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The Challenge of Advancing Health Equity During a Year of Pandemic and Crisis

Our Organization's Response

Burnes Bolton, Linda DrPH, RN, FAAN; Lee, Harlem MHDS; Mitchell, Nicole MBA

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Nursing Administration Quarterly: April/June 2022 - Volume 46 - Issue 2 - p 154-166
doi: 10.1097/NAQ.0000000000000521
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Abstract

SINCE ITS INCEPTION, Cedars-Sinai Health System has embodied the principles of health equity and the fight against prejudice and racism. It was founded as the Kaspare Cohn Hospital, the first Jewish hospital established in 1902 in Los Angeles, California, and served a new immigrant community that faced prejudice on a regular basis. Our hospital's founding was a statement that not only would the Jewish community have a medical refuge but that all Angelenos were welcome as well irrespective of their race, religion, ethnicity, or ability to pay. In a time when segregation still existed in California, that is an action worth celebrating. Our history of health equity is deeply rooted in the Judaic tradition, driven by the values of tikkun olam, “repairing the world,” and tzedakah, which is commonly translated as “charity” but more directly means “righteousness.”1

Today, Los Angeles is known as one of the most diverse urban populations and global “megacities” on the planet. More than 1 in 3 residents—approximately 3.5 million people—are born outside the United States.2 More than half of Los Angeles County residents speak a language other than English at home, and almost 50% of the population of our core service area identifies as Hispanic.3,4 Black/African Americans reside in Los Angeles in significant numbers as a result of the “Second Great Migration” of the 20th century, and, more recently, immigrants from the Asian-Pacific diaspora make up the fastest-growing ethnic group in the region.5,6 Historically the majority, non-Hispanic Whites currently make up only 26% of Los Angeles County's population.2 Given these demographic trends, identifying populations of color as “minorities” is no longer accurate. “BIPOC” or “Black, Indigenous, (and) People of Color” is a widely used inclusive acronym to identify the non-White population in the United States (including Black/African American; Hispanic origin; Asian/Pacific Islander; Native American/Indigenous; and other peoples of color), and BIPOC now make up an overwhelming 74% majority of those residing in Los Angeles County (the core service area of Cedars-Sinai Health System).2

In all of its diversity, Los Angeles remains divided by stark inequities in health outcomes and quality of life—separated by lines of color, ethnicity, language, culture, income, but most importantly by the historical impact of discrimination and structural racism, which sadly continues to the current day (Figures 1A and 1B). According to the Centers for Disease Control and Prevention, racism has been named as a public health crisis and is the fundamental driver of racial and ethnic health disparities in the United States, especially in the current time of COVID-19 pandemic.7 Despite the daunting challenges, Cedars-Sinai's core mission and values of advancing Diversity, Equity, and Inclusion (DEI) and fighting the debilitating effects of prejudice and systemic racism remain as strong as ever.

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Figure 1.:
(A, B) The impact of historical discrimination and structural racism within the core service area of Cedars-Sinai Health System (Los Angeles, California). Comparison of historical “redlining” map (the discriminatory practice of banks avoiding investment in neighborhoods with a certain racial makeup) to current map of life expectancy disparities within the same neighborhoods to show the impact of disinvestment on health outcomes and quality of life. The green and red areas of disparity match between the 1938 and 2017 maps. From Home Owners Loan Corporation (1938) and US Census (2017 statistics). Robert K. Nelson, LaDale Winling, Richard Marciano, Nathan Connolly, et al., “Mapping Inequality”, American Panorama, ed. Robert Nelson and Edward L. Ayers, accessed January 20, 2022, https://dsl.richmond.edu/panorama/redlining

Cedars-Sinai Health System continues its commitment and efforts put forth from its very beginnings, and its executive leadership is at the forefront to promote health equity, diversity, and inclusion for all of its patients, employees, members of the medical staff, and the diverse communities it serves. It lives and breathes at the core of our mission, values, and actions. Our location centered within the city and county of Los Angeles represents a unique opportunity to provide healing and care to one of the most diverse and vibrant patient populations on the planet. We are energized by the possibilities to serve as an excellent case study, testing ground, and, hopefully, an exemplary role model for best practices in the DEI space.

