3

Diversity, Equity, and Inclusion and Health Equity Commitments at the C-Suite and Institutional Level

The workshop’s second session featured a panel that engaged in a moderated discussion about the evolution of diversity, equity, and inclusion (DEI) and health equity commitments at the C-suite and institutional level. Perspectives were presented by representatives directing health equity efforts at a health care association (American Hospital Association [AHA]); a county-run integrated health system (Contra Costa Health); and a large, diversified health care company (CVS Health). Panelists were asked to describe their roles, comment on the evolution of their organizations’ DEI and health equity commitments, and share challenges faced and lessons learned.

HEALTH EQUITY EFFORTS AT THREE HEALTH CARE ORGANIZATIONS

Workshop planning committee member Yvette Calderon, dean and vice president for equity in clinical care and professor of emergency medicine at the Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, moderated the discussion among Joy Lewis, senior vice president for health equity strategies and executive director of the Institute for Diversity and Health Equity at AHA; Anna Roth, Contra Costa County, CA, health director and chief executive officer at Contra Costa Health; and Joneigh Khaldun, vice president and chief health equity officer at CVS Health and practicing emergency department physician. Calderon started the discussion by asking the panelists to describe their roles.

Lewis said that in the fall of 2020, AHA announced an organizational realignment to reflect its increasing focus on advancing equity. As part of the realignment, AHA created Lewis’s position, which has a seat at the executive management table, and assigned oversight of the existing Institute for Diversity and Health Equity to her position. Lewis noted that her work is outward facing and focuses on mobilizing action among AHA’s membership of nearly 5,000 hospitals and health systems using AHA’s health equity roadmap as a guide.¹

One of Lewis’s first tasks after assuming her position at AHA in 2021 was to update the organization’s mission and vision statements to emphasize the importance of equity in everything AHA does. Her second task was to craft AHA’s statement about racism as a public health threat and the role of racism and structural racism as key drivers of health disparities. Lewis said that she views pledges as performative at best if there is no action or follow-up. As an example of a concrete step that AHA took, she said that the organization identified three innovative Black and brown fund managers,² of Jumpstart Nova, SteelSky, and Seae Ventures, who were developing health equity solutions to improve access to care and quality and to address affordability for communities that looked like them. AHA then provided early financing to those fund managers. Lewis added that this action signaled to the field that there are innovators who have been historically undercapitalized and who do not have access to pitch their creative and innovative solutions to C-suites. “When we put our weight behind these fund leaders, other members paid attention,” Lewis said.

Roth said that when she started as a frontline nurse at Contra Costa Health, she was unprepared to confront the deep inequities within her health system. “It was shocking to me,” she said, “and as I reflect now, I understand that shock was rooted in privilege and a lack of understanding.” Even today, she said, she feels the nation’s health care enterprise has not confronted structural racism, White supremacy, and structural inequities with the same urgency as it has confronted other issues. As an example, she cited how access to dedicated resources enabled her health system to close the vaccine gap in the Latino community and nearly eliminate it in the Black community over the past two years.

Roth explained that Contra Costa Health has established DEI committees and groups dedicated to reducing health disparities and is building out a health equity office. Contra Costa County has completed a two-and-

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¹ https://equity.aha.org/ (accessed November 21, 2023).

² https://www.aha.org/system/files/media/file/2023/11/Health_Equity_Investment_Report_Evening-the-Playing-Field.pdf?mkt_tok=NzEwLVpMTC02NTEAAAGP2UHMBBt3TDTHCTJFIp2FV7UU5chxCXOdZKWOzr0WY2vXugp7ncBrMGZKEcf5t7-40-P2FsmzyYrKrqFWIu0mTsW8LDr8FErlQhTLjPtHI71SVQ (accessed January 5, 2024).

a-half-year, community-led journey to open its Office of Racial Equity and Social Justice and hired an internal department head, who would have a position equivalent to a district attorney or sheriff, and an external community-focused equity officer.

