JPOSNA® Special Edition
2022 Annual Meeting Pre-Course on Diversity, Equity, and Inclusion
Advancing Health Equity and Inclusion in an Academic Pediatric Medical Center: Priorities Addressed and Lessons Learned
1Department of Radiology, Boston Children’s Hospital, Boston, MA; 2Office of Health Equity and Inclusion, Boston Children’s Hospital, Boston, MA; 3Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children’s Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Office of General Counsel, Boston Children’s Hospital, Boston, MA; 6Department of Pediatrics, Boston Children’s Hospital, Boston, MA; 7Department of Accountable Care and Clinical Integration, Boston Children’s Hospital, Boston, MA; 8Department of Social and Behavioral Science, Harvard T. H. Chan School of Public Health, Boston, MA; 9Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA; 10Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA; 11Division of Gastroenterology, Hepatology and Nutrition Research, Boston Children’s Hospital, Boston, MA; 12Department of Cardiology, Boston Children’s Hospital, Boston, MA; 13Department of Health Affairs, Boston Children’s Hospital, Boston, MA; 14Office of the CEO and President, Boston Children’s Hospital, Boston, MA
Correspondence: Valerie L. Ward, MD, MPH, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115. E-mail: [email protected]
Received: November 16, 2022; Accepted: November 17, 2022; Published: February 15, 2023
Volume 5, Number S1, February 2023
Abstract
To provide optimal, equitable care to patients, hospital systems must have intentional efforts to advance health equity. We present both intentional and actionable steps that our senior executive leadership prioritized to improve the health equity of the children and families we serve and to create a more inclusive working and learning environment for our employees, staff, faculty, and trainees in our academic pediatric medical center. The four key concepts or lessons learned that we found essential to successfully advancing and sustaining equity, diversity, and inclusion (EDI) in our academic pediatric medical center were to 1) Prioritize the strategy for EDI at the levels of the Board of Trustees and senior executive hospital leadership, 2) Collaborate with multi-disciplinary departments, offices, programs, and subject matter experts, 3) Take an Academic Approach by creating educational initiatives and scholarship in EDI, and 4) Commit to intentionality and accountability in the work by developing and tracking metrics for EDI and health equity safety disparities. Our hospital’s approach to its EDI goals and initiatives can serve as a roadmap for other academic medical centers and healthcare organizations in their efforts to improve health equity for all patients, families, and communities.
Key Concepts
In an academic pediatric medical center, four key concepts are essential to advancing and sustaining equity, diversity, and inclusion (EDI) to create and sustain an equitable and inclusive working and learning environment for all employees, staff, faculty, and trainees1 (Figure 1).
Figure 1. Ward VL, Tennermann N, Chuersanga G, Melvin P, Milstein ME, Finkelstein JA, Garvin MM, Wood LJ, Rauscher NA, Laussen PC, Leichtner AM, Emans SJ, Churchwell KB. Creating a Health Equity and Inclusion Office in an Academic Pediatric Medical Center: Priorities Addressed and Lessons Learned. Pediatric Radiology 2022 52:1776-1785.

- Prioritize health EDI in the strategic goals endorsed by the Board of Trustees and Senior Executive Hospital Leadership.
- Collaborate with multidisciplinary clinical and nonclinical departments, programs, offices, and subject matter experts. Examples of our collaborations include the Boston Children’s Offices of Health Equity and Inclusion, General Counsel, Faculty Development, Community Health, Graduate Medical Education, and Experience and Culture; the Human Resources Department, Nursing/Patient Care Operations Department, Health Affairs Department, Program for Patient Safety and Quality, Boston Children’s Academy for Teaching and Educational Innovation and Scholarship, Institutional Review Board and Research Administration; and the Harvard Medical School’s Office of Diversity, Inclusion and Community Partnership.
- Take an academic approach and create educational and research health EDI initiatives through improving existing knowledge of key drivers and mechanisms underlying health inequities.
- Commit to intentionality and accountability for all health EDI initiatives through the development of assessment metrics and strategies to promote accountability.
