Seven Key Drivers of Pediatric Hospital Medicine Advancement of Diversity, Equity, and Inclusion

In many health systems, hospital infrastructure has aligned around 5 of the Institute of Medicine’s 6 domains of health care quality: safety, effectiveness, patient-centeredness, timeliness, and efficiency. Equity, the sixth domain,1 has lacked equivalent investment despite evidence supporting the importance of diversity, equity, and inclusion (DEI) to the health of our patients and workforce in academic medicine. Inequities and health disparities continue to disproportionately affect the health of minoritized patients and families, and underrepresented faculty experience discrimination, barriers to career advancement and leadership opportunities, and lack of representation.2–10 For example, our institution had established programs for patient safety (safety), clinical effectiveness (effectiveness), patient and family experience (patient-centeredness), and performance improvement/patient flow (timeliness and efficiency) without equivalent programmatic support for equity.Recognizing its crucial importance, our institution invested meaningfully in DEI over the past decade through the creation of a hospital Department of Diversity, Health Equity, & Inclusion with an inaugural Chief Equity Officer. Teams at other institutions have shown meaningful reductions in health disparities in pediatric hospital settings through deliberate quality improvement.11 Despite this, our Section of Hospital Medicine continued to lack internal infrastructure for DEI improvement, and hospitalist faculty pursued DEI efforts individually or not at all, with important opportunity costs and unrealized potential in hospitalist DEI advancement.In response to this gap, we aimed to develop foundational infrastructure for coordinated hospitalist DEI improvement within our Section of Hospital Medicine.We are an academically affiliated hospitalist section with more than 100 faculty. We serve patients throughout our 7-state region and provide general pediatric inpatient care to local communities. Our primary health system includes 4 freestanding children’s hospitals, including a centralized, quaternary care children’s hospital. We also deliver newborn care at 9 unaffiliated community hospitals and acute care at 2 unaffiliated, rural community sites. Our nonclinical pursuits span the academic spectrum of research, quality, education, advocacy, and hospital administration. No existing legislation affected our efforts, unlike other areas of the country where state legislation limited DEI improvement in academic institutions.12We applied Design for Six Sigma (DFSS)—guided by frameworks for DEI quality improvement including the AAP Equity Agenda13–15 and in partnership with hospital DEI leaders—to design new Section of Hospital Medicine DEI infrastructure. DFSS is a collection of tools and best practices for developing new processes that has been applied successfully in health care in many areas.16–18We intended to complete a 4-month, 9-session DEI Steering Team series to achieve our aim. The initial concept for our DEI Steering Team began as a capstone project for our institutional Captains of Inclusion Development Program, which aims to develop cohorts of DEI leaders in our institution by challenging, connecting, educating, and inspiring participants to build an inclusive institutional culture that values difference.19We performed an internal, open recruitment for DEI Steering Team volunteer members in January 2023. We supplemented this open recruitment with individual direct requests to ensure our team included members with expertise or experience in DEI concepts, quality improvement, and our local health system and community.13 Volunteers did not receive dedicated nonclinical time for this work.The DEI Steering Team meeting series consisted of 9 biweekly virtual meetings and was designed around 3 domains: team-building, education, and action (Table 1). In the team-building and education sessions, we aimed to first establish psychological safety and a shared mental model around fundamental DEI concepts and team goals. We reviewed local processes, policies, and programs to understand our institutional culture around DEI. In the action sessions, we aimed to produce the desired output through group consensus. To accomplish these aims, we applied published team facilitation tools20 for consensus building (eg, brainstorming).During the action sessions, the DEI Steering Team developed a Section of Hospital Medicine DEI values statement and key driver diagram (KDD) through facilitated brainstorming. DEI Steering Team members contributed cards to a virtual Dotstorming21 board in response to the following prompt: What do we need to do to fulfill our Section of Hospital Medicine DEI values statement? Through facilitated group consensus, individual cards with the same intention were combined, after which all remaining cards were clustered based on identified themes (Supplemental Figure 1). These themes then informed the creation of primary and secondary drivers on our initial KDD.To obtain interdisciplinary perspectives, the KDD was presented to nonfaculty partner groups and amended accordingly with minor language changes. Specifically, we discussed the KDD virtually with the system-wide family advisory council comprising caregivers of current and past patients. It was also presented to hospital executive leadership and acute care nursing and respiratory therapy leadership.The KDD was then presented at the opening session of a 2-day Section of Hospital Medicine leadership retreat to the entire leadership team representing all domains across the system: clinical, research, education, and quality. Each leader was individually challenged to consider the application of the KDD to their focus areas and prompted to provide DEI report outs throughout the retreat with accountability for specific DEI change ideas going forward.Our Organizational Research Risk and Quality Improvement Review Panel reviewed