Continuing in the spirit of tikkun olam and tzedakah, Cedars-Sinai President and CEO, Thomas M. Priselac, established 2 important offices within the health system: the Office of Health Equity led by Linda Burnes Bolton, DrPH, RN, FAAN, focused on the work around equitable patient care for all; and the Office of Diversity and Inclusion, led by Nicole M. B. Mitchell, MBA, CDP, focused on inclusion and belonging in the workplace and workforce. These offices, founded in the summer of 2019, represent Cedars-Sinai's commitment to harnessing inclusion to advance equity outcomes for our patients and families, employees, and community and secure the organization's resolve to work toward a desired future, or health equity for all.

OUR STRATEGIC PLAN (PRE-COVID)

The first charge of the new departments was to listen and learn. The teams reached out to benchmark institutions, enlisted the support of leading health care experts such as the Institute for Healthcare Improvement (IHI), and listened to employees and the medical staff to identify the current state and inventory of the internal and external DEI space.

In February of 2020, in collaboration with IHI, Cedars-Sinai held its first inaugural “Pursuing Equity” retreat with executive stakeholders from across the organization, with the objective of drafting the first Health Equity and Diversity and Inclusion Strategic Plans (Figures 2A and 2B). The following are among the key learnings from identified baseline state:

  • Most benchmark institutions across the United States, including Cedars-Sinai, are in the early development stages of their DEI strategies.
  • To provide the best care and support for the changing patient, workforce, and community demographics, there is an imperative to focus on DEI.
  • The DEI infrastructure requires strong data quality, education, and human resources to meet the well-being needs of the patient, workforce, and community.
  • DEI requires a representative and inclusive cross-departmental effort and overall governance structure to move work forward, track, and learn across the institution.
  • Cedars-Sinai should leverage its assets as a major Greater Los Angeles area business and employer to improve equity including in employee wages, financial investments, hiring, clinical care, addressing social responsibility, and business decisions such as procurement.
  • And finally, involve our patients, workforce, and served communities in all improvement efforts.
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Figure 2.:
(A, B) Cedars-Sinai Health Equity and Diversity and Inclusion Strategic Plans. CSHS indicates Cedars-Sinai Health System; CS, Cedars-Sinai.

“THE BEST LAID PLANS...” (A YEAR OF PANDEMIC AND CRISIS)

The ink was barely dry on our new Cedars-Sinai Health Equity and Diversity and Inclusion Strategic Plans when the unimaginable happened in March 2020, the beginning of the global COVID-19 pandemic occurred. Our planned DEI mobilization efforts had to go on hold as we needed to quickly pivot use of our resources to the immediate needs of the existing health emergency.

Two months later, the United States experienced the tragic, shocking, and brutal killing of an unarmed Black man, George Floyd, at the hands of a police officer in Minneapolis, Minnesota. Although the deaths of Black men and women due to police brutality happen often in the United States, this incident, where the officer knelt on Floyd's neck and back for 9 minutes 29 seconds, was captured via a viral video. Global attention was thrust upon the historical and continuing injustice of police brutality and systemic racism against people of color in the United States, exacerbating the collective suffering of an entire nation into a dual pandemic of both the COVID-19 virus and the chaotic divisive racial strife, which began to explode in response. As all Americans, and particularly those of color, struggled to face these dual pandemics, we at Cedars-Sinai were especially struck by the urgency of the intersection of racism and health care (Figure 3).

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Figure 3.:
McKinsey and Company report: COVID-19 is disproportionately impacting communities of color. BIPOC indicates Black, Indigenous, (and) People of Color. “Insights on racial and ethnic health inequity in the context of COVID-19”, July 2020, McKinsey & Company, www.mckinsey.com. Copyright © 2022 McKinsey & Company. All rights reserved. Reprinted with permission.

