Task Force Recommendations

The recommended Road Map is organized into nine sections:

Problem Statement

Systemic racism has permeated public and private institutions for generations, including those that deliver health care to patients, educate providers, and perform research. Hospitals and academic medical systems have institutionalized policies and practices that perpetuate a culture that maintains an unequal distribution of social and institutional power, hinders the advancement of people of color, supports discriminatory practices, and contributes to disparities in health outcomes. In particular, the Black community—its workforce, faculty, students, providers, and patients—is the most impacted by oppressive racist ideologies. Organizationally, this systemic oppression manifests itself in myriad injustices impacting Black people and other people of color.

Despite its long tradition of caring for the disenfranchised and striving to advance health care for all, like so many other organizations the MSHS—our corporate divisions, hospitals group, and the Icahn School of Medicine—is not immune to this culture or these challenges. While for decades MSHS has initiated and advocated for real and substantive change, we have reached a pivotal moment in our history where we must advance and accelerate our actions. We need transformative and sustainable initiatives that work to ensure that there is no structural and systemic racism or inequity across our Health System and for those we serve. Achieving these objectives will take time, courage, significant resources, and the collective will of all, and Mount Sinai remains firmly dedicated to working toward our anti-racism and equity goals. We remain resolute in our commitment to doing everything that is in our control to advance these aims while we work toward a more just and equitable society. By doing so, we will be a beacon of hope and an example for others to follow.

Overarching Goal

To be an anti-racist and equitable health care and learning institution that intentionally addresses all forms of racism and creates greater diversity, inclusion, and equity for our workforce and for those we serve.

Guiding Principles

The following guiding principles were developed by the Task Force to be used at all levels to guide the Health System’s collective action toward our goal:

Commitment and Accountability: an unwavering resolve to support the principles embodied by racial and social justice movements that are responsive to those who have been historically marginalized.
Safety to Name, Confront, and Engage in Conversations About Racism: a commitment to ensuring a safe environment where all are encouraged to speak up about racism and have the opportunity to engage in dialogue about the various manifestations of racism—interpersonal, cultural, institutional, and structural—in order to transform the policies, systems, and practices that produce inequity.
Systemic Analysis: a commitment to understanding the ways in which history, systems, policies, practices, the distribution of power, and privilege work together to create and reinforce racial inequities and injustices.
Shifting Power Dynamics and Privilege: a commitment to a rebalancing of power, privilege, and resources in order to advance anti-racism and equity. This includes leaders leveraging their privilege and power to prioritize and proactively support voices and communities most impacted by inequity, as well as their commitment to call on others to actively participate in anti-racist and racial equity efforts. A commitment to humility, self-awareness, and recognizing when it is best to listen, learn, and champion others to lead.
Accountability, Transparency, and Communication: a commitment to creating meaningful accountability structures at all levels, to transparency with regard to performance, and to consistent and omni-directional communication.
Sustained Commitment: a commitment to long-term, sustained investment of time, money, resources, and people to see this work through over the long term.

Key Strategic Recommendations

Based on existing efforts and gaps in achieving the overarching goal, the Task Force identified 11 key strategic recommendations for consideration:

Develop an equity scorecard to measure performance in order to identify where we are meeting with success and where more or different efforts are needed.
Unify and integrate clinical practices, where possible, while advocating for payment and regulatory reforms that would allow for the full integration and unification of clinical practices regardless of insurance status.
Enhance community partnerships and accountability.
Build connection and community within the MSHS to adopt a racial equity culture.
Forge new, and leverage existing, strategic partnerships and networks within the MSHS to accelerate and spread anti-racism and equity efforts.
Develop a sustained financial investment in racial equity and anti-racism.
Examine and redesign business structures with an anti-racist and equity lens.
Increase recruitment efforts, hiring, and retention of Black and other underrepresented minority (URM) staff and faculty and ensure they are represented in all levels of leadership, including high-impact leadership roles in the System.
Promote equity in mentorship.
Enhance leadership learning, capacity, knowledge, engagement, and accountability so that all leaders are able to participate fully in anti-racism and equity efforts.
Provide anti-racism education and resources throughout the MSHS in order to foster a learning community at all levels and to help advance an anti-racism and equity culture.

