Operationalizing inclusion: moving from an elusive goal to strategic action.

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Understanding Contributors to Racial/Ethnic Disparities in Emergency Department Throughput Times: a Sequential Mixed Methods Analysis.

BACKGROUND: Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level. OBJECTIVE: To characterize key contributors in racial/ethnic disparities in emergency department (ED) throughput times. DESIGN: We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians. KEY RESULTS: Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p value=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients. CONCLUSIONS: Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care.

Striving Toward Better Eye Health Beyond Our Waiting Rooms: The LXXX Edward Jackson Memorial Lecture.

PURPOSE: Visual impairment (VI) negatively impacts the quality of lives of individuals and the optimal health of populations, creating both human and financial costs. Yet, VI has not risen to a level that is considered a priority in population health. This analysis assesses the evidence currently available for strengthening the value proposition for eye health, particularly the demographic characteristics and patient-centered outcomes found in clinical research. DESIGN: Retrospective cross-sectional analysis. METHOD: Two searches of the AJO database were performed using relevant key words: Search 1 (S1): NEI-sponsored clinical trials (1970-2023); and Search 2 (S2): Quality of life (2018-2023). The Scopus Cite Score was used as a filter for each search, specifically ≥50 for S1 and ≥20 for S2. RESULTS: Of the initial 466 articles found, 100 met the preestablished criteria. Age, sex, and race/ancestry/ethnicity were reported across glaucoma, retina, uveitis, cornea, and pediatrics subspecialties in 56% ± 9.7% of the articles; 37% ± 9.5% listed either age only or age, sex, or gender. The characterizations varied and subcategories were rarely reported. Only 2% of S1 and 25% of S2 noted patient-centered outcomes. CONCLUSIONS: The characterization of study populations in the ophthalmic literature is limited by underreporting of patient-centered outcomes, useful for reaffirming the value of eye and vision health in population health. This analysis highlights the need for paying greater attention to more specific demographic categories and focusing more on patient-centered outcomes in clinical research.

Asserting Accountability to Address Diversity: Report Card as a System of Measurement.

Problem: To the best of our knowledge, there are no standard accountability measures for diversity efforts at the departmental level. Therefore, the purpose of this study is to evaluate a multiprong report card as a structure for evaluation, tracking, and reporting as well as to examine any relationships between expenditures and outcomes. Approach: We instituted an intervention that offered leadership a report card of metrics related to diversity efforts. Included are diversity expenditures, benchmark demographic and departmental data, applications to support faculty salaries, participation in clerkship programs focused on attracting diverse candidates, and requests for candidate lists. The purpose of this analysis is to demonstrate the impact of the intervention. Outcomes: A significant relationship was found between faculty funding applications and under-represented minority (URM) representation in a department (0.19; confidence interval [95% CI] 0.17-0.21; p<0.001). An association was also found between total expenditures and URM representation in a department (0.002; 95% CI 0.002-0.003; p<0.001). Other outcomes include the following: (1) women, URM, and minority faculty have all increased in representation since tracking began; (2) diversity expenditures and faculty opportunity fund and presidential professorship applications have increased over time; and (3) a steady decline in departments with zero URM representation after the tracking of diversity expenditures in both clinical and basic science departments. Next Steps: Our findings suggest that standardized metrics for inclusion and diversity initiatives promote accountability and buy-in from executive leadership. Departmental detail enables tracking of progress longitudinally. Future work will continue to evaluate the downstream effects of diversity expenditures.

Addressing Structural Racism Using a Whole-Scale Planning Process in a Single Academic Center.

Purpose: The murder of George Floyd in 2020 prompted a national demand for cultural transformation to confront the systemic racism prevalent in the country. Academic medical centers were not exempt from this urgent call. This article evaluates the efficacy of a strategic process in fostering cultural transformation within an academic medical system. Methods: A whole-scale strategic planning process was implemented over 13 months, involving multiple working groups representing key stakeholders from each entity across the system, an anonymous survey, a communication plan, and a balanced scorecard to monitor progress. More than 5500 voices, 160 recommendations, 122 data gathering sessions, and town hall meetings contributed to the creation and implementation of vital action items and a strategic framework. The Diversity Engagement Survey (DES) was administered 18 months following the process launch. Results: Of the 45,554 employees, students, faculty, and trainees, 96.5% completed unconscious bias education within the fiscal year and 76% of action items, termed "Just Do Its," were completed. Mission, vision, values, and strategic priorities were crafted to serve as a framework for intermediate and long-term actions. The DES revealed improvement in the "respect" attribute of an inclusive culture, and 64% of respondents confirmed that action for cultural transformation is addressing racism both within and outside of the institution. Conclusion: Implementing a shared purpose, engaging multiple working groups representing key stakeholders, and empowerment of stakeholders to implement changes, in conjunction with the development of a strategic framework addressing structural racism, resulted in the completion of vital action items to initiate cultural change.

