Mechanisms to Garner Support for Institutional and Policy-Level Diversity Initiatives
The committee’s analysis in the preceding chapters of this report documents that several barriers exist at the institutional (e.g., health professions educational institutions [HPEIs]) and policy level (e.g., federal and state policies and resources regarding financing of health professions education) that may contribute to the underrepresentation of many racial and ethnic minority groups in health professions careers. These barriers are largely unintentional policies, practices, and attitudes that have been understudied in relation to the problem of increasing the supply of well-prepared underrepresented minority (URM) students who are highly motivated to enter heath professions careers. Greater study of and attention to these barriers may therefore assist efforts to create greater opportunities for URM students to participate in health professions training and enter health professions careers. Institutional and policy-level barriers include:
Among health professions educators, governance bodies, administrators, students, and the general public, a lack of understanding of and commitment to the important role of diversity in strengthening the health professions workforce and in improving the educational experiences and training of all health professions students;
The lack, in many HPEIs, of statements in the institutional mission addressing the role of diversity in the institutional mission and its educational goals;
Admissions policies and practices that disproportionately emphasize applicants’ quantitative data, such as performance on standardized tests,
and fail to place appropriate emphasis on qualitative attributes of applicants that may more accurately predict success in health professions careers (e.g., empathy, leadership, commitment to service, cross-cultural experience, linguistic ability, and interpersonal skills);
The absence, in many HPEIs, of appropriate training for admissions committee members regarding diversity issues, of inclusion of representatives of relevant stakeholder groups that are affected by admissions decisions on admissions committees, and of rewards and incentives for faculty for committee service and other efforts to enhance diversity in the institution;
Unmet financial need that may disproportionately limit URM participation in health professions education programs and inconsistent federal and state support for health professions education programs that encourage minority participation in health professions careers and provide services to medically underserved communities;
The failure of some health professions accreditation bodies to establish, monitor, and enforce strong diversity-related program standards, and the failure of the U.S. Department of Education to encourage the development of such standards;
The failure of HPEIs to recognize the need to develop and regularly evaluate comprehensive strategies to improve the institutional climate for diversity; and
The lack of information for key constituency groups—such as healthcare consumer groups, leaders of communities served by academic health centers, and others—regarding diversity among the health professionals that serve them and the potential benefits of diversity for health-care consumers.
These institutional and policy-level barriers to greater URM participation in health professions can be reduced through a series of interventions aimed at a range of stakeholders. Health professions education leaders, their institutions, and the organizations that govern their operation (e.g., governance bodies, accrediting organizations) figure prominently in this effort. The hallmark of any profession is the obligation to set standards to serve the needs of the public. Accordingly, these groups must provide leadership by educating their constituencies about the benefits of diversity and establishing policies and standards that promote greater diversity among health professionals. These efforts should be directed toward HPEIs; their students, faculty, and others involved in health professions education; health professions education accrediting organizations; public and private sources of financial aid for health professions students; and all institutions that directly or indirectly serve the public and are accountable for the use of public resources to improve the public’s health.
Mechanisms to Encourage Support for Diversity Initiatives
Through the recommendations that it has generated, the study committee has identified several mechanisms to encourage the development and implementation of institutional and policy-level strategies. These mechanisms include major “fulcrum” points, such as program accreditation and sources of student financial aid, that offer incentives, as well as reprimands, to encourage diversity efforts. For example, accreditation bodies can encourage member institutions to address diversity issues in student and faculty recruitment, curriculum, and training arrangements. And federal and state health agencies must evaluate and provide greater support for programs found to be effective in increasing URM participation in health careers, and innovative partnerships with private organizations that share workforce goals should be established.