Interventions and Initiatives

The interventions and initiatives are recommendations to mutually reinforce activities or actions designed to achieve the key strategic recommendations. All interventions are organized by a specific strategy.

Strategy 1:
Develop an equity scorecard to measure performance in order to identify where we are meeting with success and where more or different efforts are needed.

It is axiomatic that we can’t move what we don’t measure. Therefore, we recommend a robust system-level equity scorecard that tracks the relevant measures related to anti-racism and equity. This would be akin to the system-level quality measures dashboard or financial performance report.

Development and inclusion of clinical disparities metrics as key quality outcomes in new and existing dashboards.
Identification and inclusion of non-clinical equity metrics in operational dashboards.
Consolidation of clinical disparities and operational metrics (above interventions) into a new Equity Dashboard with a process for communicating outcomes to MSHS staff to drive change.
Inclusion of equity dashboard metrics in executive compensation matrices, including individual bonus calculations.
Create bidirectional connectivity between operations and the Institute for Health Equity Research. These communications will contribute to performance evaluations based on equity measures. In addition, as appropriate, Institute participation will be incorporated into research design and consulted regarding definitions of metrics and development of methodology.
Build a process by which the data collection and validity for race and ethnicity data is continuously improved.

Strategy 2:
Unify and integrate clinical practices, where possible, while advocating for payment and regulatory reforms that would allow for the full integration and unification of clinical practices regardless of insurance status.

The U.S. health care system, by virtue of the way that health care payment is organized, makes it fiscally prohibitive, if not impossible, to fully unify all practices regardless of insurance status. To address this, MSHS must unify where possible while also strongly advocating for the necessary changes at both the state and federal level to make full unification possible.

Prioritize state and local advocacy for policies and legislation to address inequities in current insurance system reimbursement.
Develop financial models that maximize Medicaid reimbursement to create more parity between Medicaid and commercial insurance rates.
Assess clinical practices using existing and emerging quantitative and qualitative data and metrics, including staff interviews to define and explore the drivers of care that can result in a disparate impact based on race

- Identify missing data elements related to race and equity, design processes for data collection, and operationalize collection of data in practices.

- Advance and apply lessons learned from existing integration efforts in OB/GYN and Mount Sinai Fuster Heart Hospital to other priority areas.
Develop a Road Map with key principles, goals, and milestones, including advocacy efforts for reimbursement reform, to achieve practice integration.
Identify areas in the MSHS for meaningful change and develop a phased plan and timeline for Health System practice integration.
Continuously monitor practices through key indicators and reassess when expectations
are not met.

Strategy 3:
Enhance community partnerships and accountability.

Our customers—those in the communities we serve—should have a strong voice at the table in helping us to set our equity agenda. We recommend doing this work with them as partners rather than to them.

Recommit to the American Hospital Association Equity Pledge to eliminate
healthcare disparities.
Develop a MSHS statement that recognizes systemic racism’s effect on the health and well-being of the communities it serves and enter into strategic partnerships with key organizations that advocate for communities of color.
Increase purchasing by 3 percent of measurable spend in 2021 from local Black and other underrepresented minority vendors from neighborhoods where the MSHS’s hospitals, ambulatory sites, and schools are located.
Report on the percentage of MSHS workforce hired locally and determine additional interventions, if necessary.
Determine means for providing workforce training opportunities to the local community (whether it is funding or actual training).
Leverage the Diversity Innovations Hub and MSIP to develop a business incubator that provides capital, coaching, and networking to locally Black-owned startups and businesses, including social enterprises.
Leverage real estate development to promote local retail, employer-assisted housing, and community land trusts.

