Introduction

In consultation with diversity leaders across the country, Dr. David Acosta first presented the Health Systems Ecosystem model (Fig. 1) of an equity ecosystem to multiple cohorts of “Healthcare Executive Diversity and Inclusion Certificate” participants at the Association of American Medical Colleges. Dr. Acosta drew this diagram. Emily Pantoja, Mia Wallace, and Kaya Aman, graphic designers for the University of Utah Equity, Diversity, and Inclusion division, created the graphic illustration of Dr. Acosta’s sketch. This manuscript is designed to highlight the multiple intersections of equity, diversity, and inclusion work, not unlike Dr Camara Jones’ work on racism, using the metaphor of a garden and a gardener [1]. This adds to the literature in two fronts:

  1. 1.

    This is the first description of the ecosystem necessary for success in EDI in the academic health sciences literature.

  2. 2.

    This paper illustrates the many areas where EDI work is needed to ensure success in increasing the proportion of underrepresented students, residents, faculty, and staff working in health care.

Fig. 1
figure 1

The equity-centered ecosystem graphic

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EDI work does not survive when only parts of the ecosystem are supported. Success depends on the entire ecosystem working together. In addition, this paper provides tools and strategies to build this ecosystem.

Description of the Model Components

This equity ecosystem is based on a metaphor taken from farming. To get good fruits or vegetables, you need multiple components—good soil, water, fertilizer, and pesticides [2]. We begin by explaining what each farming component represents, and state how it fits into academic health sciences equity work.

In the center of the graphic there are four garden plots, each fenced in, some with larger openings than others, and some with closer proximity to the water. These plots represent the different health sciences schools. In most academic health centers, the program with the most resources is a medical doctor program at the school of medicine. At University of Utah Health, that is the case, and the Spencer Fox Eccles School of Medicine has the bulk of the resources along with the EDI infrastructure of Health Sciences. The School of Medicine has funded an Associate Vice President for Health Equity, Diversity, and Inclusion, [3] as well as an Associate Dean for Health Equity, Diversity and Inclusion [4] for the past 15 years, while no other diversity offices existed at other schools. In most academic health centers, the program with the most resources is the medical doctor program at the school of medicine. For these reasons, the example that has the greenest grass and the plot closest to the river is the school of medicine.

There are three other plots that can represent any of the other health sciences schools. Each of them is independent, providing professionals to work in the hospital, pharmacy, physical and occupational therapy, and dental and nursing disciplines, as the University of Utah uses a Responsibility Center Management (RCM) Model. As the school of medicine generates the highest revenue, they receive the most resources. Other schools are also dependent on the school of medicine for that reason. Additional funds generated through clinical service or research can be used to fund initiatives outside of the school of medicine. Because of its stature, the school of medicine does lead the charge toward equity, and the AVP has always been a faculty member at the school of medicine, and the revenues from medical care continue to advantage the medical school.

In the graphic, the relationship between health professions schools is manifested in how they get water. Water goes from the river to the school of medicine plot, and then to the other plots. There are great inequities in the educational space for health professionals, and University of Utah Health is working toward change. Through intentional collaboration, we are using pathway programs originally designed only for MD program students and adapting them to serve all the pre-health sciences students.

While the pathways that lead to the garden plots are means for students to get into health sciences professional schools, the whole ecosystem needs to be supported. For decades, the work of equity, diversity, and inclusion has focused almost exclusively on these pathway programs. University of Utah Health has multiple pathway programs which have documented their success through medical literature. They are the Native American Summer Research Institute (NARI), [5] the Path Maker program,[6] the Physician Assistant program, [7] the Family Medicine Residency program, [8, 9] Health Sciences LEAP (Learning, Engagement, Achievement and Progress), [10,11,12] and the Saturday Academy program, [13] all of which are funded with school of medicine grants or monies generated clinically. Each one of these programs has published their diversity successes in the medical literature. Yet, even with documented success in this space, we are moving more slowly toward significant change in the faculty composition and leadership of health sciences partially because all efforts were concentrated to the pathway programs, while all areas of the ecosystem needed attention. Even the successful pathway programs had learners leaving on side paths that took them away from graduate studies in the health sciences. This effect is even more profound when you look at underrepresented in medicine students (URiM) as defined above. While only a small percentage of those who enter the pathway to health sciences graduate education, they leave the pathway in greater numbers than their non-URiM peers. This has many reasons, but one of them is the atmosphere and ecosystem of our graduate education programs.

The essential components of the garden ecosystem are soil, water, and nutrients. Without these, no garden can grow, and without their counterparts in academic medicine, equity efforts will fall short (Table 1). Like any garden, equity requires a strong foundation. This category can be divided into the basics needed for a healthy ecosystem: Soil, which provide organic material for plants to grow; Water, which nourish plants; and Nutrients, which improve soil and enhance plants.