Needed Data and Research Efforts
Implementation of these strategies should begin with efforts to collect data and conduct additional research to assess diversity among health professionals and in health professions education and to further identify the benefits of diversity for health-care service delivery. As noted earlier in this report, the availability of data regarding the representation of racial and ethnic minority groups in health professions varies considerably, as data on URM participation in medical education are generally more systematic and widely available than in other health professions disciplines. Data are needed to identify trends in the number of URM applicants to HPEIs; their rates of acceptance, matriculation, enrollment, and degree completion; the number of URM administrators, staff, and faculty in HPEIs, including full- and part-time faculty at all levels; and the participation of URM professionals in the health professions workforce. In addition, data are needed on the total cost of health professions education, including tuition, books and equipment, living expenses, average URM student educational debt (both prior to and after completion of training), the availability and receipt of both need- and merit-based student financial aid, and the impact of debt and financial aid on URM student participation in health professions training. Health professions institutions, as well as their governing bodies and professional associations, should increase efforts to collect and report such data to key stakeholders, including health policy makers, educators, healthcare consumers, and the general public.
Similarly, additional research is needed to further assess and describe the benefits of diversity in health professions education and health-care delivery. As noted in Chapter 1, these benefits are considerable, with evidence to date demonstrating that diversity is associated with benefits for
student learning, increasing access to care among minority and medically underserved populations, and improving patient choice and satisfaction, among other benefits. Additional research is needed to quantify the benefits of diversity in health-care delivery. Such research should assess, for example, whether there are economic benefits associated with greater diversity among health professionals. Evidence summarized in Chapter 1 suggests that diversity among health professionals—associated with improved access to and satisfaction with care among racial and ethnic minority patients—can lead to better patient understanding of and compliance with treatment regimens, higher rates of follow-up and adherence, and fewer patient misunderstandings of treatment recommendations, all of which may influence patients’ health-care outcomes. The implications of this research are that better health-care outcomes among racial and ethnic minority patients—many of whom suffer from disproportionately high rates of illness, disability, and premature death—offer broad economic benefits for individuals, families, employers, and the nation as a whole, in the form of improved health status, fewer preventable illnesses, lower health-care costs, reduced workplace absenteeism, and greater productivity. These relationships should be assessed to contribute to the evidence base regarding the benefits of diversity among health professionals, and the results of such research should be widely communicated.
Recommendation 7-1: Additional data collection and research are needed to more thoroughly characterize URM participation in the health professions and in health professions education and to further assess the benefits of diversity among health professionals, particularly with regard to the potential economic benefits of diversity.
Increasing support for diversity efforts also requires strategies to educate health professions leaders, faculty, administrators, students, and others in the HPEI community regarding the benefits of greater diversity among health professionals. HPEIs should proactively and regularly engage and train students, house staff, and faculty regarding institutional diversity-related policies and expectations and the importance and benefits of diversity to the long-term institutional mission. Similarly, health policy makers, health systems administrators, and health professionals should understand how diversity improves their ability to serve the community. To achieve this goal, HPEIs can benefit from model curricula for training, including course material, workshops, and other educational strategies. Professional associations can assist in the development and dissemination of model curricula components and can serve as clearinghouses for this information. The most
powerful mechanism to encourage such educational efforts is program accreditation. HPEIs, academic health centers, and teaching hospitals should strive to meet high accreditation standards that articulate the value of diversity in the health professions and that require specific steps toward achieving diversity goals.
Educational strategies must not be limited to health professionals and health system administrators. Health-care consumers and the general public are among the most important stakeholders in the effort to increase diversity among health professionals. Public and private groups who share the goal of increasing diversity in health professions should engage in coordinated efforts to inform the public of the importance of diversity in health professions. These efforts should be directed to a range of individuals and groups that are affected by insufficient attention to diversity among health professionals, including grassroots advocacy and health-care consumer groups; businesses and corporations, particularly those that employ a racially and ethnically diverse workforce; educators, including primary and secondary school teachers and others involved in “pipeline” efforts; students; organized labor; elected officials at all levels of government; state and local health departments; religious groups, including churches, synagogues, temples, and others concerned with community health; health and education philanthropic organizations; as well as many other public and private groups. These educational strategies should emphasize the potential benefits of diversity for all Americans who are consumers of health care.