Strategic planning as a tool for achieving alignment in academic health centers.

After the passage of the Patient Protection and Affordable Care Act in March 2010, there is an urgent need for medical schools, teaching hospitals, and practice plans to work together seamlessly across a common mission. Although there is agreement that there should be greater coordination of initiatives and resources, there is little guidance in the literature to address the method to achieve the necessary transformation. Traditional approaches to strategic planning often engage a few leaders and produce a set of immeasurable initiatives. A nontraditional approach, consisting of a Whole-Scale (Dannemiller Tyson Associates, Ann Arbor, MI) engagement, appreciative inquiry, and a balanced scorecard can, more rapidly transform an academic health center. Using this nontraditional approach to strategic planning, increased organizational awareness was achieved in a single academic health center. Strategic planning can be an effective tool to achieve alignment, enhance accountability, and a first step in meeting the demands of the new landscape of healthcare.

Gender Diversity on Corporate Boards Associated with Ophthalmology.

PURPOSE: Enhancing diversity on boards has been linked to greater profitability and innovation. Unfortunately, there remains an underrepresentation of women in executive management and leadership positions in the ophthalmic corporate world. The purpose of these analyses was to examine the gender composition of directors for boards associated with the discipline of ophthalmology. DESIGN: Cross-sectional research design. METHODS: Using contemporary data, we examined a specific cohort, the American Academy of Ophthalmology (AAO) Foundation Ophthalmic Business Council corporate members as reported in the annual 2019 meeting program (N = 23). The board composition was analyzed using an online search of publicly available information in January and February 2020. The specific outcome measures included the number and percentage of women board members and their roles. RESULTS: There were a total of 23 Ophthalmic Business Council members with publicly available data; 37 of 195 total directorship seats (19%) were held by women, and 9 of 23 companies (39%) listed women as previous or current chairs of committees or outside corporations. Four of the 23 (17%) members of the Ophthalmic Business Council corporations had no women directors. CONCLUSIONS: The boards of directors of the AAO Foundation Ophthalmic Business Council corporate members remain predominately male. Despite the increasing number of women entering the specialty, women remain underrepresented in the corporate world of ophthalmology. Gender parity on boards is essential for the economic well-being of ophthalmic corporations as well as the relationship of the Ophthalmic Business Council with AAO members, health care systems, insurance carriers, government officials, and the public.

Employee Health and Wellness Outcomes Associated With Perceived Discrimination in Academic Medicine: A Qualitative Analysis.

Importance: Organizational culture and workplace interactions may enhance or adversely impact the wellness of all members of learning and work environments, yet a nuanced understanding of how such experiences within health care organizations impact the health and wellness of their membership is lacking. Objective: To identify and characterize the reported health and wellness outcomes associated with perceived discrimination among academic medicine faculty, staff, and students. Design, Setting, and Participants: This qualitative study analyzed anonymously submitted written narratives from 2016 that described experiences related to inclusion in the workplace or lack thereof. Narratives that described health outcomes associated with work- or school-based discrimination were purposively sampled. Participants were faculty, staff, and students at health-related schools or hospitals affiliated with the University of Pennsylvania. Data analysis was performed from March 2019 to January 2020. Exposures: Self-reported experiences, both witnessed and personal, of discrimination in the workplace. Results: A total of 315 narratives were collected, and 115 narratives from 115 participants were analyzed. Most respondents identified as female (70 respondents [60.9%]), non-Hispanic White (68 respondents [59.1%]), and heterosexual (89 respondents [77.4%]) and had worked at the institution for at least 1 year (99 respondents [86.0%]). The outcomes associated with adverse workplace experiences were broad and ranged in nature from emotional to mental and physical. Most reported outcomes were emotional (101 respondents [87.8%]), and more than 1 in 10 narratives (14 respondents [12.2%]) described a mental or physical health outcome. Many of the participants felt devaluated, overexerted, and hopeless, resulting in clinically relevant manifestations, such as increased stress and anxiety levels and even elevated blood pressure. Conclusions and Relevance: This qualitative study identified a continuum of negative outcomes on employee health and well-being associated with perceived discrimination and chronic exclusion in the workplace. These findings suggest the need for organizations to promote inclusion as a component of workplace wellness interventions.