In the midst of this time of grief and chaos, Cedars-Sinai's President and CEO, Thomas M. Priselac, issued an organization-wide statement and call to action appropriately named, “Our Collective Outrage,” where he emphatically called for each of us to “redouble our efforts at equity, justice and respect.”8 In a time of despair and despondence, this timely messaging from our CEO was the rallying cry we needed to mobilize and act to provide the care, support, and assistance to all who depended on us during the height of this horrible pandemic.

PIVOTING TO DUAL PANDEMIC RESPONSE

One of our first priorities in the beginning stages of the pandemic was addressing the most vital community needs in local partnerships with Los Angeles Homeless Services Authority, Community Clinic Association of Los Angeles County, the Los Angeles Fire Department Foundation, and the Los Angeles Unified School District in the distribution of 2.8 million masks and other needed supplies such as gloves, face shields, shoe coverings, and hand sanitizer. Within the first month of the pandemic, our Community Benefit Giving Office quickly shifted its funding to deploy rapid response grants in supporting emergency food access, shelter, and novel telehealth services that were desperately needed to care for patients in our most vulnerable communities during a time of lockdown. And in the following months, our funding transitioned from emergency support to building the capacity of our community partners focused on recovery, safe-at-work practices, and the increased provision of virtual mental health services.

In addition to the priority of mobilizing essential needs for our local community, we had an intensified concern for the mental health and well-being of our internal workforce as the dual pandemics met us right at our very doorstep. Not only were we battling on the front lines caring for those with COVID-19 but also the impassioned protests and demonstrations against racial injustice were taking place just 2 blocks away from the hospital. It was important for us to have real conversations on the impact this was having on our own workforce, especially with our Black/African American employees. The Office of Diversity and Inclusion strove to create safe and sacred spaces for our Cedars-Sinai family to breathe together and support each other during this difficult time. In a time of extreme and isolating mandated lockdowns, we supported the need for connection by leveraging new virtual meeting technologies. In partnership with the Spiritual Care Department and immediately after the killing of George Floyd, we held a virtual vigil that included a moment of silence to acknowledge Black lives—men, women, and members of the LGBTQ+ community—that have been lost to police violence. More than 500 of our employees heard a message of solidarity and support from our Chief Diversity Officer, our Rabbi, and the leader of our Work and Life Matters team. In another poignant moment of support, our residents, fellows, physicians, and staff mobilized together as “White Coats for Black Lives” and knelt for 9 minutes on our Medical Center Plaza to demonstrate support and allyship toward our Black/African American brothers and sisters. Similar events were held to support the Stop Asian American Pacific Islander (AAPI) Hate movement to stand in support and allyship with our AAPI workforce, which makes up 30.4% of our total Cedars-Sinai staff (the largest percentage of all racial groups). The overflow of gratitude and appreciation from our employees in need of meaningful connection and opportunities for collective action spurred continued and larger-scale efforts to create further inclusive spaces where we can listen and learn from each other's experiences (Figure 4).

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Figure 4.:
Shortly after the murder of George Floyd, Cedars-Sinai medical staff mobilized for “White Coats for Black Lives” to demonstrate support and allyship toward our Black/African American brothers and sisters.

For example, we have launched our monthly Cedars-Sinai “Conversations For All, By All” series where 3 to 4 Cedars-Sinai team members share their personal stories held in conjunction with various diversity and heritage celebration months or to address current topical events/issues of the day revolving around DEI. In addition, the Office of Diversity and Inclusion has launched the Cedars-Sinai diversity book club and an organization-wide unconscious bias learning that is now a mandatory education for all employees within Cedars-Sinai Health System.

DEDICATED COVID-19 RESEARCH TARGETED TO BIPOC POPULATIONS

We continued efforts to conduct research to learn about COVID-19 to identify new cell therapies and drugs for treatment and improve clinical outcomes (to date, there are >80 clinical trials and studies in progress). From an equity lens, Cedars-Sinai joined one of the largest coordinated efforts to advance knowledge of immunology and coronavirus in the United States—and particularly the unequal impact of COVID-19 on the BIPOC patient and community population of our core service area. Via a 5-year $8.3 million grant from the National Cancer Institute, the CORALE (Coronavirus Risk Associations and Longitudinal Evaluation) study was launched to address the well-documented racial and ethnic disparities in both the risk of infection and severity of COVID-19 disease in our local communities. The targeted recruitment of BIPOC clinical trial research participants was and continues to be an essential component of Cedars-Sinai clinical trials and research programs.