Introduction
Health equity means that everyone has a fair and just opportunity to be as healthy as possible, which requires addressing barriers to health such as poverty, discrimination and its consequences, powerlessness, lack of access to good jobs with fair pay and benefits, quality education and housing, safe environments, and equitable access to healthcare.2,3 The American Academy of Pediatrics believes that all systems of care should seek to promote and achieve health equity for all children.4 A focus on health equity means ensuring all people have equitable access to care, equitable healthcare delivery, and optimal health outcomes. The devastating and disparate impact of the coronavirus (COVID-19) pandemic on underrepresented and/or underserved populations and the 2020 national reckoning for racial justice coincided and catalyzed the urgency to address health inequities in the United States.1 This confluence of events brought the nation’s long-standing health inequities for underrepresented and/or underserved populations to the forefront.1 In response, many academic medical centers and healthcare organizations responded to the call with equity, diversity, and inclusion (EDI) statements and declarations as essential guidance documents for their organizations to develop, implement, and sustain the changes necessary to reduce and eliminate the effects of bias, discrimination, and racism on equitable healthcare access and delivery to achieve more equitable patient health outcomes.1,4,5
At Boston Children’s Hospital, we responded to this pivotal societal moment by strengthening, clearly delineating, and implementing our own commitment to EDI in the form of a “Declaration on Equity, Diversity and Inclusivity” (Figure 2).6 This Declaration was endorsed by our hospital’s Board of Trustees, senior hospital executive leadership, Office of General Counsel, Office of Health Equity and Inclusion, and Human Resources Department. Our Declaration on EDI, with its six goals and underlying commitments, provides the roadmap that guides our academic pediatric medical center’s work to advance pediatric health equity and foster an inclusive and supportive workplace.
Figure 2. Boston Children’s Hospital Declaration on Equity, Diversity and Inclusivity. [Boston Children’s Hospital website]. August 2020. Available at: https://www.childrenshospital.org/about-us/health-equity (Accessed October 1, 2022.).

In addition to our Declaration on EDI, Kevin B. Churchwell, MD, the current Boston Children’s President and Chief Executive Officer (CEO), in keeping with his strong commitment to both pediatric health equity and inclusive excellence, announced enterprise-wide in his Boston Children’s “Fiscal Year 2022 Enterprise Framework” that EDI would be prioritized across our academic pediatric medical center at the same level as the hospital’s financial sustainability; how the hospital recruits, retains, and develops its “People” (i.e., employees, staff, faculty, and trainees); and the hospital’s commitment to research, innovation, and discovery. This prioritization of EDI by Dr. Churchwell in the “HOW” we do our work at Boston Children’s was depicted in his “Fiscal Year 2022 Enterprise Framework” presentation in Figure 3 with “Equity, Diversity & Inclusion” within the concentric circle corresponding to the “How do we do it?” (Figure 3).
Figure 3. This framework diagram is based on Simon Sinek’s Golden Circle. Sinek, S. Start With Why: How Great Leaders Inspire Everyone to Take Action. East Rutherford, NJ: Penguin Publishing Group; 2009.

Dr. Churchwell showed this framework slide (Figure 3) at Board of Trustees meetings and during leadership discussions when providing updates on our hospital’s annual goals. At the center of the framework is “patient access.” Access is our shared purpose at Boston Children’s, which is to ensure every child has equitable access to healthcare and that we as healthcare professionals deliver this care equitably through our shared goals as outlined in our hospital’s Declaration on EDI and Enterprise Framework. This framework is foundational to the “how” we do our work in delivering equitable healthcare to children. At our academic pediatric medical center, EDI is not just the work of the Office of Health Equity and Inclusion; instead, it is our shared commitment that everyone, no matter the role or position, at Boston Children’s Hospital, is accountable for advancing our hospital’s EDI goals to provide equitable care to our patients (Figure 2).
Below are the intentional action steps that comprise the collaborative work to implement the six goals and multiple commitments within these goals in the Boston Children’s Hospital Declaration on EDI, which align all departments, divisions, offices, and programs enterprise-wide.
Prioritization of and Declaration on EDI
Goal 1: Be an inclusive environment that does not tolerate any form of racism, discrimination, or bias.
The first goal focuses on creating and maintaining an inclusive working environment that does not tolerate any form of racism, discrimination, or bias. In support of this goal, we have taken pride in our commitment to provide a safe and welcoming hospital environment, not only to those who come to us for care, but for all employees, staff, faculty, and trainees who choose to work and train at our hospital.5 We committed to this by aligning our work in the Office of Health Equity and Inclusion with the Office of General Counsel, Offices of Experience and Culture, Office of Faculty Development, Office of Graduate Medical Education, and the Human Resources Department. We were intentional in defining initiatives and programs that promote EDI. We also re-evaluated our approach to responding to reported incidents from employees, staff, faculty, trainees, patients, and families involving a lack of respect or professionalism, bias, discrimination, pay equity, and systemic barriers to promotion in the workplace. The Office of Health Equity and Inclusion worked closely with the Office of General Counsel and with the Human Resources Department to take action and respond to any of these reported incidents or issues. Collaboratively, these offices and department updated staff trainings and incident reporting procedures and reviewed the relevant policies.
