Racial and health equity: Five concrete STEPS


AMA STEPS Forward® podcast

Racial and Health Equity: Five Concrete STEPS

Dec 9, 2023

In this episode of the AMA STEPS Forward® podcast, Rishi Manchanda, MD, MPH, president and CEO of HealthBegins, walks listeners through the five steps health care leaders can take to start translating their commitment to racial and health equity into action.

To learn more on this subject, check out the related AMA STEPS Forward® toolkits:


  • Rishi Manchanda, MD, MPH, president, CEO, HealthBegins


  • Michael Tutty, PhD, MHA, group vice president of professional satisfaction, American Medical Association

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.

Tutty: Hello, my name is Michael Tutty, group vice president of professional satisfaction in practice sustainability at the American Medical Association. Today we are talking to Dr. Rishi Manchanda, president and CEO of HealthBegins, about how to translate your commitment to health equity into action within your health system. Dr. Manchanda, hello and thanks for being here.

Dr. Manchanda: Hello, Michael. Thank you so much for having me.

Tutty: Why don't we get started? If you could tell us a little bit about your background and how you got into the health equity space.

Dr. Manchanda: Michael, thanks for that question. I am an internist and a pediatrician by training. I went into medicine actually though, into med school, with a very specific exposure and passion for social medicine. Mentors like Paul Farmer and others that I was exposed to early in my training and work I did abroad in places within India and Botswana, Mozambique, South Africa. I had a lot of opportunities to work abroad and what that oriented me to was an understanding of this really old tradition of social medicine, which we don't really talk too much about in modern medicine, at least in the U.S., but it's always been there. It's been around for almost 200 years in fact.

When I learned about that I thought that's exactly what I want to do. I want to be a doctor who's as skilled and proficient and rigorous when it comes to learning how to take care of individual patients as I am about how to help a whole population of patients, people in the community and partners to be able to address health where it begins. That's my medical background, internist, pediatrician, public health trained. I'm CEO at HealthBegins now, where I lead a team that has a privilege of supporting clients and partners across the country to drive radical transformation in health equity, that's our mission. The way we advance that mission is by helping our clients and our partners across the country to address the social and the structural drivers of health equity, and I'm happy to talk a bit more about that.

But in a nutshell, I'm a physician, public health trained, with a deep, deep passion for improving health where it begins and addressing the root causes of health equity.

Tutty: Excellent. Dr. Manchanda, you've been doing a lot of work with the AMA. Recently, you co-authored an AMA STEPS Forward® toolkit entitled “Racial and Health Equity: Concrete STEPS for Health Systems,” which is available now on stepsforward.org. Can you tell us a little bit more about this toolkit?

Dr. Manchanda: Yeah, happy to. I'm happy to describe it if it's helpful, a little bit more context about how it came to be. Because I'm excited about the toolkit, but like most good pieces of work, collaborative pieces of work, there are a lot of people behind it, and there are a lot of relationships and there's a lot of story written about what led to that moment.

So this toolkit, which really excited about at HealthBegins, and very honored to have produced this in partnership with the AMA, including Marie Brown and Denard Cummings at the Center for Health Equity. What led to this toolkit, before we describe a little bit about what's in it, was a series of conversations and opportunities to partner with the AMA, as you said. Specifically, with the new Center for Health Equity, at least was new a couple of years ago.

What was inspiring to learn about as a member of the AMA myself, was work that many of the listeners for this podcast will remember, perhaps that many of the House of Delegates of the AMA, many medical students, members of the AMA, pushed for many years, which is to focus on health equity, including racial equity, and to memorialize that in part and to help advance that in part by the creation of a center of health equity.

When I saw that news, I was excited about that and when we learned then that Dr. Maybank was going to come on board to help spearhead that new center and create that new center, even more excited. Aletha and I had a chance to meet, Dr. Maybank and I had a chance to meet a couple of years ago, along with some of the early colleagues within the center and I think saw a clear opportunity to align. Especially to help support the development of the Center for Health Equity and support AMA leaders in understanding what it means to move upstream. In other words, to address those social and social drivers of health equity. As part of that conversation and the work we were doing to help support a lot of the incredible leaders within the AMA who were taking this charge to advance racial justice and health equity, we were asked by the team at STEPS Forward® if we could help do a review of the literature and try to, in the way that STEPS Forward® modules tend to do, really focus in on some of the key takeaways, the key steps that physicians in different types of health systems could address, could take, excuse me, to catalyze internal transformation in their health systems.