Other notable efforts to learn more about BIPOC disparities experienced from the pandemic include an extensive literature review by our Office of Clinical Transformation, and from our Cedars-Sinai Cancer Research Center for Health Equity, the development of a COVID-19 severity risk score and mapping tool to identify those most-impacted communities in our core service area with the highest prevalence of underlying medical conditions associated with severe COVID-19 illness.

This knowledge base proved to be an invaluable resource to identifying the root causes of COVID-19 disparities among our local BIPOC populations and directing us with a razor-sharp focus to provide support and assistance to the most vulnerable and disadvantaged within our community during the pandemic. These factors were found to be intersectional across race, ethnicity, language, zip code, poverty level, education, and social determinants of health (such as density of housing, food and nutrition, insurance status, and work status).

In 2021, the highly awaited COVID-19 vaccines became widely available, but we soon realized 2 additional health equity challenges that required our attention and impacted our served communities—vaccine access and vaccine hesitancy among BIPOC populations. With this knowledge, we began to utilize not only our resources but also our expertise and voice, by collaborating on several community access and education initiatives with trusted local partnership organizations specific to the neighborhoods and communities identified as most in need.

EXPANDING VACCINE ACCESS

In addressing the disparity of vaccine access among our most disadvantaged and vulnerable populations, we were committed to meet our patients and community members where they are located. To accomplish this, we focused on working with local partners who had an established and trusted presence within the neighborhoods identified as most at risk from our data discovery and knowledge base. The data directed us to neighborhoods that lie within the geographic location of South Los Angeles, a section of Cedars-Sinai's core service area located about 10 miles southeast of our central campus. According to the Los Angeles County of Public Health, this area (“Los Angeles County Service Planning Area 6”) is 98% BIPOC: 68% Hispanic/Latinx and 28% Black/African American.9 One example of our partnership interventions was conducted with Martin Luther King Community Hospital (MLKCH) and the Boys & Girls Club of Metro Los Angeles focused on administering COVID-19 vaccinations through “pop-up” clinics specific to these targeted neighborhoods in South Los Angeles within a 2-month period (March-May) in 2021.

Postintervention data show that we were successful in providing COVID-19 vaccination to those populations identified as most in need: 74.6% were Hispanic/Latinx and 81.6% were either uninsured or on Medicaid/Medi-Cal. The top 10 zip codes of vaccine recipients were all residing in South Los Angeles, and visualized on our C-S COVID-19 severity risk map this corresponds exactly to the local areas we deemed most at risk. Additional partners were signed on through the Cedars-Sinai Community Benefit Giving Office to ensure that more residents of South Los Angeles and other impacted local areas would have easy neighborhood access to COVID-19 vaccinations and therefore save more BIPOC lives that otherwise might be needlessly lost to the pandemic.

One of our most successful partnerships to date to provide vaccine access was conducted with the Los Angeles Unified School District (LAUSD), in which the newly built SoFi Stadium also located in South Los Angeles was repurposed as a “megasite” to provide COVID-19 vaccinations on a massive scale to LAUSD educators and staff. Cedars-Sinai provided expertise in setting up the operations: from technical and site planning assistance to pharmaceutical and medical consultation. More than 37 000 vaccinations were administered, which ultimately resulted in the successful reopening of LAUSD schools. More than 60% of those served were BIPOC (Figures 5A and 5B).

