Dr. Maria Hernandez, PhD, is President and COO, Impact4Health and is principal researcher on the Inclusive Leader 360, Inclusion Scorecard for Population Health. Leading Alameda County’s first Pay for Success Asthma Initiative. She serves on the Board of Trustees at Alameda Health System—one of the California’s largest public healthcare systems. She is interviewed by Dora Barilla.

Dora Barilla: Hello, everyone. Welcome to Next Generation Community Health with Providence St. Joseph Health and Stakeholder Health. I’m your host, Dora Barilla. Today we’re joined by Maria Hernandez. We’ll be talking about the importance of health equity in healthcare. Let’s get started first by welcoming Maria to the show. Thank you for joining us today, Maria.

Maria Hernandez: Thanks so much, Dora. It’s a pleasure to be with you.

Barilla: We’re so glad that you could take time today and we could have this conversation. I really want to get into some questions about this just on a personal level, Maria. I wanted to start by asking, why do you care personally about diversity, equity, and inclusion work? I mean, what parts of your personal story inform this work for you?

Hernandez: Well, you know, it’s pretty clear as the daughter of immigrants from Mexico. I’ve grown up with an enormous sensitivity around human rights and social justice. I became a health equity advocate actually about almost 10 years ago when my dad began his first battle with cancer. He was being wheeled into surgery. My brothers, my mom, and I were wishing him well and telling him how much we were there to support him. Of course, we were speaking in Spanish. He suddenly raises his hand and he says, “Stop. Don’t speak Spanish. They’re going to think I’m stupid and they’re not going to take care of me.” That just floored me. I just said, “Oh, my gosh. Here I am working on diversity, inclusion, and belonging inside major corporations. I started to just think about what’s going on in healthcare.

It was around that time that the class standards from the Office of Minority Health were really getting a lot more traction. I just started to read more and more about how this really is a need in healthcare. I started then to really redirect my career so that I could do what I do today. I just felt the passion around making sure anyone who walks inside a hospital and needs care feels that they’re going to get the same treatment, the same level of respect, the same level of guidance and support, that anyone else would regardless of race, regardless of gender, ethnicity, sexual orientation, or age. That was, for me, my lightening rod. I’m really quite blessed that I get to do this work. I hope that I’m doing my dad a lot of honor for having directed me to think about this in a different way.

Barilla: Well, I truly am sorry that you had that experience for your father, but so glad that it catapulted you into really addressing this issue in healthcare because I think it’s really important. Can you explain what you mean by diversity, equity, and inclusion? Maybe share with us how that’s different from political correctness?

Hernandez: Well, let’s start with political correctness because I just want to dismiss that right away and say, basically that’s lying. I mean, political correctness is how people keep their biases to themselves rather than facing the real challenge of true discourse around their beliefs. Let me give you kind of a charged example. If you believe, for example, that left-handed people are inherently lazy, and you work with a person who’s left-handed and you never say anything about what you’re thinking or believing or assuming about them, yeah, you’re being politically correct. You’re being polite about never speaking to that.

But just imagine what that’s doing to the relationship that you have with that person. It might mean you never give them a chance to do a project that’s really demanding. It might mean you don’t include them in certain activities because of those beliefs. You’re being polite. You’re basically never saying anything about those left-handed people. For me, I think that just allows for the bias to continue. It means people smile at you and say nice things to you, but they’re really harboring some ideas that really do limit the potential you have in that working relationship.

When I think about diversity, inclusion, and equity, we tend to lump those all together. But we have to really recognize three really distinct ways in which those need to show up in our conversations. First, when I think about diversity, I think about the demography of our nation. It’s always been multi-ethnic, multi-cultural. We may have ignored it, but it’s always been a very diverse nation. When we think about the ideals of equality around living in this pluralistic society, then that means each of us has this never-ending responsibility to learn how to be more inclusive of others. To do that, in spite of the fact that human nature really pulls us to be tribal, to be divisive, to notice what does that person have that I don’t have? I know inclusion is a noun but, to me, it’s everything we have to do around demonstrating our values and our beliefs that diversity makes us stronger and better and more innovative.

I try to really distinguish between those as much as I can. I do know that the tendency is to lump them altogether, but I really believe those are really key distinctions to have in mind and to recognize all of those are important and to leverage, again, those distinctions as we start to work on achieving that kind of pluralistic society that our founding fathers…  that was indeed the gift of being in the United States.