Strategy 4:
Build connection and community within the MSHS to adopt a racial equity culture.

Building on existing platforms and creating additional structures for listening and capturing information and data are critical. Advancing this work will require strengthening our community and ensuring a supportive climate across the Health System through authentic communications and timely responses to issues of racial and social equity of importance to our staff.

Scale up existing Chats for Change monthly interactive dialogues centered on racism and racial equity across the Health System.
Ramp up existing efforts to promote reporting of instances of racism and bias (experienced or witnessed) in the work, learning, research, or clinical environment.
Develop and implement a robust two-way interactive communication strategy that encourages participation across the MSHS.
Launch a year-long “listening tour” and storytelling project across the Health System to uncover how racism manifests and is experienced in our environment and to authentically listen to voices who have been historically marginalized and silenced.
Conduct a system-wide climate and culture survey among faculty, staff, trainees, and students and share data across the Health System. Use these findings to inform the scorecard and other key strategies and to track performance over time.

Strategy 5:
Forge new, and leverage existing, strategic partnerships and networks within the MSHS to accelerate and spread anti-racism and equity efforts.

Building on existing structures for guidance, support, and accountability, and creating additional ones where necessary, is critical for advancing this work and for alignment with other efforts. Formalizing relationships with the Executive Diversity Leadership Board (EDLB), diversity councils and committees, and other stakeholders across the system, including the school, is key toward this end.

Create a formal process to collaborate with existing MSHS committees and groups to advise and engage in participatory decision-making to ensure the EDLB is accountable and working toward the anti-racism and equity goals.
Form a network for those who are accountable and responsible for implementing the interventions.
Report progress to the MSHS Boards of Trustees regularly.

Strategy 6:
Develop a sustained financial investment in racial equity and anti-racism.

As the organization progresses toward its aim of being more anti-racist, the work will continue beyond these recommendations and initiatives. Sustained financial commitment will be critical. We do not cease our focus on, and investment in, quality or patient experience when key projects or programs are complete; we seek the next set of interventions. This same level of sustained focus and financial support will be critical to our long-term success in equity and anti-racism.

Ensure adequate funding for existing structures with a mission of eliminating racism and inequity (e.g. ODI, RBI). Commit to a funding level for these structures that is, at a minimum, equivalent to their current funding, adjusting upward as the size and complexity of the organization grows.
Develop detailed investment plans for funding the strategies and interventions within the Road Map. Define and approve the financial resources needed for each intervention.
Hold all leaders and departments accountable for equity and anti-racism metrics in their purview as defined by the shared measurement system. Commit to adequate funding such that performance on these metrics is not an unfunded mandate.
Incorporate criteria for equity and anti-racism into existing business planning tools for
new initiatives.

Strategy 7:
Examine and redesign business structures with an anti-racist and equity lens.

Successfully driving this work will require vertical and horizontal integration of effort and embedding the prioritization of our communities of color into existing relevant policies, practices, and business structures for recruitment, hiring, management, and investment decisions.

Review HR policies and procedures with an anti-racist and equity lens and create a mechanism for monitoring (including hiring practices, employee codes of conduct, holiday policies, etc.).
Assess the MSHS supply chain and increase contracts with businesses that are minority- and Black-owned.
Train and monitor department leaders and quality committees to embed an anti-racist lens in all policies and procedures and redesign other business structures at the department level.
Integrate an anti-racist and equity lens into the Quality Leadership Council top-line goals and processes.

Strategy 8:
Increase recruitment efforts, hiring, and retention of Black and other URM staff and faculty and ensure they are represented in all levels of leadership, including high-impact leadership roles in the System.

An intentional and consistent focus on advancing recruitment, hiring, development, and retention of staff and leadership of color is critical. This will require review and examination of existing policies, practices, and programs; creating new programs and efforts with an equity lens; and holding all leaders accountable for measurable gains across the organization.