Table 1 Growth-promoting components of the equity ecosystem
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Like any garden, plants can be harmed by pests, harmful microorganisms, weeds, and varying ground conditions. It is important to not only understand essential farming components, but the stunting components as well. In the equity ecosystem, the stunting components manifest as biases, racism, stereotype threat, and harassment (Table 2). Like any garden, equity efforts can be derailed by hate and discrimination (pests). This category can be divided into Weeds, which compete for water and nutrients; Insects, which slowly bite at plants, taking small pieces at a time; Microorganisms, which infect and kill plants from the inside; and Animals, which eat off large parts of plants and impede growth.

Table 2 Stunting components of the equity ecosystem
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Like any garden, equity efforts can be cultivated by prevention and intervention efforts. This category can be divided into Cultural controls, which focus on changing the environment to redirect pests; Mechanical controls, which use physical objects to remove pests; Biological controls, which introduce plants or insects that control the introduction of pests into the garden; and Chemical controls, or poisons that stop pests. Periodic and consistent Soil testing offers important feedback on the status of the ecosystem and the various plants within it. Soil tests help ensure system maintenance for all plants to thrive (Table 3).

Table 3 Tending to the equity ecosystem
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Cultivating an Equity-Centered Gardener

The gardener represents the conscious ability to control variables within the ecosystem and, like Camara Jones’ allegory, The Gardener’s Tale, can control factors such as the fertility and health of the soil, or location of a particular plant and its access to water and sun. In Dr. Jones’ allegory, a gardener favoring a particular plant and not investing in equity could end up feeding an original bias by systematically favoring and protecting one plant over another. If the gardener is neglectful or uninformed, they can make mistakes that can be passed on and assumed instead to be due to the failure of a plant. An example of this may be a succulent that cannot tolerate excessive watering and will be at risk of rot. An attentive, informed gardener would be able to notice the change in vigor and adjust sun and water exposure appropriately; an inattentive, uninformed gardener may conclude the plant to be a poor specimen and pull the plant from the garden and search for a fresh, new specimen to take its place. Even worse, this gardener may develop partiality following these experiences and conclude that the succulent never belonged in the garden anyway, are delicate and fickle, no longer worth investment, and incapable of growing well in an established ecosystem without questioning why generations upon generations of plants have failed under the same systems of care. This gardener misses the diversity and representation in the garden, but also the resilience and potential role this water-wise plant may bring to the entire landscape in seasons of drought. Similarly, the Health System Ecosystem can only achieve equity when the faculty, staff, and administration (gardeners) tend to each learner (plant) with appropriate care.

Implementing the Equity Ecosystem

Collaboration/Integration of Interventions

In any biologically based ecosystem, multiple variables will affect the outcome and balance of any living organism. Interventions require not just investment but also responsiveness to the intervention. In some cases, thinking beyond the limited scope of the immediate ecosystem into other ecosystems and environments and understanding the comparative challenges and disadvantages but also committing by intention to as diverse and adaptable an ecosystem as possible.

Advancing the diversity of leadership is an important goal. University of Utah Health, through its transparency website, shared demographics of the major leadership teams in the system. Shortly after this intervention, successful recruitments of high-profile historically minoritized and marginalized individuals increased, with hospital executives and chair groups seeing the highest percentage change.

How an Equity-Centered Ecosystem Can Help other Institutions

Individualizing the equity-centered ecosystem and applying this model to other universities and health systems require an infrastructure that not only recognizes and supports diversity, but resources and financial initiatives that promote equity. We detail five considerations for institutions as they consider this work in adapting the model for specific institutional needs.

The first consideration would be defining the essential components of the ecosystem. [15] The analogous components of the ecosystem are the soil, water, and nutrients. Collectively, they represent the health system, schools, and resources available for their work. The first step in defining the ecosystem is to assess and address infrastructure (soil) across the health science colleges to identify strengths and weaknesses throughout the infrastructure. Second, institutions need to identify each health science college’s access to the water supply. An approach to defining proximity to the water supply would be a review of budgets and allocations for each school as well as a review of staffed positions as identified on an organizational chart. Budget and staff allocation for EDI are clear indicators of a school or college’s commitment to moving this work forward. Working with individual school or college leadership, it can be determined which schools have the most EDI resources. Because resources for EDI work can vary across schools, it is important to understand the intersections of this work for the whole of the organization to ensure that those who are least resourced or more distal from the water supply can create equitable and inclusive experiences for all faculty, learners, and staff of the health science center campus. It is important to assess brick-and-mortar spaces dedicated to DEI, staff dynamics, and programming, to be sure that efforts are fully resourced to maximize success and those who are less resourced are supported to be successful. Lastly, an institution must identify protective factors such as mentor programming (fertilizer) and financial aid (mulch) that bolster EDI throughout the system.