While this is a historic development, the many questions she and her colleagues have been asking for the past 30 years remain, such as why there is an 11-year disparity in life expectancy, why Black and brown community members are disproportionately represented in detention settings, and why police are being sent to behavioral health emergencies in the community. Other questions include why her health system’s leadership does not reflect the community it serves and why they are trying to answer these questions without involving the community. Roth concluded that asking those questions has triggered a plethora of activity, including challenging where the boundaries of the health system’s input and voice should be.

Khaldun stated that at CVS Health, the role of chief DEI officer and her role as chief health equity officer are separate. She added that these roles are not framed as internal versus external facing and that she considers her role to encompass all business lines by providing services that “leave no one behind.” Over the two years Khaldun has been at CVS Health, she has established an expert health equity team and advanced the company’s health equity strategy. Given the reach CVS Health has—it touches 100 million lives annually through its many business lines, and 85 percent of U.S. residents live within 10 miles of a CVS Health facility³—she believes that there is the opportunity for its work to improve health equity nationwide.

One part of Khaldun’s job is to ensure that CVS Health’s 300,000 plus colleagues have a deep understanding of the health inequities that impact the people CVS Health serves and are provided with resources and tools to help address those inequities. Khaldun’s team leads internal work to expand and improve the company’s data infrastructure to help it understand where disparities exist among its customers, members, patients, and local communities. Khaldun added that her team uses data insights to guide the company’s health equity work, while also assessing the programmatic and policy levers the company can use to advance its health equity strategy.

Calderon asked Roth to describe the evolution of Contra Costa Health’s DEI and health equity commitments over the past five years. Roth explained that Contra Costa Health has established several programs over the past five years to address DEI and health equity commitments, including an initiative to reduce health disparities, and has estab-

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³ https://cvshealth2021inreview.com/ (accessed November 13, 2023).

lished a DEI committee in the health delivery system and health plan. She said that public health has been a leader on these issues in her system and the community it serves. Over the past three years, Contra Costa Health has created community-driven committees led by its Office of Equity and moved its chief equity officer and equity team into the C-suite next to her office. To inform its work, Contra Costa Health brought in the Justice Collective, a women of color, locally owned group with expertise in working with the community and government. It has also centered its work using the Institute for Healthcare Improvement’s (IHI) equity framework,⁴ provided business intelligence capabilities to the equity unit, and assigned communications teams to help the community navigate and understand the data the health system generates, Roth said.

In fall 2020, Contra Costa Health worked with elected officials and the County Board of Supervisors to declare racism a public health crisis, highlighting the sense of urgency and how a big a threat racism is to the health and safety of the community.⁵ At the same time, Roth and the rest of the leadership team have set the tone around how important addressing health inequities is, acknowledged this work is hard, and established safe environments to have hard discussions through a lens of authenticity and humility. “This is not checking-the-box work,” Roth said. “This is hard work, painful work, and it is liberating.”

Calderon asked Lewis to describe what evidence AHA gathered to ensure staff input throughout all levels of the organization when setting its DEI and health equity commitments. Lewis said that when she assumed her role at AHA, she inherited a grant from the Robert Wood Johnson Foundation to build the tools and resources to implement the health equity roadmap. Attached to those funds was a requirement for AHA to conduct a self-interrogation of its internal capabilities to lead the field. Lewis noted that in the fall of 2020, AHA conducted an internal DEI assessment comprised of focus groups and interviews with staff that ranged in professional levels and titles, pay range, and office location. The resulting exercise generated a comprehensive report that led the organization to establish a DEI task force, which distilled the report into 16 recommendations to inform a multi-year strategic plan. One recommendation was to create an internal DEI position reporting to the chief operating officer, and today that individual works closely with Lewis and the head of human resources. The result, Lewis said, is an inside/outside strategy that enables cross-pollination of ideas to move equity work for-

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⁴ https://www.ihi.org/resources/white-papers/achieving-health-equity-guide-health-care-organizations (accessed November 21, 2023).