this initiative and provided a not human subjects research determination.We completed 9 DEI Steering Team sessions with a cohort of 21 hospital medicine section members including 1 hospital medicine fellow, 4 advanced practitioners, and 16 physicians with diversity in clinical and nonclinical focus. The faculty included 7 instructors (4 senior instructor), 10 assistant professors, 2 associate professors, and 1 professor. A hospital-employed DEI consultant also participated in the sessions. The sessions lasted less than 1 hour (mean 52.4 +/− 5.5 minutes) with 65% attendance (mean 13 +/− 2 faculty).These sessions culminated in the completion of an interdisciplinary values statement and KDD for hospital medicine DEI improvement (Figure 1). We identified 7 primary drivers with 21 secondary drivers. The 7 primary drivers were: Commit to advancing DEI with unequivocal investmentMinimize child health disparities for our hospitalized patients and familiesBuild a culture of inclusivity and belonging intolerant of discriminationRecruit, develop, advance, and sustain a diverse workforceBuild DEI knowledge and awarenessEngage diverse partners in all Section of Hospital Medicine activitiesDevelop foundational data systems to guide the above DEI effortsFeedback from relevant stakeholders included recognition of the importance of this body of work, appreciation for the deliberate engagement of diverse partners, and an acknowledgment of the enormity of the task ahead. Specifically, our patient and family partners highlighted the importance of maintaining momentum to translate these planning steps to improved outcomes.Guided by this KDD and the change ideas produced at our Leadership Retreat, our Section of Hospital Medicine faculty have completed the following efforts since completion of the DEI Steering Team: faculty education on implicit biases and microaggressions, quality improvement to increase in-person medical interpreter use, research to understand inequity in response to patient behavioral escalation, updated faculty recruitment strategies to deliberately and fairly recruit individuals with diverse lived experiences, quality improvement to reduce bias in narrative assessment of trainees, and incorporation of inequity as a prompt for Section-wide case review. We also recruited our inaugural Section of Hospital Medicine DEI Lead whose responsibilities—supported by 0.1 nonclinical full-time equivalent from internal Section funds managed by our Section Head—included DEI incorporation into Section of Hospital Medicine pursuits through advocacy, education, and collaboration/consultation with leaders in other domains (Supplemental Figure 2). Our next steps center around the development of a Section-level strategic approach to DEI improvement that prioritizes and addresses each of our key drivers in a coordinated manner.Our Section of Hospital Medicine DEI Steering Team successfully developed a values statement and KDD through team consensus building inclusive of interdisciplinary perspectives. The KDD provided a guiding framework to our faculty for ongoing DEI improvement coordination, priority setting, and accountability for hospitalist-driven efforts within our Section of Hospital Medicine.Our KDD and its development approach may have different utility to hospitalist groups at different stages of DEI improvement work. We included a detailed description of our approach to development of this KDD in hopes that the preparatory steps taken by the DEI Steering Team may inform similar work at other institutions looking to embark on DEI improvement. For institutions further along in their DEI effort, this work may provide a framework for translating ideas into practice and/or opportunities for collaboration and benchmarking across institutions.Identified as a secondary driver for primary driver #7 above, we must underscore the importance of data-driven DEI improvement. Clearly defined measures, goal setting, and data tracking over time facilitate more effective interventions and enhance accountability. Whereas some patient-focused equity measures may require sophisticated data systems, other workforce-focused measures may be more easily evaluated with basic human resources data. Institutions may start with measures associated with known problems in pediatric hospital medicine, including inequity in patient safety3 and gender pay gaps.22 For us, we identified measures around our key change ideas including medical interpreter use, workforce diversity, and cognitive bias training for faculty.Our study has several limitations. Specifically, although we took measures to promote inclusivity and recruit diverse perspectives, our DEI Steering Team consisted entirely of hospitalist faculty members without consistent contributions from nonhospitalist, interdisciplinary partners. Similarly, our work aimed to achieve team consensus among hospitalist faculty from a single health system, limiting the generalizability of our output. Additionally, we reside in a state unaffected by legislation limiting DEI efforts by academic and/or health care institutions, limiting generalizability to affected states and highlighting the importance of political advocacy. Finally, this work does not improve diversity, equity, or inclusion without translating our KDD into realized change, and we do not yet have evidence that this KDD impacts actual DEI outcomes.Hospitalists have privilege and influence that position them as crucial change agents within their health systems and communities. Through facilitated brainstorming and consensus building, our team identified 7 primary drivers of pediatric hospitalist advancement of DEI. This first step can facilitate systematic change driven by pediatric hospitalist groups.We wish to acknowledge Diversity, Health Equity, & Inclusion leadership at Children’s Hospital Colorado for their support of this effort and dedication. Specifically, we wish to acknowledge the Captains of Inclusion program for its profound impact on individuals and system culture.