Continue targeted initiatives to identify and position existing mid-to-senior Black managers for high-impact leadership roles within MSHS and to educate hiring managers regarding demographic composition.
Develop an assessment tool to determine the challenges for recruiting, hiring, and retaining Black and other URM staff and faculty, and implement strategies to address these challenges.
Develop a two-year high-potential leadership development program for Black senior managers and directors who aspire to move into executive-level positions.
Employ a broader pay equity analysis to explicitly examine racial disparities and remedy pay inequities, if noted.
Provide optional protected time and credit to leaders and faculty of color who devote disproportionate time to mentoring, guiding, supporting, teaching, and representing the diversity of the institution.
Review and address advancement and promotion criteria and track progress of Black and other URM faculty.

Strategy 9:
Promote equity in mentorship.

There is an abundance of talent in the MSHS that we can better promote and tap into if we ensure that robust cohorts of Blacks and other underrepresented minorities are included in our mentorship and leadership development programs.

Create a network of existing mentorship programs to increase access and scale up across the MSHS.
Work with HR to develop system-wide mentorship programs with focus on Black employees.
Expand existing programs with intentional goals and adequately resource them (including administrative fellowships).
Establish a new targeted leadership program for mentorship, coaching, and sponsorship.

Strategy 10:
Enhance leadership learning, capacity, knowledge, engagement, and accountability so that all leaders are able to participate fully in anti-racism and equity efforts.

Our greatest impact is achieved through our leaders. The more our leaders, at all levels, have the requisite knowledge, skills, and attitudes to engage in anti-racism and equity work, the more likely we are to achieve our aims, and to do so faster. This will require ongoing leadership development.

Build equity and anti-racism content into the Health System Leadership Academy.
Expand equity and anti-racism content in the existing HR Leadership programs.
Create new Black and other URM high-potential pipeline and leadership
development programs.
Commit to advancing racial diversity in the Boards of Trustees.
Leverage early retirement program opportunities to ensure we are being inclusive of Black and other URM candidates in filling vacancies. Build equity and anti-racism goals into executive incentive compensation matrices (ties to “scorecard”).
Make clear the expectation that all leaders mentor Black and other URM members of the MSHS workforce. Increase URM mentees of all leaders at every level.
Increase executive leadership commitment to self-reflection and education in recognizing manifestations of racism through workshops and other learning.

Strategy 11:
Provide anti-racism education and resources throughout the Health System in order to foster a learning community at all levels and to help advance an anti-racism and equity culture.

Ultimately, achieving anti-racism and equity will come down to each and every member of the Mount Sinai family. We should ensure that everyone, therefore, has ongoing learning opportunities and opportunities for dialogue and reflection and participation so that racial equity, diversity, and inclusion become our normative culture.

Evaluate and enhance existing educational efforts to develop and implement learning opportunities for staff and leadership to gain insight into racism and equity at the personal, interpersonal, institutional, and structural levels; build knowledge about how to become anti-racist; and promote racial equity in their day-to-day roles.
Provide leadership development to promote active support and leadership for the changes necessary to move the MSHS toward anti-racism and racial equity.
Hire content experts to develop anti-racist and racial equity educational materials (toolkits) to foster a learning community across the system.

Implementation Approach

The task force recommends using the approach of Collective Impact to advance the work toward the goal of becoming an anti-racist and equitable health care and learning institution. The proposed approach is aligned with Collective Impact best practices to promote strategic guidance, support, and partner-driven action to implement the interventions across the system. In addition, the approach leverages existing structures and supports those that already exist. Figure 1 outlines the recommended structure in detail.