Goal 2: Recruit, develop, and retain a diverse workforce.
It is well documented that having healthcare providers who are representative of the diverse backgrounds and cultures of the patients and families they serve can reduce health inequities and improve patient health outcomes.7,8 The importance of diversity in promoting workforce health and well-being underscore our hospital’s commitment to recruiting, retaining, and developing a diverse workforce by starting early, being intentional, and providing initiatives that are well-resourced.
Our strategy for improving diversity is centered on creating inclusive career pathways (previously referred to as ‘pipeline programs’) for all individuals to have opportunities in the fields of medicine, nursing, allied health professions, research, and hospital administration beginning as early as high school and college as well as for our current hospital employees, staff, and faculty. We are creating innovative programs for longitudinal mentorship, coaching, and sponsorship, and developing career pathway initiatives and programs to promote, retain, and advance underrepresented in medicine (UiM) employees, staff, faculty, and trainees. We are also providing employees, staff, and faculty with leadership development opportunities. An example of a career pathway program is the Boston Children’s Hospital’s “Scribe and Mentoring for Premedical Students (SCRIPT)” pathway program for UiM and/or financially disadvantaged premedical college students. This program includes mentorship, educational sessions, clinical observerships, and training to become a medical scribe. Another example is a faculty development and academic advancement program for outstanding early career UiM faculty at Boston Children’s that entails discussion seminars, mentorship, and coaching by senior faculty, Department Chiefs, and Division Chiefs.
Goal 3: Eliminate structural racism from all policies, guidelines, and practices.
In order to eliminate structural racism from the policies and procedures that guide our hospital’s healthcare delivery, we created the following innovations: incorporated an ancillary EDI review for all human subjects research protocols submitted to our hospital’s Institutional Review Board, reviewed our Health Insurance Portability and Accountability Act (HIPAA) policies for bias, added our Senior Vice President and Chief Equity and Inclusion Officer to our hospital’s enterprise-wide policy review committee, added our Declaration on EDI to our request for proposals and contracting process, created trainings to eliminate bias from our interviewing and hiring practices, and reviewed all clinical pathways to identify whether a race identifier was necessary in a clinical algorithm and removed race where unnecessary.
Goal 4: Comprehensively educate on the impact of racism on child health, unconscious bias, bystander-upstander awareness, and the role of difficult conversations in culturally effective pediatric healthcare delivery.
As a part of our commitment to being a hospital with an inclusive working and learning environment for all employees, staff, faculty, and trainees, we developed a “Bystander to Upstander” Inclusive Workplace Workshop. This training was mandatory for all employees, staff, and faculty in our workforce to become aware of microaggressions and biases and to be accountable to each other when instances of microaggressions and/or bias are witnessed in the healthcare setting. This workshop used real scenarios from our own hospital to ensure that the circumstances portrayed in the scenarios would resonate fully for employees, staff, faculty, and trainees in our clinical, research, administrative, and operational departments. The workshop provided participants with a novel framework for responding to bias in the healthcare setting as well as definitions and shared language related to health equity and inclusion. We are currently in the process of evaluating the efficacy and sustainability of this workshop. Also, our Office of Health Equity and Inclusion collaborated with departments throughout the hospital to engage in open conversations regarding EDI and how our institution can best support employees, staff, faculty, and trainees. We did this through “reflection rounds” as safe spaces to raise discussions around EDI, and open meetings, town halls, and listening sessions.
Goal 5: Be a leader in eliminating child health disparities in our community and in our nation.