Several recent initiatives offer examples of innovative efforts to increase awareness of diversity issues and involve diverse, powerful constituents in the effort to increase diversity in health professions. The Sullivan Commission on Diversity in the Healthcare Workforce, funded by the W.K. Kellogg Foundation, has attempted to increase public awareness regarding the problem of insufficient health workforce diversity and generate broad support among the public and policy makers for diversity efforts. The commission, named for former U.S. Secretary of Health and Human Services Louis Sullivan, M.D., includes 15 health, business, and legal professionals and other leaders. Former U.S. Senate Majority Leader Robert Dole and former U.S. Representative and Congressional Health Subcommittee Chairman Paul Rogers are honorary co-chairs. The Sullivan Commission has held field hearings in six cities across the country, providing an opportunity for commissioners to gather data and hear testimony from health experts, community advocates, business leaders, local governmental officials, and consumers. In the process, the commission has increased public awareness of the problem of minority underrepresentation in health professions and of the need for broad and effective strategies to address the problem. A final report of the commission will be released in Spring 2004.
The Washington Business Group on Health (WBGH) has led efforts to
increase business leaders’ awareness of racial and ethnic disparities in health and access to health care and the implications of these disparities for employee productivity and well-being. WBGH is exploring ways in which businesses can become involved in solutions to improve the health and productivity of all its employees, serving as an information source to employers on health disparities and providing the tools and resources necessary to address the health needs of their diverse employees. For example, WBGH recently introduced a computer-based evaluation tool to assist health plan purchasers in assessing efforts by health plans to reduce racial and ethnic disparities in care, including tools to assess the diversity of health plan providers.
These local and national efforts share a common goal: to increase understanding of the imperative to enhance diversity among health professionals and to build consensus among a range of stakeholders regarding steps that should be taken toward this goal.
Recommendation 7-2: Local and national efforts must be undertaken—through community dialogues, forums, and other educational initiatives—to increase understanding of the imperative to enhance diversity among health professionals and to build consensus among a range of stakeholders regarding steps that should be taken to achieve this goal.
Building Coalitions to Support Diversity Efforts
Educational efforts, as well as institutional and policy-level interventions to increase diversity, represent only the first steps toward action in support of institutional and policy-level strategies to increase diversity. Just as important are efforts to build coalitions of broad stakeholder groups—including, as identified above, health professions leaders, health-care consumer groups, grassroots and community organizations, business leaders, educators, and others—that can provide effective advocacy for change. Such coalition-building and advocacy can be viewed within the framework of community benefit principles discussed in the previous chapter. Community benefit principles provide insights for the public expectations of both nonprofit health-care providers and institutions that train these providers. Just as nonprofit hospitals are expected to play a role in addressing priority unmet needs in local communities, HPEIs can appropriately be expected to play a direct role in responding to priority unmet health needs at the local and/or societal level. Community benefit principles should therefore form a conceptual cornerstone by which health professions education accreditation organizations and state governments can set expectations for the advancement of societal goals tied to racial and ethnic diversity of the healthcare workforce.
Efforts to build coalitions can benefit from strategies to increase the involvement of diverse stakeholders in key decision-making processes and to inform the public of progress toward efforts to increase the diversity of the health-care workforce. In addition, private and public (e.g., federal, state and local governments) entities should convene community stakeholders to inform them about community benefit standards and to build awareness that placing a priority on diversity and cultural competency programs is a societal expectation of all institutions that receive any form of public funding.
Several examples exist of initiatives that seek to build coalitions and utilize community benefit principles to increase support for health workforce diversity. As an example, Community Catalyst, with support from the W.K. Kellogg Foundation, has initiated the Physician Diversity Project in two sites (Boston and New York) to identify community-based strategies to increase medical workforce diversity. The overarching goals of the Physician Diversity Project are:
to increase key stakeholders and other community leaders’ awareness of the problems associated with the lack of physician diversity in the workplace,
to gain the commitment of key stakeholders and other community leaders to make efforts to increase physician diversity a key policy priority, and
to develop models from the existing sites that can be replicated in other locations.