Figure 1: The MSHS’s Strategic Structure for Collective Impact

Click to Enlarge

Strategic Guidance and Support

Steering Committee: Executive Diversity Leadership Board (EDLB)

The Task Force recommends leveraging the Executive Diversity Leadership Board, which is chaired by Dr. Davis and includes system and school executive leaders, to become the steering committee that:

Provides strategic direction for the work by engaging advisors in participatory decision-making and review of the shared metrics
Champions the work
Aligns Health System priorities to the common agenda
Mobilizes and aligns resources to support the work
And has key steering committee members serving as those accountable for the work

Advisors/Decision-Makers

Since the MSHS includes many different stakeholders across different locations, the Task Force recommends leveraging the existing leadership teams, committees, and councils across the system that have a demonstrated track record of diversity, equity, and inclusion efforts. The stakeholder groups (Hospital and Corporate Diversity Councils, System Learning Council, Quality Leadership Council, Patient Experience Committee, Icahn Mount Sinai Leadership Groups, Icahn Mount Sinai Diversity Councils and Committees, and Student Council) could become an Advisory and Decision-Making core that:

Advises and engages in participatory decision-making process with the Steering Committee (EDLB) to inform strategic direction
Reinforces accountability mechanisms
Serves as communication champions across the MSHS

Backbone Support

The Task Force recommends that the backbone support structure be developed and housed within the Health System’s Office for Diversity and Inclusion. The backbone structure:

Provides dedicated staff to focus on collective impact
Guides vision and strategy
- Builds a common understanding of the problem
- Provides strategic guidance to develop a common agenda
- Serves as a thought partner for the Steering Committee

Supports the intervention (mutually reinforcing activities)
- Coordinates and facilitates continuous improvement, communication, and collaboration
- Convenes those who are accountable and responsible for the work and drive the participatory decision-making process
- Seeks out opportunities for alignment with other efforts
- Creates paths for, and recruits, new partners so they become involved

Establishes shared measurement practices
- Works with Shared Measurement Groups (see below) to collect, analyze, interpret, and report data
- Catalyzes or develops shared measurement systems (working with IT)
- Provides technical assistance to build data capacity

Partner-driven Action: Intervention and Implementation

As part of the accountability structure, the “Accountable” and “Responsible” individuals and workgroups (typically led by those who are accountable, supported by the backbone):
- Develop a tactical plan to implement the interventions and initiatives
- Collect data from stakeholders
- Engage in data-informed decision-making and course correction when needed
As part of the accountability structure, the Communications Team and others will continue to keep MSHS and other stakeholders updated regarding progress, milestones, and continuous learning.

Shared Measurement System for Collective Impact

Shared measurement is a critical piece of pursuing a Collective Impact approach. Shared measurement allows us to identify common metrics for tracking progress toward our common agenda to address racism across the MSHS, and provide a scalable platform to share data, discuss learnings, and improve our strategy and action.

The benefits of using shared measurement:

Improving data quality
Tracking progress toward a shared goal
Enabling coordination and collaboration
Learning and course correction
Catalyzing action

Key Features of Shared Measurement

Focus on measuring outcomes and impact: shared measurement should focus on measuring the difference an intervention or initiative makes to an issue (e.g., addressing racism) or a group of people.
The system includes a common/shared set of indicators and data collection methods that can provide timely evidence of (or lack of) progress toward the outcomes.
A participatory process is used to determine a common set of indicators and data collection methods.
The system can adapt to changes in measurement priorities and approaches as the initiative evolves.
Facilitated process for participants to share data and results, learn, and better coordinate efforts.

Shared Measurement Structure and Roles

Below you will find the recommendations for the proposed structure and roles that would be required to track and monitor the strategies and interventions/initiatives.

