by Susan Ehrlich, MD, MPP and Bruce Siegel, MD, MPH (NEJM Catalyst 5/25/2022)

In the wake of the Covid-19 pandemic and George Floyd’s murder at the hands of police, millions recognized the urgent need to combat structural racism. Many organizations publicly declared their intent to address this long-standing ill and the gross inequities and disparities that result. Health systems across the U.S. quickly developed and acted on plans designed to combat structural racism within their organizations and in their communities.¹

Earlier equity efforts have yielded uneven and sometimes fleeting results. When a 2015 national campaign asked hospitals to pledge to increase diversity and reduce disparities, most hospitals did not endorse the effort.² Activities at individual organizations often have focused on isolated efforts to improve access or target social determinants in specific geographies or populations, leaving the organizational culture essentially unchanged.

We believe any effective work to combat structural racism requires broader and deeper efforts deployed at local and national levels. Here, we briefly describe such efforts by a public, academic safety-net hospital (Zuckerberg San Francisco General Hospital and Trauma Center), in concert with a national advocacy group (America’s Essential Hospitals). The hospital CEO (one of the authors) chaired the America’s Essential Hospitals board of directors during much of 2020. She worked to move the group toward a forward-leaning, anti-racist posture based in part on her own experience at Zuckerberg. This example shows how persistent, resilient, iterative, data-driven approaches at the local level, supported by complementary actions in national organizations, can make meaningful and demonstrable changes to improve health equity.

ZSFG appointed a diverse equity council that represented all parts of the organization, from frontline staff to leadership, to develop its strategy, with three core elements:

Better understanding patients by ensuring accurate data for improving health outcomes. Frontline registration staff were trained to capture accurate race, ethnicity, and language (REAL) and sexual orientation and gender identity (SOGI) data. REAL data were almost 100% accurate within a year. This result was accomplished by an extensive training program for staff registering patients, so that they would use preexisting standard fields within the electronic medical record 100% of the time.

Developing and educating the workforce. We identified issues through a staff survey (for example, we asked staff to assess how active their department was in improving racial equity), and we trained staff about equity and disparities. We advanced equity in individual departments by designating voluntary equity champions and local equity councils. These councils develop learning events for their staff. For example, the Critical Care department hosts an education board that provides opportunities for staff discussion on topics such as white fragility. The clinic providing outpatient care to people with AIDS and HIV hosts a monthly Cultural Humility lecture series. Throughout ZSFG, there are currently 12 local councils, based on department interest in forming them, ranging in size from 7 to 18 individuals representing frontline staff to local leaders.

Identifying and reducing health care disparities among patients. One element of ZSFG’s strategic goal to improve equity is to increase the percentage of departments identifying and improving health care disparities. Over the past several years, ZSFG has gone from 27% of clinical and operational departments voluntarily identifying equity metrics stratified by REAL data, to 51% of these departments not only identifying these metrics, but also using the data to drive improvements. Eventually, the goal is to reach 100%, but they recognize that they must take an incremental approach to achieving this ambitious goal.

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