Barilla: Thank you for outlining that. I think it’s so important that we do understand the different components of that. I know, working in community health, that it’s just real easy… I’ve made assumptions that people understand the importance of really addressing this and having this as really thinking about it for organizations in healthcare as a comprehensive and integrated strategy. It’s not something that one person is doing in a cubicle. Really, it’s something that we really need to highlight in healthcare. I know that the American Hospital Association has begun to address this several years ago, but would really love to hear from you, why is addressing diversity, equity, and inclusion so important in healthcare?

Hernandez: Well, I mean, we can’t have quality of care if it’s only for just some patients. I don’t think the Hippocratic Oath ever had a clause that said, “Oh, this is about treating patients who look just like me.” I think we have to accept that, as human beings, we’re wired to essentially take those mental shortcuts that re-enforce bias. It means we have to ask ourselves constantly these really tough questions. How does patient care get influenced by gender, ethnicity, or race? How can we build some protocols to protect against bias? What are those mental heuristics that we want to follow to make sure we’re really thinking through what’s the best thing to do for a patient? And to take into account the unique aspects of that patient’s life and social circumstances.

Whenever we talk about health equity, we show a graphic that I think now has become ubiquitous when we talk about health equity. It either shows three people trying to reach for an apple and we give people of different heights the same little box to stand on. It just doesn’t help that short person, of which I relate to being 5’2″, how to reach that apple. Instead, equity is giving people what they need to actually reach that apple. For me, my box would need to be bigger. You’re taller than me, Dora, your box wouldn’t have to be as big. It’s that kind of customized view of what we do in healthcare to really help you stay healthy that I think is at the heart of DE&I I healthcare.

We cannot do this without starting to have, I think, the woke conversations in healthcare. Finally we’re starting to really crunch hard data about what this means. The conversations around health disparities, I think, are truly in their infancy. But we’re beginning to point out, “Hey, if you’re an African-American women and you’re having a child in a hospital in the United States, there are some really distinct risks for that woman that almost mirror what happens in third-world countries. Why is that happening? Well, there are certain assumptions being made just by the fact that this person is African-American and they’re coming into the hospital to have a baby. I think those conversations can’t happen fast enough. I believe the reason the urgency is now very apparent is because that data is finally coming through. It’s finally pointing to some real problems that we can’t ignore.

Barilla: I think that’s so profound that we do have the data and we can look at it and we need to look at it. Pretty much the whole country is looking at population health strategies. Can you just talk a little bit about the value of addressing health disparities for a population health strategy?

Hernandez: You know, I think it is going to start by looking at health outcomes and segmenting that data by gender, race, ethnicity, sexual orientation, or even by zip code. I do believe that class is another factor. When people know that you’re coming from a certain part of town, that’s another ding against you in some environments. When I think of a system today that looks at trying to address that high-risk population by just looking at one data point, let’s say it’s hospital readmission rates. Let’s say you’re just looking at that by a specific condition. It begs the harder question. What are those unmet needs of the patients that are in that health system that we failed to recognize? If you’re saying we just have a lot of diabetics that get in the ED and they keep coming back and we’re not looking at where they live and work. Do they live in a food desert? Do they have access to a primary care physician? Are they in a follow-up program that’s culturally relevant? I mean, if we’re not asking those kinds of questions, then we’re just going to continue to see the same people come back.

For a system that wants to be efficient, effective with the patients, and have the best healthcare outcomes, if those questions don’t get asked, I just don’t know how you’re going to drive that. I believe we are at a point, given all of the data that now we’re collecting, where we have to have that courageous conversation and say, if we keep seeing high readmission rates for one or two conditions, are we looking at the demographics of that group? Are we looking at where they live? Are we looking carefully at what drives them to come back? Then to ask ourselves, well, we seem to have a lot of these kinds of patients that keep doing these things as they come back.

What are we doing in partnership with communities, in partnership with the coordinated care that we’re supposed to be managing? What are we doing that’s going to fit the unique needs of those patients? We cannot treat everyone the same, give everyone that same size box to reach the apple, and expect different outcomes. Those are the tough conversations that I think people are having now, or trying to have. Some are more effective at those right now than others. I think all hospital systems will eventually realize those are the conversations that need to be part of their population health strategy.