To achieve these goals, Community Catalyst has organized and supported efforts to address public and private policies and increase community involvement in health-care priority-setting as part of a larger healthcare reform effort. The Boston site will develop a highly visible campaign that will include activities such as campaign strategy development and implementation, leadership recruitment and mobilization, constituency and coalition building, and legislative and policy research and analysis. The New York City site is attempting, through the reauthorization of the Health Care Reform Act (HCRA), which governs Medicaid reimbursement rates for hospitals, hospital uncompensated care pool financing, and state allocations for the cost of training medical residents, to gain stakeholder support for public policy designed to promote diversity in medical education and the physician workforce. Activities at the New York City site include coalition building, setting and promoting the coalition’s policy agenda, and other activities.
The W.K. Kellogg Foundation also supports the Community Voices Program, which is designed to strengthen community support services and
strengthen the health-care safety net for vulnerable and medically underserved populations. Thirteen communities across the nation are participating in this 5-year initiative; each community is piloting different approaches and strategies tailored to the specific needs of the populations served. Among the initiative’s goals are to increase access to health services for the vulnerable (with a focus on primary care and prevention) and to develop models of best practice for communities to adapt to their unique circumstances. As part of this effort, each project develops plans to help communities become informed about and empowered to improve the health-care infrastructure in their communities. This is accomplished by the development of:
a plan and capacity for informing the public and marketplace policy;
community involvement in strategic planning and activities that includes all the key members of the community;
efforts to link the provider and community network together through infrastructure that includes management of information systems, legal agreements and initiatives to establish and expand provider–community relationships;
explicit responsiveness to the community’s culture and environment for creating health and wellness; and
other efforts to help community members to assume leadership roles in shaping community-based health-care delivery.
These and other efforts to stimulate coalition building at the grassroots and national levels should be supported to pursue a coordinated agenda aimed at encouraging policy changes among HPEIs, their accrediting bodies, health-care providers (e.g., health professionals, hospitals, health plans), and others.
Recommendation 7-3: Broad coalitions of stakeholder organizations—including health professions leaders, health-care consumer groups, grassroots and community organizations, business leaders, and others—should vigorously encourage HPEIs, their accreditation bodies, and federal and state sources of health professions student financial aid to adopt policies to enhance diversity among health professionals.
Several mechanisms offer promise to garner support among a diverse array of stakeholder groups to increase diversity among health professions. Broad support is needed among many groups—including health professionals, the HPEI community, health policy makers, affected communities, edu-
cators, corporate and business leaders, organized labor, and the general public—in order to create the necessary “push” to support institutional and policy-level strategies to increase diversity among health professionals. As a start, health professions organizations should assess and disseminate information about HPEI applicants, matriculants, and graduates from URM groups, as well as the participation of URMs among HPEI faculty, staff, and professionals in the workforce. Educational efforts are also an important step to raise awareness of the problem among these stakeholders. Local and national efforts must be undertaken to increase understanding of the imperative to enhance diversity among health professionals and to build consensus among a range of stakeholders regarding steps that should be taken to achieve this goal. In addition, efforts to develop coalitions of stakeholder groups can help to create a political impetus for federal, state, and local strategies to increase diversity. Broad coalitions of stakeholder organizations—including health professions leaders, health-care consumer groups, grassroots and community organizations, business leaders, and others—should encourage HPEIs, their accreditation bodies, and federal and state sources of health professions student financial aid to adopt policies to enhance diversity among health professionals. Finally, federal and state government health agencies should increase support for policies that increase diversity among health professionals and should explore new initiatives to create incentives for HPEIs to adopt diversity efforts.