After the analysis of main ecosystem components, it is important for schools and colleges to identify the stunting components of the equity ecosystem (e.g., pests). Like any garden, these pests, structural racism, and other harmful agents can erode the health of the ecosystem. Identification of the pests must be done at the school and college level and should take on a strengths, weaknesses, opportunities, threats (SWOT) approach or othered structured approach that would allow for full and thorough characterization of these elements, noting their full impact on EDI initiatives, programming, and research at the health science center. [16] An example of a pest may be an institutional policy that is inequitable for faculty, favoring faculty who are well represented in medicine while disadvantaging those who are underrepresented and possibly causing isolation, diversity efforts, clinical efforts, or promotion disparities. The current literature gives institutional leaders resources to help identify factors that impact the health of the ecosystem by assessing and addressing the needs of underrepresented faculty and addressing equity and inclusion across the health science center campus. [17,18,19,20] Resources include approaches to evaluating and changing institutional culture to better provide resources and support for faculty growth, [18] to providing faculty development that emphasizes psychological safety and nurtures the diversity of faculty interest [17, 21].

The equity in the ecosystem, like a garden, can be tended to. Once pests have been identified, institutions can also explore existing or potential opportunities to cultivate belonging, increase access, offer training and development, and offer accountability measures (pesticides). This may include exploring and characterizing experiences of learners who are in schools or colleges closer to the water supply and how to increase resources and programs across the system to avoid suffering from limited resources for EDI that can impact academic or clinical growth [22]. For example, a department may not have a formal EDI committee that is actively involved in all aspects of the department structure (e.g., faculty recruitment and retention, mentorship, education and training of learners). In this case, different individuals within the department may be duplicating efforts or working in silos due to the lack of structure related to EDI issues. Taking the time to evaluate current EDI endeavors within the department in a systematic manner could help the department mitigate potential problems (e.g., lack of faculty racial-ethnic diversity) when they arise.

A critical exercise for health systems once the garden has been fully tended to (e.g., soil, water, nutrients, pests, and pesticides have been addressed) is to engage in conducting climate assessments (soil tests). These tests offer the institution feedback to further tend to the needs of the ever-adapting ecosystem. Climate assessment also allows institutions to identify where diverse needs (new plant species) are being introduced into the ecosystem so that adaptations can be made for everyone to thrive.

At the center, but often invisible, is the work of the gardeners who are charged with the maintenance of the ecosystem. The gardeners have the conscious ability to control variables within the ecosystem and can control factors such as the fertility and health of the soil, or location of a particular plant and its access to water and sun. Institutions will need to carefully consider who serves as the gardeners. These individuals will need supported time, budget, and resources to fully care for the ecosystem, making sure that areas in need of water receive hydration and nutrients as important to meet ecosystem needs. These individuals will also need the ability to identify and eradicate pests that threaten the ecosystem, such as identifying the gardeners, assessing their ability to cultivate a healthy garden, and ensuring practice skills and knowledge growth. A commitment to the development of all gardeners will ensure their preparedness to tend to a diverse ecosystem. The Health System Ecosystem can only achieve equity when the faculty, staff, and administration (gardeners) tend to each student (plant) with appropriate care [23].

How an Equity-Centered Ecosystem Benefits All Identities

The equity ecosystem model requires a long-term commitment, and requires tending to the pathway, nurturing the educational process, and growing the health professions career itself. Working on one area will not bring the desired changes in outcome, but working on all three can. Because equity, diversity, and inclusion are required for accreditation in every educational program in health sciences, including residencies, many institutions need to show that they are working toward these goals. To date, there is no requirement that states how this must be done, and institutions who have frequent leadership changes tend to focus on the early wins and short-term gains. This can be overcome with the development of strategic plans. Focusing on the ecosystem will require moving beyond intention and can be included in this plan [24]. For example, University of Utah Health had a robust system of rewards for departments who interviewed people from the diversity categories decided upon by the individual schools. When we reviewed the program, we learned that departments received reimbursement for recruitment costs for people they failed to recruit. Since then, the incentives have changed, and now all rewards are based upon successful recruitment; costs are not reimbursed until the faculty member begins employment with us. These alignments of rewards with outcomes are one example of how University of Utah Health was able to move beyond intentions.

An equity-centered ecosystem allows for a rich and diverse landscape with interesting textures and colors, and, with enough intentionality, can be built to showcase unique aspects of beauty and function in all seasons. A summer rose may give way to an ornamental kale, and then both fade against the lushness of an evergreen bush in winter, when neither can bring forth growth or color. Likewise, in periods of drought, it will be the low-growing succulents that will maintain their green and even thrive and flower, while the grass browns. The intentional inclusion of diversity when planting this garden, and the attention to each plant’s unique attributes and strengths, allows a living ecosystem to be rich in function and form no matter the season as well as the resilience to weather variability and climate from year to year.

Conclusions

By applying an equity-centered ecosystem, institutions can create lasting change in the diversity of health professions. This will benefit learners, faculty, and staff, and improve the career trajectory and success of historically minoritized and marginalized health professionals. This change, in turn, benefits those of all identities as they progress toward self-actualization and positions of leadership.