Barilla: Absolutely, Maria. We thank you for elevating those at a national level and even within Providence St. Joseph Health. We’re just so committed to addressing this. I think, even though we have it as a core to our mission, always something to learn. Thank you for elevating the conversation and guiding us along the way as well. As an industry in its totality, we really lag a little bit behind some of our partners in terms of diversity, equity, inclusion strategies, including business and education and even government. Healthcare just tends to behind. Yet, healthcare ends up treating impacts of inequality. Why do you think that healthcare tends to lag behind? What’s getting in our way to advance some of these strategies?

Hernandez: You know, it’s something that I’ve really thought about a lot. I’ve worked in major corporations early on in my career. I’ve watched the efforts in some of those name brands that everybody would recognize, what they’ve tried to do internally. It’s everything from looking at leadership models to looking at how people collaborate to looking at how to tear down silos that exist in the organization. I think one of the challenges that healthcare has is that it does come from a unique culture, academic-based culture, where there are real values placed in hierarchy. If you think back in university life, you have the tenured professor, and then you have the assistant, the associate, the lecturer. That kind of hierarchical approach to the culture of an organization, I think, is very real in healthcare.

Then there’s another layer of this. That’s the values assigned to people at the highest pinnacle of healthcare. I once heard somebody say, “There’s God and then there’s the physician. Everybody else falls underneath that.” If that kind of hierarchy is really embedded in your culture, I think it’s very difficult to try some of those very different innovative approaches to leadership, to management, to organizational structures. That’s part of our history, I think, in healthcare. We need to accept that, and then accept the next hard truth. That is most physicians are white and male. Right now in the United States only 4 percent of physicians are black. Only 6 percent of physicians are Latino. The black population of the United States is at about 13 percent. Latinos are now almost approaching 20 percent of the population. It’s missing the diversity that you might find in other industries. I’m not saying that the tech sector or the consumer products sector has figured everything out, but there are so many efforts to make sure that the diversity of the employee base tries to mirror the diversity of the population that they serve, or their customer base. I’m not sure we’re there yet.

Again, AHA Institute for Diversity and Health Equity found that, I think, 11 percent of hospital leaders are women. As far as I know, we’re half of the population so we’re missing in action there. Only 14 percent of leaders in hospitals and on the boards are from ethnic or racial groups. Again, not having that diversity of thought creates a challenge. By no means do I think you need to be a diverse person to be a champion of diversity. I can say this, I think that when you have that lived experience of watching what my dad went through, for example, I come at this work with a personal passion that says I know what it’s like to be someone who’s fearing for the life of a loved one just because they speak another language. I have a memory of being my mom’s interpreter at her doctor’s visit when I was 10 years old. I know what that feels like. I am going to be really, really, determined to make sure we’re not avoiding those conversations about the course of treatment or the course of bringing the class standards to life.

I believe anyone can be passionate about that, but it does take, in my opinion, some of those lived experiences to really call out what do we need to do? I think we have some catching up to do. I think it’s possible to do. I would say, in healthcare, we just have a very strong culture around the hierarchy that keeps people kind of in their place and in their silos. There’s one thing I often say about health equity: It can’t rest in one department. It’s everybody’s job to achieve health equity.

Barilla: Those are pretty profound insights, Maria. Really wrapped up with a lot of uncomfortable conversations that really we need to have. I’m wondering if you have any recommendations for health systems who need to address the dynamics of a dominant culture, both within and around our institutions? How can we really talk about these norms without putting people on the defensive and squelching the dialogue that so needs to happen?

Hernandez: I think in healthcare there are ways in which we can build on inclusion and diversity efforts as you look at other initiatives that are taking place. I’m a trustee at a hospital system. One of the things that we adopted a few years ago was this just culture that anyone can bring up a concern around an error or a potential error and not get sidelined in their career. You know, that’s a real sensitive topic. Right? Every hospital is always trying to promote the highest quality of care. If there is the potential for an error and you’re going to raise that and you’re going to raise that about someone else, someone in power, someone higher up the ranks, wow, to have permission to do that in an environment that says we care about quality and we must be outspoken about anything that threatens that quality.

Imagine, this is an opportunity for a system to say we need to talk about how, in fact, one of the things that can come up in terms of medical errors is when someone doesn’t speak the language, someone assumes something about how someone understood instructions. I think you can weave it into programs that already exist. That’s one.