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Figure 5.:
(A, B) Cedars-Sinai Health System's successful targeted intervention of COVID-19 pop-up vaccination sites in partnership with Martin Luther King Community Hospital and Boys & Girls Club of Metro Los Angeles. The darkest red areas of greatest risk shown in the first map (our C-S COVID-19 severity risk score tool) directly correspond to the green areas in the second map showing the top 10 zip codes by number of COVID-19 vaccine doses administered during our pop-up vaccine drive in March-May 2021. From Cedars-Sinai Cancer Research Center for Health Equity; Cedars-Sinai Community Benefit Giving Office.

ADDRESSING VACCINE HESITANCY: COMMUNITY EDUCATION AND OUTREACH

We started with our own internal workforce in a dual approach to (1) work with our leadership and teams to educate and discuss why BIPOC communities had hesitancy around vaccines and; (2) work with our employees to gain access to accurate information around the vaccine. After review of employee demographics data, 2 challenges were uncovered related to frontline employees. Most of these employees did not have access to computer stations, which was how employees were to register for vaccine appointments, and, second, there was a language barrier issue that eroded trust with our Spanish-speaking employees. We quickly addressed these issues by deploying our leadership to work with and assist frontline employees to register on the spot, be on hand to answer questions, or bring them directly to our vaccine clinics. We further translated our communications around the availability of vaccines, which at the time were only in English, into Spanish, which represents a sizable number of our frontline workforce. The final piece was using our data to track impact and to continue learning where we may have gaps.

Continued community engagement and partnership are key to our DEI and COVID-19 education efforts. “Doses of Hope” is a health education campaign that features videos, social media messages, digital assets, community tool kits, and town hall/community conversations to promote COVID-19 vaccination in communities that have the lowest rates, including older citizens, Black, and Latinx communities in Los Angeles. Not only are we focusing on local impact but also we furthered our reach through our Embracing our Community: Live Series by partnering with BlackDoctor.org, a member of The White House COVID-19 Response team and community leaders to reach more than 15 000 live viewers and more than 41 000 as the end of April 2021 and followed by our most recent Embracing our Community: Live Event/Dosis de Esperanza: Latinx Communities & COVID-19 with a focus on the Hispanic/Latinx community and plan to continue these discussions for additional BIPOC communities as well (Figure 6).

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Figure 6.:
Cedars-Sinai addressed vaccine hesitancy to local BIPOC communities during the COVID-19 pandemic by leveraging new meeting technology and providing language concordant messaging through such events as “Embracing Our Community LIVE.”

NEXT STEPS

Our next steps are to continue to advocate and address the stark disparities experienced among BIPOC populations in our local communities, and the social determinant factors that are exacerbating the underlying inequities in COVID-19 and across all health outcomes and quality of life. Our priority current work includes the following:

  • The Cedars-Sinai 3-year diversity and inclusion framework, which includes goals and metrics related to the 5 strategic areas, (1) culture, (2) leadership, (3) diversity and inclusion infrastructure, (4) recruitment and retention, and (5) pipeline development and career advancement, will be used to guide, align, and measure impact of efforts across the organization.
  • The Cherished Futures Project for Black Moms and Babies in collaboration with the Hospital Association of Southern California (HASC), addressing maternal/infant morbidity and mortality disparities among African Americans within our local served community.
  • Pursuing Equity Initiatives to evaluate and address BIPOC disparities in clinical health outcomes in collaboration with the IHI. Within this collaborative, we are specifically addressing disparities found in stroke outcomes, colorectal cancer screening rates, stroke outcomes and colorectcal cancer screening rates.
  • Improving the delivery of language concordant care across our health system to better the outcomes and experience of our limited English-speaking patient population.
  • Enhanced recruitment and retention efforts to build a more representative workforce across all areas of our health system operations including leadership, research/academics, and professional areas.
  • Supporting our Health Equity Grants program and the alignment of community funding to our overall Equity Strategic Plan.
  • Anti-racism initiative in nursing in collaboration with Office of Diversity and Inclusion and the American Nurses Association to educate and empower regarding the effects of systemic racism on the health care outcomes of our BIPOC patients.
  • Supplier Diversity and Investment initiative with our Finance Office to address the impacts of structural racism, including procurement and supporting the creation of affordable housing in our local communities