Declaration Goal #5 underscores Boston Children’s Hospital’s commitments as an Anchor Institution in the City of Boston ensuring hiring, purchasing, and investment practices that help to drive economic mobility and security for underrepresented and/or underserved communities and populations in the city. Goal #5 also reinforces our intentional approach to supporting patients and families experiencing health-related social needs and collaborating with community partners to address social barriers to health in our surrounding communities. One example of how Boston Children’s Hospital addresses these barriers is through our in-house Medical Legal Partnership (MLP) program. The MLP is a collaborative effort between our clinicians and the Office of General Counsel. In fiscal year 2021, our MLP program received 201 referrals that were primarily from pediatricians, but also from Emergency Department physicians and pediatric subspecialists, for patients needing legal support to address multiple issues and health-related social needs, such as housing and homelessness, immigration status, access to benefits, family law matters including guardianships, and access to appropriate education programs. These referrals were primarily handled by an in-house MLP legal fellow functioning in our hospital’s Office of General Counsel or referred to outside pro bono counsel and legal service agencies. This well-resourced, in-house MLP underscores Boston Children’s Hospital’s strong commitment to addressing the health-related social needs of our pediatric patients and their families.
In addition to the legal services provided by the MLP, our hospital has committed to an academic approach to eliminating disparities in underrepresented and/or underserved populations in our communities. The academic approach has been defined by innovative educational opportunities for healthcare providers in the form of annual symposia on health equity, visiting professorship lectures, and grand rounds in pediatric health equity and inclusive excellence to improve the cultural effectiveness of our healthcare delivery. We also established health equity research collaborations between our Office of Health Equity and Inclusion and departments and divisions enterprise-wide. For example, an impactful collaboration with our Department of Orthopedics was a quality improvement initiative that resulted in improvements in recruitment processes and consent practices that led to an increase in the study enrollment and participation of racially, ethnically, and linguistically diverse infants with brachial plexus birth injury into a clinical research trial.9 Additional opportunities for impactful health equity research have been made possible by the creation of innovative funding mechanisms at our hospital in the form of three dedicated pediatric health equity grants (ranging from $15K to $100K). These grants are now offered yearly to encourage all faculty to conduct research that will reduce inequities in health outcomes. Moreover, our hospital is in its third year of funding a dedicated pediatric health equity fellowship slot within the Harvard-wide Pediatric Health Services Research Fellowship Program. This dedicated health equity fellowship provides support each year for a Boston Children’s Hospital faculty member to obtain a Master of Public Health degree at the Harvard T.H. Chan School of Public Health, and to learn rigorous health equity research methodology to advance their academic career with an emphasis on pediatric EDI.1
Under the leadership of Dr. Churchwell, both rigorous EDI scholarship and research methodology have been made a strategic priority. This strong commitment to leverage Boston Children’s Hospital’s international reputation as a premier research institution is exemplified in the vision, mission, and three focus areas (health equity research, inclusive excellence, and health equity policy) of a new major EDI initiative created at Boston Children’s Hospital in 2021: the Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion (Figures 4 and 5), which aims to advance pediatric health equity locally, nationally, and globally. The Fenwick Institute is named for our hospital’s retired CEO Sandra L. Fenwick, MPH, and honors her long-standing, strong commitment to advocating for improvements in pediatric healthcare and research for all children. The Institute conducts innovative research with rigorous EDI principles embedded into every aspect of the pediatric clinical research process5,10 and develops professional advancement initiatives for inclusive excellence in the next generation of clinical, research, administrative, and operational leaders in biomedical research, pediatrics, and pediatric subspecialties. The Fenwick Institute’s rigorous research methodologies, research findings, and professional development initiatives are aimed to translate into more impactful and efficacious public policy recommendations that improve health equity for all children.
Figure 4. Vision, Mission and Focus Areas of the Boston Children’s Hospital Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion.

Figure 5. Timeline for Health Equity, Diversity and Inclusion at Boston Children’s Hospital.

Goal 6: Lead in the development, implementation, and tracking of metrics for EDI.
The Joint Commission considers addressing health inequities a quality and safety imperative as well as a moral and ethical duty and has provided medical centers with guidance on how to position their approach to disparities as a central part of their performance and patient safety improvement initiatives that will be a requirement in 2023.11 At Boston Children’s Hospital, we are committed to continually assessing EDI metrics to be intentional around our work and hold ourselves accountable by developing, implementing, and tracking metrics to assess our hospital’s impact on the reduction of pediatric health inequities and in particular pediatric safety disparities. This work is a collaborative effort between our Program for Patient Safety and Quality and the Office of Health Equity and Inclusion. We developed a dashboard of health-equity-quality metrics that is stratified by patient demographics and includes race, ethnicity, language, insurance status, and missed appointments to better understand which of our patient populations were disproportionately affected by both inpatient and ambulatory safety disparities. Our hospital also collaborated in a national pilot to assess race and ethnicity disparities in pediatric patient safety, called the Solutions for Patient Safety’s “Patient Harm Associated with Race and Ethnicity” (PHARE) Pilot. Our hospital’s participation in these local and national collaborations heightened our urgency to improve race, ethnicity, language, and patient demographic data collection in our electronic health record and subsequently allowed us to disseminate our best practices around demographic data collection to other academic pediatric medical centers nationally. Through these efforts, we have demonstrated our commitment to leading in the development, implementation, and tracking of EDI metrics.
