Between taking care of patients, filling out medical charts and teaching students, doctors and nurses at Hennepin Healthcare in Minneapolis are taking the time to do their own education. For about three hours each month, staff from across the system sit together in small groups to discuss racism in the broader world and inside the walls of their own institution.
Using documentaries, podcasts and instructor-led conversations, staff from across the health care system spend time discussing, learning and, ideally, implementing the training in a clinical setting.
While diversity, equity and inclusion programs are common in health care, having this kind of intensive requirement is an atypical move. Hospital leaders, though, say it’s vital as they work to serve the entire city and eliminate disparities in care for people of color. While DEI efforts face pushback in other workplaces, Hennepin Healthcare is pushing ahead.
“If we live in fear of what may happen, then we’re already telling the groups that are constantly dealing with issues that the worry of someone who may be offended is more important than my personal safety, well-being and mental health,” Chief Equity Officer Nneka Sederstrom told a crowd during a presentation of the program in February.
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“We decided that if someone is really uncomfortable doing this work: thank you for working at Hennepin Healthcare, you have the right to go work somewhere else. And that's as simple as it is.”
Since the program launched last year to system leadership, officials at Hennepin Healthcare say they have seen some people leave because the institution was no longer a good fit.
‘Our public hospital’
Health care systems often partner with community organizations, or bring in outside professional organizations to lead trainings, as well as focusing on hiring diverse staff members.
Hennepin Healthcare took a different tactic. Its program, Compass, was designed by leaders inside the institution to educate staff about the history of marginalized communities, racism in health care and microaggressions.
“This is an institution that serves Black communities, brown communities, communities that are lower income,” said Hennepin County Commissioner Angela Conley. “This is our public hospital where a lot of folks who are experiencing homelessness, who are checking all those boxes for marginalized communities are going to get basic health care, to get their immediate needs met, when they're in crisis.”
The first cohort of 1,700 employees began the training in January, the second is set to begin in July. Sederstrom said they estimate all employees will have completed the training by 2025.
The financial investment in the program is significant. It’s designed to be completed during work hours, and with every employee required to participate. Vice President of Health Equity Talee Vang, who developed Compass, didn’t put a specific dollar amount to the effort but estimated the cost could be in the millions by the time everyone has completed it.
Vang said the price of not doing it is much higher.
“If somebody says, ‘I don’t care about racism, I don’t care about the treatment of our trans population,’ for example. Should they be here taking care of those populations?” Vang asked. “Should they be here? Can they truly provide the best care for the populations that we serve? Probably not.”
Because of the hospital’s importance in the community — it’s a level one trauma center and the county hospital — and its role as a teaching institution, leaders felt it was important for the system to commit to diversity, equity and inclusion training, Vang said.
“We’re teaching the providers of tomorrow,” she said. “And because of that, we have this unique position to make a real change, and to make a really, really bold statement.”
The first steps included getting executive leadership on board and getting people to recognize and speak honestly about racism and discrimination inside health care institutions, including theirs.
Vang said before the Compass training began, there were some staff who did not believe that racism existed within the hospital system.
Observers say implicit bias may not be immediately visible to a practitioner. Sydney Johnson works as the African American cultural navigator at Hennepin Healthcare. In her role as a patient advocate, she said people sometimes call on her for help when they don’t feel heard or feel like they’re experiencing discrimination.
“Some patients are very not vocal about that at all, because there’s a fear, or there’s, like, a guard,” she said. “You have that mistrust that has been built by a lot of the harmful ways that people have been cared for in communities of color.”
‘We need the whole system to be better’
Bridging the gaps between people of color and the health professionals who treat them is crucial in Minnesota.
A February report from the Minnesota Department of Health said that state’s ongoing health disparities “mean that compared to whites, people of color and American Indians in Minnesota experience shorter life spans; higher rates of infant mortality; higher incidences of diabetes, heart disease, cancer, and other diseases and conditions; and poorer general health.”
Research shows implicit and explicit bias and discrimination in clinical settings lead to worse health outcomes for people of color, like a lack of accurate diagnosis or being provided fewer options for pain management. A 2014 study found a link between implicit bias and cognitive stressors, like crowded emergency departments.
“I can’t tell you the number of times I’ve been gaslit — even in my current capacity as commissioner — going to the doctor's office, talking about pain, talking about things that I’m experiencing, and not being taken seriously,” Conley said. “Hennepin Healthcare absolutely needs to do this,” she said of the equity effort. “Health care is an institution, just like our governments or institutions, and they are notorious for perpetuating institutionalized racism.”
Social determinants of health, including access, education and economic stability, can play a significant role in the health of patients and ultimately whether they’re able to follow through on a treatment plan or get treatment at all.
About a year ago, a patient came to see Dr. Rahel Nardos at the University of Minnesota.
Nardos, who’s not affiliated with Hennepin Healthcare, specializes in female pelvic medicine and is director of global women’s health at the U’s Center for Global Health and Social Responsibility.
She often sees patients with pelvic floor issues, typically related to childbirth. But some also come in with damage as a result of female genital mutilation, a ritualistic nonmedical cutting of genitalia common in some parts of the world but illegal on children in the U.S.
The patient has severe chronic pain as a result of the practice when she was young, and the numerous surgeries she’s had to resolve the issue.
“She actually goes to the emergency room regularly because of severe pain, and no one can find what’s wrong with her,” Nardos said. “Because all the imaging they do, which they keep doing, is normal.”
When Nardos saw her, she recognized that the patient is also experiencing symptoms of post-traumatic stress as a result of what happened. And after a number of false starts finding an interpreter the patient felt comfortable with, the two decided on a course of action: surgery followed by an integrated approach of mental health care and pelvic floor physical therapy.
Despite that, one year later, her patient is still unable to access much of the ongoing care that Dr. Nardos referred her to. She lives far from the Twin Cities and doesn’t have reliable transportation, so getting to regular appointments is difficult. Coupled with the language barrier and ongoing mental health issues, Nardos said “she just falls through the cracks.”
“The work that I did surgically didn’t actually succeed because she needed those kinds of follow up care in order for my work to be successful,” she said. “I’m still actually trying to figure out how to help her.”
These barriers to care, from navigating cultural and language differences, to the economic disparities around transportation and housing are just some of the challenges patients can encounter when they try to access health care.
“When we talk about health equity, it’s not a quick fix. We need the whole system to be better,” said Nardos, who views the Hennepin Healthcare Compass effort as a step in the right direction for the hospital and the health system.
“I think that general awareness of the story, [the] context, the bias and the racism, all those things, it’s important to discuss those things,” she said. “Ultimately, it comes to you, as a person, and your practice and how you want to show up in the real world.”