There were two particular modules that we were asked to produce. The first was concrete steps for physicians and clinicians working in smaller practices, smaller independent practices, for example, our primary care or outpatient settings. Then the second module, which is the one that we're talking about today, was developed for physicians and clinicians and others who work in larger, medium or larger-sized health systems. So that's the context for it.

As you pointed out this module, as with the other one, really has five takeaways, five steps that are really meant to help physicians. Not within one module understand everything they need to and know everything they need to do to be able to transform an institution to become an anti-racist organization or to solve for health equity within one module. That's far beyond the scope or the ambition of this module. What this module does, and what we designed it to do, was to help physicians and clinicians and other health care leaders within health systems who are motivated, who have already a strong commitment to advance racial equity, to center equity within their health care delivery operations. To think about ways to help those motivated, committed champions within health systems, take the initial steps, the five major steps that can be really helpful to help accelerate their progress as internal change makers, as champions of health equity and work with, identify and work with colleagues who share that passion and learn about translating that passion into concrete strategy and action.

Again, this is meant to be part of a broader. This module assumes that physicians and clinicians out there and health and professionals, administrators in different settings, understand that equity as a process and not just as an outcome requires us to view this approach, this work, as part of a continuous cycle of improvement, a continuous cycle of learning. These five steps are meant to at least be part of that broader transformational process. Not be the end all of everything that needs to be done, but to be an initial catalytic part of how to start in this process.

Tutty: Could you highlight what those five steps are for our audience?

Dr. Manchanda: Absolutely. The first step that we really focus in on and I think it's more important these days than ever. We started writing this last year and I think it remains relevant. Step one is really to commit as a health system to do the work. Easier said than done, and I think many people might say, "Well, my health system has made a public commitment on our website or has communicated documents that say we commit to advancing racial justice and to express solidarity." We think that's good, but it's not sufficient. For step one, community as a health system means being able to create the space and the resources for champions and leaders for health justice, for health equity and racial justice to be able to do the work. So, translating the commitments on paper to actually doing the process. That takes commitments of resources and time and true commitments to understanding and creating a shared understanding of what racial justice means, of what racism is, what anti-racism means, et cetera. So, commit to do the work is step one.

Step two is, start shifting organizational norms in practices by learning about what you don't know. That's verbatim, step two. Again, start shifting organizational norms and practices by learning about what you don't know. What we mean here is to name it, frame it, explain it. What are we talking about here? What we're talking about is racism. What is racism? What are the different forms of racism? As the AMA itself in its organizational plan to embed racial justice and health equity, advance health equity is outlined, there are four types of racism: structural, institutional, interpersonal, internalized. And so, step two really, in this module, gives some very quick orientation to the really deep body of knowledge that's out there that more and more of us in health care need to understand to start to shift our organizational norms and our practices by again, learning about what we don't know. Many of us in health care, many physicians included, haven't gone through an educational process, whether in training or in continuing education, to really understand these forms of racism and understand how it's affected health care and health care delivery.

Step three really briefly is to then, based on that foundational understanding and that commitment, to get a handle on their data. This means improving data collection for race, ethnicity, language. It means understanding how to interpret the data. What is the story that the data's telling us when it comes to as we stratify our performance measures, our clinical measures, our patient satisfaction measures? As we stratify those by race, ethnicity and language, what's the data telling us about these patterns of inequity? What are additional things we can do to refine understanding about those inequities using the data? Again, getting a handle on the data.

Step four is, develop a compelling vision and goals for the entire system. This is performance improvement. This is change management 101 but applied here to racial justice. There are very specific resources and steps that outline how to translate the vision and the goals that emerge from that data into a strategy. Especially, to make sure that as that strategy is being developed, that people with lived experience, people who belong to historically marginalized communities, are part of the process of goal setting. That we're truly centering in the margins, as many talk about these days.