One of the most important lessons our organization will take forward is the efficiency, impact, and focus gained from disaggregating REAL (race, ethnicity, and language) data to drive decision making and prioritize improvement intervention projects in our DEI work. We recently established an executive leadership taskforce to optimize the reliability, accuracy, and utilization of REAL data. Across clinical, quality/safety, patient experience, workforce, and community outcomes, we are now incorporating best practices to report out data using REAL and other connected sociodemographic variables to identify the greatest and most significant improvement opportunities in reducing unwanted variations in care and experience among our most historically vulnerable and disadvantaged within our hospital service area. We are also in the process of building a comprehensive “Equity of Care” REAL data platform: gathering, validating, and visualizing current health equity statistics at Cedars-Sinai to identify populations and diseases of interest. These tools will be essential in our postpandemic DEI efforts to measure change and track progress in achieving our objective to operationalize successful interventions that will reduce health disparities and advance health equity in our served patients and communities.

“GETTING CLOSER TO THE PRIZE”

In many respects, the unanticipated arrival and chaotic impact of the COVID-19 pandemic and racial crisis in 2020 served to accelerate our DEI work in unexpected but beneficial ways. We focused on “laying track as we go,” given the immediacy and unforeseen impacts of the pandemic. Ultimately, we were able to act quickly, learn, and serve.

Unfortunately, despite successful vaccination efforts and proactive local public health policies, surges related to COVID-19 variants continue to threaten the patients and communities we serve here in Los Angeles. It is uncertain what the future will hold in the evolution of the COVID-19 virus and its impact on our community. Whatever the outcome, we will continue to respond with the agility, adaptability, and humility as we have always strived to do and have demonstrated throughout the current public health crisis. What we know and have experienced is that our Cedars-Sinai journey to health equity is more akin to a marathon and not a sprint; we are in this for the long haul, and it will take all of us making continual baby steps together with compassion and resilient resolution to get us closer to the “prize”: a more equitable, just, and inclusive culture where the quest for health equity can be achieved for all.

REFERENCES

1. Cedars-Sinai Offices of Community Benefit and Health Equity. Summary of Our Equity History (Cedars-Sinai) [internal document]. Los Angeles, CA: Cedars-Sinai.
2. Lewis K, Burd-Sharps S. A Portrait of Los Angeles County. Los Angeles County Human Development Report, 2017-2018. Brooklyn, NY: Measure of America; 2017.
3. L.A. Speaks: Language Diversity and English Proficiency by Los Angeles County Service Planning Area. Los Angeles, CA: Asian-Americans Advancing Justice; 2009. https://advancingjustice-la.org/media-and-publications/publications/la-speaks-language-diversity-and-english-proficiency-los-angeles-county. Accessed November 8, 2022.
4. US Census Bureau. Quick Facts, Los Angeles California. https://www.census.gov/quickfacts/losangelescitycalifornia. Published July 2019. Accessed November 8, 2022.
5. Sides J. L.A. City Limits: African American Los Angeles From the Great Depression to the Present. Berkeley, CA: University of California Press; 2003:36–43.
6. Los Angeles Almanac. Racial/ethnic composition of Los Angeles County (1990-2020). http://www.laalmanac.com/population/po13.php. Accessed November 8, 2022.
7. Centers for Disease Control and Prevention (CDC). Media statement from CDC Director Rochelle P. Walensky, MD, MPH, on racism and health. https://www.cdc.gov/media/releases/2021/s0408-racism-health.html. Published April 8, 2021. Accessed November 8, 2022.
8. Priselac T. President's perspective [electronic internal newsletter]. Cedars-Sinai Health System Newslett. The Bridge. Broadcast date June 3, 2020.
9. Los Angeles County Department of Public Health. Service Planning Area 6, Supplement to Community Health Assessment. http://publichealth.lacounty.gov/plan/docs/SPA6Supplement.pdf. Published 2014. Accessed November 8, 2022.
Keywords:

COVID-19; diversity; equity; health equity; inclusion; racism

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