Shared measurement advisory group: This group is made up of members of the Task Force and other individuals across Mount Sinai who have prior experience evaluating or researching racial equity, health disparities, and related domains. The role of this group is to advise the Shared Measurement Coordinator and the Office for Diversity and Inclusion’s backbone team to support the three phases of the shared measurement system development.
Shared measurement platform group: This group would be responsible for creating and overseeing the shared IT information system or platform. It would also be the common entity that stores all the data on behalf of all the partners (those who are responsible and accountable for implementing the interventions).
Shared measurement director (backbone support): One FTE will coordinate the three phases of the shared measurement system development and play a leadership role in the backbone support.
Data analysis group: This group would be made up of experts who can be called on to provide continuous assistance analyzing data for the strategic guidance and support teams.
- PhD-level data scientists to conduct queries of various databases, restructure the data
  for analysis, and provide components of the data management.
- An additional expert with substantial technological expertise to set up and maintain the server, analyze the data in RStudio, and build the infrastructure for a private Mount Sinai GitHub repository to store the datasets that the data scientists will be posting on a
  regular basis.
- Biostatistics faculty members to provide statistical oversight for all analyses conducted
  and reports generated.
- A Master’s-level Biostatistician II and a Statistics/Data Science Graduate Research Assistant to conduct additional data management, conduct all analyses, create reproducible reports in RMarkdown for storage in the GitHub repository, disseminate findings, and create all data visualizations.

Developing a Shared Measurement System Multi-Phased Plan

We anticipate phase 1 will begin in April 2021, assuming the coordinator (1 FTE) is hired. The three phases are informed by the Learning for Action toolkit.

Phase 1: Design

Develop a shared vision and design for the system and its relation to the broader goal and strategies
Review current state of knowledge and data
Develop governance and organization for structured participation
Develop theory of change for each intervention (prioritize interventions within two years) in order to identify short-term and long-term outcomes
Identify metrics (including shared measures) and data collection approach

Phase 2: Develop

Develop web-based platform and data collection tools
Refinement and test platform and tools
Develop a plan outlining how data is analyzed and reported, including participatory decision-making processes

Phase 3: Deploy

Learning forums and continuous improvement
Ongoing infrastructure support
Collect baseline data

Resources, Priorities, and Metrics

We recognize that for Mount Sinai to be an anti-racist organization, equity needs to be a core value that is the work of all 42,000 employees, not just those in existing diversity and inclusion functions. In this way, it is much like quality, which is not the accountability or responsibility of just the office of the CMO, but a core value that all Mount Sinai employees prioritize in all of their work.

Therefore, the strategies and recommendations for interventions of the Road Map all have accountable parties who are the operational leaders of the corresponding functions (e.g. supply chain leadership for supplier diversity, HR leadership for training programs). We recognize that the work of the Road Map needs to be incorporated into the daily work of many leaders; thus, we did not focus on identifying specific incremental resources in most areas.

Instead, we recommend that MSHS executive leadership make clear to all leaders in the organization that the work of the Road Map is to be prioritized appropriately, such that the strategies and interventions are advanced during the identified timelines. Leaders should then be held accountable for advancing their assigned road map interventions and achieving the relevant metrics, much as they are for the clinical and financial metrics associated with their work. And, if needed, other less important initiatives ought to be deprioritized or additional resources should be approved to allow accountable leaders to advance the work defined in the Road Map.

Recommended Action Steps for Leadership

Approve requested incremental funding for ODI+ Backbone to advance the overall project management and impact evaluation of the Task Force Road Map.
Review all accountable and responsible stakeholders to ensure completeness and consistency with system responsibilities.
Direct accountable and responsible stakeholders for each intervention to determine additional resource needs, organizing needs by department and type of resource:
- Time Allocated
- Additional FTEs
- Consultants
Review required investments (along with existing priorities) with accountable stakeholders, Finance, and Operations to reprioritize existing priorities as needed and ensure adequate resourcing for Road Map priorities, either with existing or new resources.
Set targets for accountable and responsible stakeholders for achievement of their Road Map priorities.
Hold stakeholders accountable for meeting these targets and Finance accountable for providing agreed-upon incremental resources.

Conclusion

We recognize that these issues are as challenging as they are important. The recommendations put forth comprise the collective thinking, experiences, and opinions of the Task Force over the past nine months on how best to move Mount Sinai and the communities we serve forward to a more fair, just, anti-racist, and equitable community.