Assessment of Cumulative Incidence and Severity of Primary Open-Angle Glaucoma Among Participants in the Ocular Hypertension Treatment Study After 20 Years of Follow-up.

Importance: Ocular hypertension is an important risk factor for the development of primary open-angle glaucoma (POAG). Data from long-term follow-up can be used to inform the management of patients with ocular hypertension. Objective: To determine the cumulative incidence and severity of POAG after 20 years of follow-up among participants in the Ocular Hypertension Treatment Study. Design, Setting, and Participants: Participants in the Ocular Hypertension Treatment Study were followed up from February 1994 to December 2008 in 22 clinics. Data were collected after 20 years of follow-up (from January 2016 to April 2019) or within 2 years of death. Analyses were performed from July 2019 to December 2020. Interventions: From February 28, 1994, to June 2, 2002 (phase 1), participants were randomized to receive either topical ocular hypotensive medication (medication group) or close observation (observation group). From June 3, 2002, to December 30, 2008 (phase 2), both randomization groups received medication. Beginning in 2009, treatment was no longer determined by study protocol. From January 7, 2016, to April 15, 2019 (phase 3), participants received ophthalmic examinations and visual function assessments. Main Outcomes and Measures: Twenty-year cumulative incidence and severity of POAG in 1 or both eyes after adjustment for exposure time. Results: A total of 1636 individuals (mean [SD] age, 55.4 [9.6] years; 931 women [56.9%]; 1138 White participants [69.6%]; 407 Black/African American participants [24.9%]) were randomized in phase 1 of the clinical trial. Of those, 483 participants (29.5%) developed POAG in 1 or both eyes (unadjusted incidence). After adjusting for exposure time, the 20-year cumulative incidence of POAG in 1 or both eyes was 45.6% (95% CI, 42.3%-48.8%) among all participants, 49.3% (95% CI, 44.5%-53.8%) among participants in the observation group, and 41.9% (95% CI, 37.2%-46.3%) among participants in the medication group. The 20-year cumulative incidence of POAG was 55.2% (95% CI, 47.9%-61.5%) among Black/African American participants and 42.7% (95% CI, 38.9%-46.3%) among participants of other races. The 20-year cumulative incidence for visual field loss was 25.2% (95% CI, 22.5%-27.8%). Using a 5-factor baseline model, the cumulative incidence of POAG among participants in the low-, medium-, and high-risk tertiles was 31.7% (95% CI, 26.4%-36.6%), 47.6% (95% CI, 41.6%-53.0%), and 59.8% (95% CI, 53.1%-65.5%), respectively. Conclusions and Relevance: In this study, only one-fourth of participants in the Ocular Hypertension Treatment Study developed visual field loss in either eye over long-term follow-up. This information, together with a prediction model, may help clinicians and patients make informed personalized decisions about the management of ocular hypertension. Trial Registration: ClinicalTrials.gov Identifier: NCT00000125.

Assessment of Perceptions of Professionalism Among Faculty, Trainees, Staff, and Students in a Large University-Based Health System.

Importance: With a renewed focus on medical professionalism, an opportunity exists to better define its standards and application to meet the needs of an increasingly diverse workforce given the important association between interprofessional behavior and patient care. Objective: To examine the context of how professionalism is operationalized and perceived in diverse health care work and learning environments. Design, Setting, and Participants: A qualitative mixed-methods analysis of survey data collected from February to April 2015, was conducted followed by analysis of narrative data collected in June 2017. The setting was 2 health systems and 4 health professional and graduate schools. Participants were faculty, trainees, staff, and students (3506 survey respondents and 52 narratives) affiliated with the University of Pennsylvania and the University of Pennsylvania Health System. Data analysis was conducted in 2018 and 2019. Exposures: Independent variables included the following respondent characteristics: gender identity, sexual orientation, race/ethnicity, position, generational age group, length of employment at institution, disability status, belief system or religion, and primary site of work or study. Main Outcomes and Measures: Survey questions were used to assess participants' perception and experiences of professionalism in the workplace as measured by a 5-point Likert-type scale. Results: For the survey, there were 3506 respondents from a pool of 18 550 potential respondents (18.9% response rate). Of 3506 survey respondents, 2082 of 3231 (64.4%) were women, 331 of 3164 (10.5%) identified as gender or sexual minority groups, and 360 of 3178 (11.3%) were non-Hispanic Black individuals. In adjusted analyses, women compared with men (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.3) and Asian individuals (aOR, 2.0; 95% CI, 1.7-2.3) and Hispanic individuals (aOR, 2.0; 95% CI, 1.4-2.7) compared with non-Hispanic White individuals were more likely to value institutional professionalism. In addition, gender identity and sexual minority groups compared with heterosexual respondents (aOR, 1.5; 95% CI, 1.2-1.8) and non-Hispanic Black individuals compared with non-Hispanic White individuals (aOR, 1.3; 95% CI, 1.2-1.4) were statistically significantly more likely to consider changing jobs because of unprofessional behavior at work. The qualitative analysis of narratives revealed that marginalized populations (including but not limited to women, gender and sexual minority groups, racial/ethnic minority groups, those who identify as having a disability, and religious minority groups) reported (1) greater infringements on their professional boundaries, as well as increased scrutiny over their professional actions, and (2) a tension between inclusion vs assimilation. Conclusions and Relevance: The findings of this study highlight the need for health care organizations to revisit how they define and operationalize professionalism to improve inclusivity.