The second is that, when we begin to talk about inclusion or we begin to talk about diversity and health equity, we have to be honest and say, “This benefits everyone.” When you have an inclusive workplace culture, it’s not just benefiting women. It’s not just benefiting people of color or the LGBTQ community. It benefits everybody because we have a higher quality of care and we have a culture where everyone feels that they can actually engage and do their best work.

I know that argument resonates well with everyone. When, say, a white male hears that, they feel safer. Like, oh, this is going to help me be in a place where I’m actually going to benefit by having more engaged employees, more innovative employees, more satisfied patients, better outcomes. Who’s not going to stand for that? I do know that, historically, even in the corporate sector, DE&I training sometimes went off the deep end and really created more challenges than solved problems. I think we’re beyond that. I think we’re now really clear inclusion is strategy. It’s an approach to the way that work gets done. It’s not meant to benefit just one part of the organization. That kind of mindset, I think, is super important to bring to this work. Also, to bring people really practical tools to help them learn how to do this, and to see the benefit for the patients and to see the benefit for the bottom line.

Barilla: I think that’s so important. You know, it really is. It does impact us all. I remember when my dad was about to pass away. He had been in and out of the hospital. He had horrible swelling in his feet and none of his shoes fit. He used to wear these horrible slippers that really made him look like he was someone experiencing homelessness. I used to tell him, “Dad, don’t wear those.” For fear that he’d have to call 911. One day he got up and wanted to just use the restroom. My mom put the slippers on. He said, “No, no, no. Dora said not to wear those, not to wear those. I think she’s embarrassed of me.” It just broke my heart.

The reason I didn’t want him to wear those was because I grew up in hospitals. I knew that people are going to have that unconscious bias. I didn’t want him to wear those slippers. I always think of that story, Maria. It just breaks my heart that anyone of us would have to think that someone would be treated differently. It’s so key because it really does impact us all when we’re not looking at just the individual in the whole person and who they are. Thank you, again, for elevating this and bringing us all along and really realizing that it impacts everyone.

As we move forward in the healthcare system, what recommendations would you have or suggestions would you have for healthcare systems that are really wanting to deepen, or for those that need to begin a diversity, equity, inclusion commitment. How would you recommend getting started?

Hernandez: You know, one of the things that our firm has done… This is our parent company that actually started the Inclusive Leader 360. We have these two tools that we try to promote as much as we can. There are many tools like this so it’s not just self-serving, but I want to give an example of something that I think is super important to do. The first part is to recognize this is a systemic-wide issue. It has to include all the departments of the hospital in order to actually make a dent in the kind of culture that we’re striving for. The first thing that I often recommend is that you need to have senior leaders understand, well, what does it mean to be an inclusive leader? The Inclusive Leader 360 is a unique measure. You all have seen a 360 where you get your feedback by peers, your direct reports, your boss. You find out, gee, I’m perceived in a certain way by these very different constellation of individuals that I engage.

Well, our 360, in addition, gives you your results by gender, by generation, by ethnicity, and even by department. What this measure can do is really give a leader insight as to where their blind spots might be. When I’ve debriefed with a leader using this tool, I’m always amazed at how appreciative they are that, finally, there’s a really specific set of behaviors that they can look at as a leader and understand, wow, I do a great job when I’m doing this with people who are just like me. But, for some reason, when I’m working with millennials, I just don’t come across as collaborative, or I don’t come across as someone open to new ideas. Of all of the dimensions of diversity that I think have really raised some challenges in healthcare, it’s the new generation of workers who are the most diverse. They’re multi-ethnic, and their generational difference has challenged the boomers in the organization to think and do things differently.

When a leader starts to recognize, if I don’t respond and be as open to those ideas as possible, number one, I’m going to have a lot more churn. I’m going to lose those individuals. They’re going to go find work somewhere else. Or they’re basically going to park half of their brain in the car when they walk in the door. They’re just going to bring the sort of robotic approach to work. “I know my boss doesn’t care about what I think, so I’m just going to do my job, be quiet, get through the day, and go home and be my whole self when I get home.” Who wants that? Right?