Then finally, step five is based on the goals and the vision based on their earlier foundational understanding that you start developing. How do you launch targeted improvement efforts across the system? That's step five, targeted improvement efforts. There is very specific examples and highlights of health systems across the country that have started to launch very targeted equity-focused improvement efforts across the system. And what's really remarkable about those examples, which I'm happy to talk about in a minute, is many of these vanguard health systems are demonstrating that the highest quality care is, by definition, equitable care.

Tutty: Yes.

Dr. Manchanda: That's, I think, a really key takeaway.

Tutty: That's a great framework you've laid out with the five steps in the module. You mentioned that you're aware of some health systems who have engaged in this process. Can you highlight some examples, some best practices that you have seen?

Dr. Manchanda: Yeah. In the module, we highlight a couple of examples and I'll bring in a couple of others that we've learned about and actually worked with. In the module, we highlight, for example, the work of UW Medicine, University of Washington Medicine. In 2016, six years ago, they formed a multidisciplinary committee to advance health equity in the health care system. The work of that committee then led to the release, the following year, of what they call the health care equity blueprint. That was a strategic plan with equity as its focus, very much based on a review of their internal data, patient data, as well as utilization data that they were able to access.

By 2019, the committee expanded the use of health care equity dashboard system-wide and health care system leaders then merged that work, the health care equity blueprint, the dashboards, the improvement efforts that they had created. They merged that work with other efforts that were addressing diversity equity inclusion to create a whole new office of health care equity to advance that work. They created the resources to be able to make sure that their operations reflected the strategic commitment to advanced equity by creation of this office. That's just one example.

Another example that I think is important, especially to underscore what it means to create targeted quality improvement efforts where equity is a focus, is an example that involved five different cancer centers across the country. Different health systems across the country, including Cone Health System, for example in North Carolina and four others, in a trial that was called the ACCURE trial. Those five cancer centers across the U.S. focused specifically on how to improve and advance racial equity within care for patients with early-stage lung and breast cancer. What they looked at as they saw the data, they realized that there were perhaps not surprisingly, but still very tragically and unnecessarily inequities between Black patients who had early-stage lung cancer and the treatment outcomes they were receiving compared to white patients as the comparative.

The ACCURE trial demonstrated through a quality improvement focused effort, looking at equity as the central goal, that they were not only able to reduce and close the gaps in treatments and outcomes between Black patients and white patients with early-stage lung the breast cancer, but they actually increased outcomes across the board for Black and white patients. In other words, inequity-improvement strategy not only closed inequities, it also improved overall outcomes.

Tutty: Those are tremendous examples of important work going on in those health systems. This journey to improve racial health equity, we're on this journey. How far have we come? What are the challenges ahead?

Dr. Manchanda: I think that we have a long way to go and it doesn't mean that the progress that's being made doesn't give me hope.

Tutty: Yes.

Dr. Manchanda: Let me explain what I mean here by making sure that I share my diagnosis, if you will, of the system and it's not something that I developed. It's something that I've come to recognize and learn about from many others, including scholars like David Williams, Dr. Aletha Maybank herself and many others who have... Dr. Camara Jones, for example. There are many scholars, including of course, scholars of color who for decades, frankly, have and going back even a century or more, right, have been ... W.E.B. Du Bois for example, have been very, very astutely and objectively have described the fact that there have been deep-rooted inequities.

Tutty: Yes.

Dr. Manchanda: What we should learn from that, the fact that these inequities have been so persistent for so long, isn't an assessment that says, "Well, okay. Well, the system we have is broken. We need to fix it." Because that framing assumes that the system that's designed is just broken on the edges, has a couple of cracks, just needs some basic modifications and then we'll be right again.

Tutty: Yes.

Dr. Manchanda: It's not that. What we have to recognize is that the outcomes that we receive, just as quality improvement teaches us, we get the outcomes that are perfectly designed to be achieved, right, by a system. If we have inequities in our health care system, if we have inequities in our society, it is because the systems and the structures that we have are designed for exactly that. That means a little bit of a gulp in the throat for some people to say what we're saying is, "Wait a second. The systems I'm currently in, including the health care system, is designed to create inequities?" The answer is objectively, clinically, it's hard to come to a different conclusion.