Minority primary care physicians' knowledge, attitudes, and practices on eye health and preferred sources of information.

BACKGROUND: Racial and ethnic disparities exist in the prevalence of certain eye diseases. Minority primary care physicians are in a unique position to help prevent vision loss and blindness, especially among minority populations. METHODS: To measure physicians' knowledge and attitudes regarding eye health and to better understand the facts regarding patient information and counseling concerning eye health and disease, the National Eye Institute included key eye health knowledge, attitude, and practice questions in the 2007 DocStyles Survey, a Web-based survey of primary care physicians about physician perceptions and attitudes concerning communication with patients. RESULTS: A total of 428 minority primary care physicians responded to the survey. Results indicate that minority primary care physicians have favorable attitudes regarding eye health and the role they should play in talking with patients about eye health. Approximately 60% indicated that they could identify patients at higher risk for eye disease; however, only 52% of physicians indicated that they have adequate knowledge to advise their patients on vision health. Regarding information sources, most minority physicians prefer to obtain information about vision and eye health from professional journals, medical Web sites, and continuing medical education. CONCLUSIONS: Findings from this research reveal both a need and an opportunity with regard to increasing physician confidence in identifying patients at higher risk for eye disease and advising their patients on eye health.

Community-based strategies for recruiting older, African Americans into a behavioral intervention study.

PURPOSE: To describe community-based strategies that were effective in recruiting older African Americans into a behavioral intervention study designed to increase eye examination behavior. METHODS: Sites were identified that targeted older African-Americans, including senior centers, senior housing, and church groups. We conducted presentations at these sites, networked with community organizations, placed ads on the radio and in newspapers, and attended health fairs. Potential participants also called us in response to flyers and through word of mouth. RESULTS: We conducted 147 activities at 118 sites. A total of 688 potential participants were screened, with 330 (48%) enrolling, 33% ineligible, and 19% not interested. Highest enrollment rates were for word of mouth (69%), flyers (67%), and senior centers (66%). Barriers to participation included hesitancy of seniors to leave their apartments to attend presentations and competing health issues taking precedence over eye concerns. CONCLUSIONS: A multifaceted recruitment approach incorporating both direct and indirect activities at a variety of sites should be used to recruit older African Americans into a behavioral intervention study. Establishing relationships in the community, both prior to initiating recruitment activities and as an ongoing process, was important to the study's success.

Historically black medical schools: addressing the minority health professional pipeline and the public mission of care for vulnerable populations.

Substantial changes in not only access to care, cost, and quality of care, but also health professions education are needed to ensure effective national healthcare reform. Since the actionable determinants of health such as personal beliefs and behaviors, socioeconomic factors, and the environment disproportionately affect the poor (and often racial/ethnic minorities), many have suggested that focusing efforts on this population will both directly and indirectly improve the overall health of the nation. Key to the success of such strategies are the ongoing efforts by historically black medical schools (HBMSs) as well as other minority serving medical and health professional schools, who produce a disproportionate percentage of the high-quality and diverse health professionals that are dedicated to maintaining the health of an increasingly diverse nation. Despite their public mission, HBMSs receive limited public support threatening their ability to not only meet the increasing minority health workforce needs but to even sustain their existing contributions. Substantial changes in health education policy and funding are needed to ensure HBMSs as well as other minority-serving medical and health professional schools can continue to produce the diverse, high-quality health professional workforce necessary to maintain the health of an increasingly diverse nation. We explore several model initiatives including focused partnerships with legislative and business leaders that are urgently needed to ensure the ability of HBMSs to maintain their legacy of providing compassionate, quality care to the communities in greatest need.