When I think about what creates the most insight for a leader, it’s when they really recognize that inclusion is a set of behaviors that you can actually quantify and identify. That’s number one. Get leaders to really understand what does it mean to be inclusive and what are the benefits of that for my team, for my department, and for my culture in my organization? The second thing is really to take a systematic view of what are all of the different efforts in your system that are pointing towards better care for everyone at the right time at the right price? Achieving that Triple Aim. When we started to look at population health strategies, we said, “Hmm, the thing that’s missing in a lot of environments is that lens of inclusion.”

We started to look at what are those best practices that help drive population health strategy? With that idea that we need to be very careful to see populations are very diverse and different and unique depending on where your system is located in this country. Are you in an urban environment, a rural setting? Are you in a place where there’s a really large number of Latinos? Are you in a place where there’s a large number of African-Americans? Is it a population of unique cultures? In Detroit we have a really high number of individuals from Southeast Asia. There’s just these really important diverse components of a population that has to be looked at.

The inclusion score card to population health is just a guide to help you look at are you doing some of those things that we know work? How are you tracking that progress? I think we’re all doing the best we can in terms of identifying the way we use data. I’m not sure we’re looking at the data that, in essence, is around inclusion metrics. Those two steps taken in tandem, I think, can set the stage in the right direction. Set course in the right direction I should say. For a system that says we know we have a diverse population that we need to serve, we have a diverse employee base. Are we connecting all the dots together to actually make things happen?

If I can, I want to give you a really simple example from one setting where we did this. We found a physician in a clinic that had created kind of a telenovela around diabetes. It was aimed at the Latino population that he served. This was something he went out and corralled a whole group of folks to be basically act in a little sequence where he showed how a mom had suddenly discovered that she was pre-diabetic. She was about to take a trip to Mexico. The doctor was trying to convince her, “Oh, here are the things that you need to do to stay well on your trip. Here’s a prescription for some medicines that you need to take. You need to follow this.” He did an amazing job of creating this little series that you could watch on your phone or on a computer. Nobody in the system actually knew that he had done this, or at least not the people that needed to be able to use this.

What came of that was people said, “Wow. That’s actually a great way to reach an audience that we don’t reach. Why don’t we use that for other diseases like asthma or heart disease?” The process of assessing your strengths and your challenges can find these real important gems of opportunity and the heroes that are behind the scenes doing great things. It can actually leverage that talent to be able to solve other problems. That would not have happened had they not taken the time to start the score card process. It’s a simple case study, if you will, of what happens when you start to look for the solutions that you might already have but just need to leverage in more powerful ways.

Barilla: You know, that’s a great example of how we probably are all doing some things, but how can we really build on that? I love that story. Thank you for sharing. Maria, just a few final questions here. In terms of just being… Providence St. Joseph Health is a Catholic health system. We have many other health systems that are rooted in faith traditions. Do you see any advantages, or any additional context, for those health systems rooted in faith whose mission is to serve the poor?

Hernandez: Well, you know I grew up going to Catholic school. I grew up in a Catholic parish. I was very involved in some of the outreach ministries and some of the programs that were designed around serving the less fortunate. I don’t know of any better mirror of society than to say, how do we treat our poor? How do we treat the disadvantaged? If you’re a person of faith, and if you’re a culture in which faith is your grounding source of what you do and it drives the mission, I just think this is the absolute right way to approach the work that needs to be done and to know that your faith actually calls upon you to do this. I think that, when we see the connection between the values of taking care of those who are less fortunate, making sure that we are mindful of how they see the experience in healthcare, and mirroring that with our faith, it is a blessing to be able to live that.

I’ve been at Providence and seen some of the remarkable ways in which you call out your values and you call out your beliefs, and you do it in a way that’s very respectful of all faiths and all traditions. I don’t know of any faith that doesn’t have a central value of caring for one another. Providence St. Joseph is living that in its ultimate experience of providing wonderful care for everyone regardless of their ability to pay, regardless of their background, gender, ethnicity, or faith. It’s ideal. It’s a beautiful, beautiful way to live the values that we grew up with.

Barilla: Well, I can’t think of a better note to end our conversation on, Maria. I just want to thank you, Maria Hernandez, from Impact4Health for joining us today, and to everyone for listening. We look forward to our next conversation in our journey on highlighting who’s doing some remarkable things in our communities around the country that are really improving health and bringing people together. This is Dora Barilla from Providence St. Joseph Health. Thank you for listening.