⁵ https://cchealth.org/directorsmessage/2021-0316-letter.php (accessed November 13, 2023).

ward. Calderon followed up by asking Lewis to describe AHA’s health equity roadmap. Lewis explained that the roadmap is designed to meet AHA’s members wherever they are on their equity journey and to help them develop their own capabilities to craft a path to the desired end goal of health and the elimination of health disparities in communities they serve. The roadmap consists of six levers of transformation that research and experience show are important in the transformation of health care organizational structures. These include the following:

• Provide culturally appropriate patient care,
• Establish equitable and inclusive organizational policies,
• Collect and use data to drive action,
• Develop diverse representation in leadership and governance,
• Collaborate with the community to develop and implement solutions, and
• Implement systemic and shared accountability.

Lewis noted that members complete a health equity transformation assessment that AHA uses to form a profile of where an organization is regarding the six levers. This provides AHA’s members with a baseline of where they currently sit and helps them devise a plan to move forward. To further these efforts, AHA created an open-source health equity action library—a curated list of resources, how-to guides, and toolkits—that is available for anyone to access. At the time of the workshop, approximately 1,500 hospitals and health systems had engaged with this resource.⁶

Calderon asked Roth to share how she has navigated challenges to continue moving initiatives forward despite organizational or legislative attacks grounded in White supremacy and racism. Roth said her organization has addressed these through liberating data and voice. Helping those in power see how actions to address racism and health inequities are linked to other outcomes they care about is important, Roth said. She added that focus and rigor have grounded their work, noting that they lead this work by “really tackling as a system what are the things that we will no longer tolerate…and then…razor block on those and really eliminate [them] so that we can then get to the next thing.” Roth concluded by stating that “without focus, we have not made gains” and that success does not need to take generations and decades. “There has to come a time when we say no, this has to change today,” she said.

Calderon asked Khaldun to share lessons learned about setting and prioritizing DEI and health equity initiatives at CVS Health. Khaldun stated that it is impossible to boil the ocean, so focusing on specific issues

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⁶ https://www.aha.org/heal (accessed November 21, 2023).

and setting specific goals for outcomes is key to success. CVS Health, for example, focused its health equity work on hypertension, depression, and maternal morbidity, all conditions with broad health disparities and evidence-based interventions that were not being leveraged. Given the scope of the organization, her team felt these were areas where it could have a significant impact by deploying those interventions widely.

Another lesson, Khaldun said, is the importance of aligning health equity programs with the organization’s business goals. Doing so sends the message that addressing health equity is not a one-off activity for which the chief health equity officer is solely responsible. Khaldun said it is critical to think hard about how the organization embeds health equity into its goals and how that will produce value. “As health equity practitioners, we have to get beyond just trying to pull on people’s moral compass and heartstrings to do this work,” she said.

Khaldun added that, in the end, health equity is about quality improvement and not about launching one-off programs. “You need to have a strong culture of quality improvement in your organization to be able to advance health equity,” she said, “which means looking at your data, identifying opportunities to improve, piloting those improvements, and then learning and improving over time.”

DISCUSSION

Noting that there are many marginalized communities that cannot make their way onto the agendas of institutions, an audience member asked the panelists for the advice they would share with representatives of those groups regarding advocating for their communities. Lewis replied that health care organizations should not wait for community groups to come to them but should go into the community without an agenda, listen actively, solicit feedback, and integrate that feedback into their activities. Roth, speaking from the C-suite perspective, said it is imperative to recognize and acknowledge the imbalance of power and then take steps to redistribute that power into the community. This can be challenging, she said, and it requires developing leadership skills and the competency to have comfort rebalancing power.

Khaldun noted that the COVID-19 pandemic triggered a sudden wave of outreach to and relationship building with communities for the first time. “I think the onus is absolutely on organizations to take it upon themselves to build that trust, earn that trust of communities, and not wait for the crisis to hit,” she said. Khaldun concluded that it is important to identify champions and advocates inside an organization who can drive home the message that addressing health inequities is central to the organization’s mission.