Summary
The past several decades have seen increasing recognition and promotion of health equity as an integral component to population and individual health. A catalyst in 2020 provided by the devastating health inequities in underrepresented and/or underserved populations illuminated by the COVID-19 pandemic combined with the national reckoning of historical and current racial injustices led many health systems to commit to improving health equity.1,11,12 Our hospital has committed to creating, developing, and sustaining meaningful and actionable initiatives, programs, funding opportunities, and innovations to achieve more equitable healthcare access, delivery, and outcomes. It is our hope that our organization’s approach, goals, and initiatives will be disseminated and used as a health equity, diversity, and inclusion roadmap for other academic medical centers and healthcare organizations in their efforts to improve health equity for all children and their families.
Disclaimer
V. Ward: Co-Leader of the Health Equity Core and Health Equity Advisor for the Children and Youth with Special Health Care Needs Research Network (CYSHCNet). This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under UA6MC31101 CYSHCNet. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, and the U.S. Government; M. Garvin: board member of BCH UK Charity, Ltd.; S. Katz-Wise: Diversity Consultant for Paramount Global; S. Fenwick: board member of Teladoc Health, Inc., Patient Discovery, Inc., Wyss Institute for Biologically-inspired Engineering at Harvard University, Inc., BCH UK Charity, Ltd, Risk Management Foundation of the Harvard Medical Institutions, Inc., and Controlled Risk Insurance Company, Ltd.; K. Churchwell: member of the Massachusetts Business Roundtable, a board member of the Boston Chamber of Commerce, Massachusetts Hospital Association, MIT Corporation, the Whitehead Institute, Children’s Hospital Association, Children’s Hospitals’ Solutions for Patient Safety, Controlled Risk Insurance Company Ltd., Risk Management Foundation of the Harvard Medical Institutions, Inc., Advisory Board for The Boston University School of Public Health, American Medical Student Association, and the Boys and Girls Club of Boston.
References
- Ward VL, Tennermann NW, Chuersanga G, et al. Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned. Pediatr Radiol. 2022;52(9):1776-1785.
- Health Equity. World Health Organization. Available at: https://www.who.int/health-topics/health-equity#tab=tab_1. Accessed June 26, 2022.
- Braveman P, Arkin E, Orleans T, et al. What is Health Equity? And What Difference Does a Definition Make? 2017.
- AAP Equity Agenda. American Academy of Pediatrics. Published January 25, 2021. Available at: https://www.aap.org/en/about-the-aap/american-academy-of-pediatrics-equity-and-inclusion-efforts/aap-equity-agenda/. Accessed October 3, 2022.
- Health Equity: Our Bold Path. Boston Children’s Hospital. Published 2021. Available at: https://secure.childrenshospital.org/site/SPageNavigator/Stories/story_health_equity.html. Accessed October 3, 2022.
- About US: Health Equity. Boston Children’s Hospital. Available at: https://www.childrenshospital.org/about-us/health-equity. Accessed October 26, 2022.
- Trent M, Dooley DG, Dougé J, et al. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.
- Alberto CK, Kemmick Pintor J, Martínez-Donate A, et al. Association of maternal-clinician ethnic concordance with Latinx youth receipt of family-centered care. JAMA Netw Open. 2021;4(11):e2133857.
- Tennermann N, Tartarilla AB, Bauer AS, et al. Quality, Safety and Value (QSVI) Practices to Enhance the Diversity of Pediatric Participants Consented into Orthopaedic Research. Available at: www.jposna.org.
- Barker J. With a dose of health equity, brachial plexus study enrolls more patients. Boston Children’s Hospital. Published November 11, NA 2021. Available at: https://answers.childrenshospital.org/health-equity-brachial-plexus/. Accessed October 3, 2022.
- Joint Commission. Addressing health care disparities by improving quality and safety. Sentinel Event Alert. 2021;(64):1–6.
- Yao Q, Li X, Luo F, et al. The historical roots and seminal research on health equity: a referenced publication year spectroscopy (RPYS) analysis. Int J Equity Health. 2019;18(1):152.