6 Lessons for Moving Upstream to Dismantle Structural Racism

Highlights from Health Systems in a HealthBegins Learning Collaborative


When four healthcare teams from across the country came together in early 2021 to advance equity in HealthBegins’ Social Drivers of Health Equity Learning and Action Collaborative (SDLC), they willingly took on a unique challenge. Whereas participants in previous learning collaboratives had started at the ground level, with social-needs interventions, and built upward to address larger-scale structural racism, this group would do the reverse. They were setting out from the beginning to tackle inequity at the largest scale.


Addressing structural drivers of racial and health inequity is a challenge many health systems and clinics face, as the pandemic has driven awareness of how wide and deep is the change we need. How can teams approach that formidable challenge from inside a healthcare institution?


It starts with specificity about the particular slice of the larger problem that you want to approach first, as a means both to make impact and to test methods that could scale to future initiatives. So each of the four teams chose an area of focus, i.e. an inequity to tackle:


Cone Health, a private health system in Greensboro, North Carolina, identified reducing poverty and ending racial discrimination as their priorities, then honed in on providing stronger financial assistance programs to patients as one way to achieve these goals. At the same time, Cone Health is working to acknowledge, apologize for, and address its own institution’s history of racial segregation, an ongoing effort that drives and shapes its racial health equity work. 


Metrohealth, Cleveland’s public hospital system, had two teams participate in the SDLC, one team focusing on lead-safe housing for pregnant women and another on voting and civic participation. Both teams are centered at MetroHealth’s Institute for H.O.P.E., which is tasked with addressing social determinants and improving community-wide health equity. This was the institute’s first leap into addressing inequity at the structural level. 


OHSU Family Medicine at Richmond, a federally qualified health center in Portland, Oregon, opted to address diabetes and convene community members to let their priorities dictate which structural drivers of diabetes to address. OHSU Richmond employs a full-time community organizer, and the clinic’s learning collaborative participants place community voice at the core of their work.


As the teams’ work unfolded over the ensuing 18 months, they met challenges, made mistakes, marked breakthroughs, and saw immediate positive impacts from their efforts. Here are some of the most essential lessons that shaped their work and can strengthen the work of others.

  1. Listen and learn first. Engage community members to understand how structural racism affects them and which health equity problems and solutions are their highest priorities. This engagement needs to be approached intentionally, not haphazardly, to be effective. It takes time to develop this trust, but it’s essential to ensure that efforts are applied where they’ll make a meaningful impact and to lay a foundation for further community collaboration. Cone Health leaders, for example, have done Upstream Gemba walks, going down to the proverbial shop floor to visit neighborhoods and shadowing partners, so as to avoid unwittingly validating their own ideas. Cone Health also invited community input to shape the designs for a new women’s medical center, on everything from the services offered to the art on the wall. OHSU Richmond has convened listening sessions and established an advisory board of patients and community members (who are, importantly, compensated for their time).

  2. Reckon with racism. Make space to educate yourself about the history of systemic racism in health care—both broadly and within your own institution. Name racism where it arises, understand it, and help colleagues discuss what racism is and how it presents within your institution. For example, Cone Health has publicly apologized for its history of racial segregation and mandated biannual racial equity training for all its physicians.

  3. Start small to scale. It’s essential to start small when tackling a problem so big, both to make the effort approachable and to demonstrate impact. While listening and gaining insights (see lesson 1), find opportunities to do small tests of change and gather learning. Then, with this as a starting point, you can use a continuous improvement approach rooted in implementation science to begin improving and building upon your first actions. For example, teams in the SDLC learning collaborative used a 3×3 planning matrix (HealthBegins’ Upstream Strategy Compass) to identify opportunities at the individual, institutional, and community levels of impact. Many started by choosing interventions at the individual level, in realms clearly within their ownership, and then analyzed data and built buy-in from internal stakeholders so that by the time they had enough insights to address community-level problems, their organizations were ready to move. MetroHealth’s lead-safe housing team, for example, started with a pilot project to screen all pregnant women at its main campus OB-GYN clinic for lead exposure and use new workflows to refer them for services if needed.

  4. Set yourself up for early wins. While you’re starting small, choose an intervention where you can quickly make and see a difference. For example, MetroHealth’s civic participation team started with an initial voter registration/vote-by-mail drive in partnership with local organizations at three MetroHealth locations. Their early quantifiable success helped to bring volunteers and partner organizations on board to support this work. The OHSU team quickly responded to a community organization looking to partner to provide OHSU patients with access to community and at-home gardens. In addition to connecting patients with services, the OHSU team was able to use this partner’s physical meeting space and network to help organize their clients to design interventions that best meet their needs.

  5. Identify equity-specific goals. This is essential to aligning efforts to move upstream with equity as an explicit goal. It also provides the focus and direction that you need ultimately to move from listening to action. These goals should be quantified, specifying how much you intend to move which needle. It can be hard to pick these numbers in the early stages, but be assured that you can make your best estimate and then move the goalpost as you continue to learn. For example, the OHSU Richmond team revised their project charter early in the learning collaborative to make equity more explicit in their goals—stating, for example, that within two years the diabetes prevalence rate for BIPOC patients would be decreased to less than 9% (the current rate for White patients). Remember that you are more likely to see the change you want to accomplish if you name it.

  6. Identify existing opportunities and coalitions rather than reinventing wheels. It’s impossible to address structural racism with your internal team alone. External stakeholders and partners could include CBOs, public agencies, neighborhood organizations, and coalitions. Ask how you can support work that’s under way, going to their table rather than expecting others to come to yours. MetroHealth has convened community partners to develop interventions for lead-safe housing, collaborating to develop an asset map of existing resources in the community. Their partners include a community development corporation, the Lead-Safe Cleveland Coalition, the city of Cleveland, and the regional Environmental Health Watch. OHSU Richmond is partnering with Growing Gardens, a community garden prescription CBO. For insights on what it takes to build trust with community partners, read more about Cone Health’s work here.