Based on that, the question isn't so much about whether we find some cracks in the wall and think about how to spackle those? Or some things that are broken in a complex clock and tinker with some of the broken pieces within it and fix it. What authors like Isabel Wilkerson and others have written about so eloquently is this requires us to understand that in the foundation itself, there is a rot, right?

Tutty: Yes.

Dr. Manchanda: And that if we need to really address inequities, we have to give ourselves the courage to hold ourselves to the highest standards of professional rigor. Also, give ourselves the kind of compassion to recognize that while we live in these systems, we don't have to accept them. In fact, what we need to do is to understand how to understand the roots and the foundation, what set these systems in place to be able to create these inequitable outcomes? Outcomes driven by structural racism, for example, and then pause and say, "Well, how do we now transform the foundation while we're also working within and outside the systems to be able to achieve important incremental improvements?" Incrementalism plus foundational transformation are both required here.

If we can approach it that way then, which is what I'm seeing more and more people talking about, that gives me hope. I think that this is not a bleak picture in terms of what the future can be, but it is bleak now in terms of the level of inequity that's just entirely preventable. We have created and allowed ourselves to operate in systems where inequity is a core part of the business and that is unacceptable. The question now is what are we going to do about it? The good news is, with these five steps in the module and many other efforts that AMA and the Center for Health Equity, that many other health care leaders across the country, and as importantly, many other upstream partners in policy, in social movements and in other sectors. All these folks, now more and more people, are joining this movement to be able to truly transform the foundations, while also driving demonstrable concrete improvements in the lives of people that we serve.

Tutty: Excellent. Dr. Manchanda, this has been a great conversation. Any last thoughts or insights you'd like to share with our listeners who are looking to provide more equitable health care to patients within their health system?

Dr. Manchanda: Yeah, Michael. I think what is probably one of the most exciting parts of this specific module, the STEPS Forward® module, are the resources and the citations that we happened to include in this piece. The examples, the specific links to the work of authors like Dr. Camara Jones, like Isabel Wilkerson. Like the work that's happening across the country for example, with vanguard organizations like the Southern Jamaica Plain Health Center in Boston, that has transformed itself from a health care clinic that advances racial equity to a racial justice organization that provides health care, over the last 10 years.

There are so many examples that are out there. In the module, there are a few links, just initial ones, just to point people towards the authors, the scholars and the practitioners really, who have been at the vanguard of this for a number of years. My suggestion for those who are looking to progress in thinking about how to translate their commitment to racial justice and health equity, think about how to incorporate that particularly within their health care settings? If you're a clinician, if you're a physician, if you're a health care administrator, if you're a frontline staff member on a care team, if you're a registration clerk, if you're a community health worker, if you're someone who, regardless of the role you play within the health care system, knows that there are deep inequities and has decided not to be resigned to those inequities as something that should just be accepted. But instead of saying, "We need to do something," my recommendation is to look at those resources, look to those people who have been at the vanguard for a long time. Those scholars, those practitioners, particularly those of color, and reach out to them. Ask questions, read more, listen to this podcast and then click on one of those links and spend time with one of those links and the resources to really just understand it.

What's so powerful about this journey for us at HealthBegins and I think of a lot of our partners, is that what we're doing is truly exemplifying what it's like to be part of a continuous learning team system. This is a critical gap in the learning of all of us in the country. This is a critical gap in learning for those of us in health care and I think the next step really is to foundationally develop deeper learning, deeper understanding. The best way to do that is to go to those who've been working in advancing this work for a long time.

Tutty: Agreed. Dr. Manchanda, thank you so much for your time today and thank you listeners for joining our podcast. If you're interested in learning more about the AMA STEPS Forward® toolkit entitled “Racial and Health Equity: Concrete STEPS for Health Systems,” please go to stepsforward.org. Thank you for joining us today.

Dr. Manchanda: Thanks for having me.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.