether in-person or virtually, for mentorship and collaboration on outreach efforts at the elementary school level (includes mentorship programs and parental support).
   

It is essential to build pipeline programs to encourage and to build budding health care providers and leaders. While women have made great strides in representation in science, technology, engineering, and mathematics (STEM) fields, their attrition during graduate school and in the workforce remains problematic. The same pattern applies to ethnic minorities. Pipeline programs that build positive STEM experiences, bolstering interest and self-confidence among elementary and junior high students are key. As students enter high school, pipeline programs that develop these STEM interests and provide skills for success are imperative. An ideal system would entail standardized programs and specific metrics of success and include ample STEM training for teachers, guidance counselors, and school leaders on how to best sustain interest in STEM and to prepare students to excel in these fields. Further, programs that emphasize long-term, experiential learning in the form of community, school, and internet-based initiatives offer more opportunities for impact.

Community engagement, particularly involving volunteerism from health care professionals, will undoubtedly engage children in a meaningful way. It is also important to note that parental involvement is of paramount importance. As a result of the Short-Term Enrichment Program (STEP) of the University of Pennsylvania School of Dental Medicine, which included workshops for students and parents, students in dental school or predental programs had the highest percentage of parental involvement (discussions about career goals and participation in STEP). Evidence shows the benefit of early intervention on influencing children’s outcomes, with studies referencing first grade as an important exposure threshold.

Mentorship skills are necessary to prevent attrition from the health care workforce and encourage more diverse individuals to pursue leadership positions. Not only do mentors provide tools to help mentees master their subject matter, but they also provide emotional support, career advice, and wisdom. Dedicated mentorship programs will also help develop leaders in all aspects of the medical field to include patient care, education, and biomedical discovery. Mentorship can be in-person, virtual, or a combination of the two. One virtual program during the COVID-19 pandemic improved students’ career self-efficacy.

It will be important to provide health care institutions of higher learning specific guidance on best practices to uphold the ideals of equity, diversity, inclusion, and justice. A standardized set of guidelines; dashboards that track data specific to equity, diversity, and inclusion; precise metrics of success; and accountability of leadership will be instrumental in ensuring a diverse health care workforce and optimal learning and working climates.

1. Build collaborations between health care institutions of higher learning and key state stakeholders to form a statewide diversity in health care coalition.
2. Include national partners to forge collaborations with the statewide diversity in health care coalition.
   
3. Create opportunities to engage community-based organizations and pipeline programs across the state that play a vital role in increasing diversity in health care professions.
   

Collaboration across disciplines increases diversity in health care. Medical students and health care professionals benefit from exposure to cross-disciplinary teamwork and core concepts of medical innovation. To address complex challenges in patient care, diversity in collaboration across disciplines, including medicine, nursing, optometry, dentistry, business, and engineering is critical.

Collaboration between health care institutions of higher learning and key stakeholders will also serve in the mission to diversify the health care workforce. Examples of key state stakeholders include, but are not limited to, the Illinois State Medical Society, Illinois Alliance for Welcoming Healthcare, National Association of Hispanic Nurses-Illinois chapter, Medical Organization for Latino Advancement-Chicago, Chicago chapter of the Black Nurses Association, Philippine Nurses Association of Illinois, and the Illinois chapter of the National Arab American Medical Association. Examples of essential national leaders include the Healthcare Diversity Council, National Diversity Council, National Medical Association, National Area Health Education Centers, American Medical Association, and American Medical Women’s Association. The ultimate goal is to unite as one diversity in health care coalition to provide resources and tools to Illinois health care organizations to optimize diversity, equity, inclusion, and justice in the health care workforce.

It is through cross-sectional collaborations that health care organizations can diversify the health care workforce, thus building bridges among health care systems, strengthening the health care infrastructure, and optimizing health care and health for our patients.

There are several high quality paradigms which will help guide future discussions. During the 2021 Association of American Medical Colleges (AAMC) Learn, Serve, Lead meeting, Dr. Geoffrey H. Young, senior director of HealthCare Workforce Transformation at the AAMC, described a tripartite strategy to diversify the physician workforce, which can be applied to the health care workforce as a whole. Dr. Young’s strategy includes leveraging data for change, widening the path to medicine and other health professions, and addressing culture and climate for equity. Dr. Young asked individuals and institutions to ponder the following questions:

• What are your spheres of influence and control?
• For what and whom do you publicly advocate?
  
• How do you frame and deliver your messages?
  
• Where do you allocate resources?
  
• How do you use your institutional data?
  
• What are the professional and learning culture(s) at your institution?
  

Dr. James Guevera and colleagues, in a recent publication in the New England Journal of Medicine, discuss more strategies for racial and ethnic diversity at medical schools, which again can be applied to the establishment of health care institutions of higher learning. Guevera’s strategies are summarized below:

• Institutions shift from an applicant-deficient lens to a system-deficient lens.
• Standardize the design and evaluation of pipeline programs.
  
• Develop consensus on diversity-related measures and metrics of success.
  
• Faculty recruitment and promotion committees are diverse and trained in implicit bias.
  
• Measure and improve inclusivity in clinical training environments.
  

The Task Force will review and analyze the results of the survey. From there, we will actively engage with state and national stakeholders and think tanks through a summit to determine key priority areas with a focus on solutions. Further, we intend to provide health care organizations and institutions of higher learning a framework for prioritizing equity, diversity, inclusion, and justice in their settings, and utilize data gleaned from the survey and these discussions to guide leadership development in health care through collaborative partnerships. Our hope is that this will be the first of many summits to actively engage with our leaders in health care to fulfill our mission of diversifying the health care workforce in Illinois.