IFDHE Case Study
Cone Health serves residents in several counties in and around Greensboro, N.C. The not-for-profit health care network is comprised of more than 100 locations, including five hospitals, 1,300 physician partners and a total workforce of 13,000 employees. In 2020, Cone Health received the Carolyn Boone Lewis Equity of Care Award from the American Hospital Association for efforts that include integrating health equity practices into its physician-training curriculum and within the governance of its board of directors.
Throughout its long history, Cone Health’s mission has been to meet its community’s evolving health care needs, including on the equity, diversity and inclusion front. Today, all its physicians with privileges are required to complete continuing medical education (CME) pertaining to the social and racial influences of health care. Furthermore, to ensure high equity of care levels for all patients, Cone Health collects race, ethnicity and language preference (REaL) data using patient-centered interview techniques, which include electronic medical records that also capture patients’ preferred language.
However, implanting this requirement of CMEs did not come easy. Cone Health significantly overhauled its culture after a revealing look at how its own staff perceived the organization’s values. The process began more than 10 years ago with health care leaders asking a simple question: Who do we want to be?
In 2010, Cone Health conducted an internal assessment that asked staff what they thought were the main drivers and core values. What administrators learned was that employees thought Cone Health mostly focused on cost controls and patient volume.
“That was not inspiring to anybody,” said Paul Jeffrey, president of Cone Health’s Wesley Long Hospital. “The organization was accepting that it was a good health system, but not one aspiring to be great. We worked on who we wanted to be — a patient-centric health care organization, focusing on improving different areas of quality and patient experience.”
Moses Cone Hospital in Greensboro, N.C.
Not only was Cone Health challenged with getting administrators and staff to buy-in on a wholesale culture change, it also faced earning back the trust of African American community members by distancing itself from a past rooted in discriminatory policies. In 1963, nine African American doctors successfully brought legal action against Moses Cone Hospital to join the medical staff and desegregate care for African American patients. This lawsuit resulted in a landmark federal decision and was a precedent for numerous similar lawsuits throughout the country. Decades later, community perceptions of the hospital needed to change.
Following the 2010 assessment, Cone Health’s leaders launched a significant effort to address diversity, equity and inclusion. Eventually, a Physician Council for Health Equity was formed, and that group went to work on several early initiatives to demonstrate the need for more training among physicians. When the medical executive committee (MEC) first received the request for physician cross-cultural education in 2016, it pushed back and turned it down, offering only to establish minimal training. Then something happened that became a turning point for Cone Health.
Six months after the MEC’s decision to reject cross-cultural education for physicians, Cone Health’s CEO, Terry Akin, offered a public apology to the last surviving plaintiff of the original 1963 desegregation lawsuit. “It was a really big deal, locally,” said Dr. Alvin Powell, chief health equity officer for Cone Health. “It was an opportunity for Cone Health to separate itself from its past, develop trust within its community and move forward with a new initiative of health equity.”
Cone Health CEO, Terry Akin, apologizing to the last surviving plaintiff of the Simkins v. Cone lawsuit.
The community’s reaction to the candor and courage by Cone Health’s top leader, coupled with health care disparities identified in patient data, helped the committee reconsider its decision. Through collection of REaL data, the hospital could show the MEC that real racial disparities of care existed. After reviewing the data and learning more about the reality of unconscious biases affecting patient care, the MEC unanimously decided to mandate cultural competency training.
With the committee’s endorsement, Cone Health made education a key driver for underscoring equitable care as a priority. It adopted new physician training methods and updated patient-data collection standards to ensure high-quality care for its patients and within its surrounding communities.
“Courses and trainings are required of all physicians throughout Cone Health’s system,” said Powell. “We felt that if we really wanted to impact health equity within our community, it had to be led by the physicians.”
All physicians at Cone Health are required to take two courses for each reappointment cycle. Medical professionals earn two CME credits for each 2-hour completed course and have great flexibility in choosing which cross-cultural topics they’d like to learn more about in order to best serve their patients.
In developing new cultural competency training for clinicians and staff, Cone Health realized that educational offerings had to be flexible in order to meet everyone’s scheduling needs. Required courses are now offered in a variety of ways to fit within changing work schedules.
“Physicians have flexibility to select training that works best for them,” said Laura Vail, Cone Health’s director of health equity. “Pre-COVID-19, some courses were made available in person. We offered a social determinants of health series as lunch and learn sessions. In the COVID era, we have adapted and are offering more courses through digital platforms. Our physicians have attended racial equity courses and bias courses over the last year. Cone Health’s physician practice group has developed webinars on various topics including interpreter services, empathy and discrimination in patient services. Online courses are also available for physicians on-demand.”
Another eye-opening development stemming from Cone Health’s focus on health equity and cultural competency education are the questions and positive conversations that were being generated by the staff. As clinicians learned more about their patients’ lived experience, their perceptions of the medical field, and about their patients’ social and economic determinants of health, they became more aware of many patients’ points of view.
Vail added, “Physician feedback has been positive and the physicians said the training raised awareness of many important issues, such as racial justice, criminal justice disparities, as well as health care disparities and issues that touch on equity in health care. It has helped ‘create the conversation’ and that’s powerful. Training has raised awareness and people are talking about it. It’s a good thing.”
Because these conversations were already taking place among the staff before 2020, Vail believes equity was at the forefront as the COVID-19 pandemic quickly materialized. As the national conversation began to shift toward social, economic and health inequities, Cone Health had already addressed inequity issues in driving its new organizational culture. “It’s really good that our culture was in place before COVID happened,” she said. “When we began to see these inequities arise, we quickly began to partner with the faith community. We went to historically African American churches and said we’d like to offer COVID testing and partner with you.”
Vail also said Cone Health teamed up with its Hispanic and Latino organization partners to offer the same services and provide translated information through fliers and radio advertising.
As Cone Health’s leaders look to continue a primary focus on health equity, they realize that it’s important to remember where things started in order to move ahead.
“There was a time when we were not patient-centered, when we weren’t looking at every patient through a lens of equity,” Vail said. “There’s been a culture shift in our organization which really had to occur first for this health equity work to take root.”
Dr. Powell pointed to Cone Health’s innovative patient data collection methods and how it’s important to pair that effort with advanced technology so patients at all connection points within the system may benefit. “Now we are able to measure a lot of these things system wide. Our data analytics teams can accurately measure disparities. When we look at health equity, we have to be very intentional in doing this work to unwind institutional and systemic processes that result in disparities.”
Furthermore, Dr. Powell notes a culture of health equity, diversity and inclusion must be sustainable. Maintaining a successful future entails reaching out beyond hospital walls and making better connections with people in Cone Health’s communities.
“We need to think about continuing to create a culture of equity. We’re also continuing to look at health inequalities outside of our institution and in communities of need. We are building a mobile strategy to go into these communities and brick and mortar facilities for long-term access to care closer to home. We also recognize that there needs to be diversity with respect to who are the caregivers within your institution. The caregivers need to mirror the community for which they are caring.”