Introduction

Cancer inequities are unfair, unjust, and avoidable differences in cancer burden and outcomes that are caused by social, economic, and environmental disadvantages [1,2]. Observed cancer health inequities among historically marginalized people (e.g., Black people, LGBTQ+ people) are caused by structural classism [3], racism [4–6] sexism [7], cis-heterosexism [8,9], and their intersections. Ultimately, cancer inequities require multi-level interventions to dismantle systemic biases and address long-standing barriers to care access [10–12]. Diversity, Equity, Inclusion, Justice (DEIJ) commitments implemented in cancer centers – from the clinic to the leadership – can meaningfully advance health equity.

To address observed cancer health inequities [13–15] we organized and coordinated three DEIJ Task Forces in their respective cancer centers, each with distinct clinical environments and diverse patient populations. The task forces assessed, prioritized, and implemented strategies to address structural inequities impacting historically marginalized patients.

Methods

This study was approved by the Georgetown University IRB (#00004397). All participants consented verbally or in writing to participate in DEIJ Task Force activities. Decisions made in the course of operations to advance DEIJ Task Force work have been summarized here.

Curriculum development

The curriculum was organized into eight required educational sessions and six optional technical assistance sessions (Table 1). Sessions progressed from evaluating individual-level biases to examining institutional-level policies and practices to exploring successes at other institutions initiating structural changes. Optional technical assistance sessions from external subject matter experts were available to learn from successful efforts at other institutions. All sessions were open to the public for individuals to promote collaborative information sharing [19]. All sessions were recorded and made publicly available [16].

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Table 1. DEIJ task force educational sessions.

https://doi.org/10.1371/journal.pone.0341662.t001

Development of DEIJ goals

In July 2023, each task force began an organizational assessment (see Table 2) which guided the task forces’ action plan development. Each task force developed a 12-month action plan with goals based on needs identified during the organizational assessment.

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Table 2. Select questions from organizational assessment.

https://doi.org/10.1371/journal.pone.0341662.t002

Task forces refined goals into specific, measurable, achievable, relevant, time-bound, inclusive, and equitable (SMARTIE) goals, which evolved over time based on what was within the authority and capacity of task force members (see Table 3) [20].

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Table 3. Evolution of task force goals and accomplishments.

https://doi.org/10.1371/journal.pone.0341662.t003

Results

Action plans prioritized improving patient information accessibility, expanding the reach of implicit bias training, and improving accurate socio-demographic data collection to assess inequities. Overall, SMARTIE goals evolved over time (see Table 3). Progress was made in improving accessibility of patient information and expanding reach of implicit bias training, but little progress was made on improving accurate socio-demographic data collection.

Discussion

There is an urgent need to advance cancer health equity in the US [22]. Our quality improvement project contributes to the literature by documenting accomplishments and challenges in implementing DEIJ initiatives in clinical cancer care environments. Though many academic medicine DEIJ initiatives focus on a sense of belonging for historically marginalized faculty and staff [23], and increasing knowledge of systemic injustices [24–26], our task forces specifically sought to improve equity for patients in the context of cancer care delivery.

A major overall accomplishment of the task forces was to infuse DEIJ efforts into operations and higher-level discussions at three University-affiliated cancer centers in Washington, DC. DEIJ initiatives at other US academic institutions are often led by assistant professors [26]; however, we were able to recruit leaders across multiple levels of influence (administrative, patient care, research) to collaborate on our DEIJ task forces. Across the three institutions, steps were taken toward advancing CLAS standards in practice and integrating DEIJ values into institutional culture. Our focus on patient education and quality improvement aligns with needs identified in the literature. For example, in a study of individuals initiating DEIJ work in radiation oncology, 23 of 34 (76%) respondents expressed that patient education was a primary focus [26].

Lessons learned included the importance of leadership engagement and buy-in and the critical need for protected time and designated staff to advance specific DEIJ work. DEIJ champions in other institutional settings have reported challenges such as fatigue from individuals spearheading initiatives in their institutions, limited time/competing demands and lack of leadership buy-in [27]. Our experience suggests that providing protected time for staff whose roles align with and are rewarded by DEIJ work can contribute to more rapid achievement of DEIJ goals. Additionally, we found that when DEIJ principles were centered in an organization’s mission, requests for increased resources and staff to advance DEIJ goals were more successful. Integrating goals with quality improvement requirements for cancer committee accreditation also facilitated greater success.

Barriers to success included limited human resources (e.g., staff turnover, competing demands) and institutional support (e.g., data access, protected time). For institutions 1 and 3, DEIJ work was not explicitly rewarded. Without clear resources, protected time or institutional incentives, members at institutions 1 and 3 were unable to devote the effort they wished to achieve their team goals, reporting structural barriers to success related to capacity and commitment. Members at these two institutions reported an underlying perception that DEIJ work is approved, but pragmatically un-supported (e.g., protected time). Staff turnover slowed down task force work at these two institutions. Our experience aligns with previously reported limitations to DEIJ work documented in the literature. For example, among 50 radiation oncology departments with DEIJ initiatives, only 38.2% of DEIJ leaders had administrative support, only 29.4% had funding, and only 23.5% had protected time [26].

All task forces faced barriers with hierarchal, bureaucratic departments and structural or cultural barriers, as well. For example, institution 1 reported a heavily siloed structure that impeded cross-departmental collaboration. Institution 2 struggled to identify patient information needs, as patient materials were not clearly identifiable and organized for sharing with the task force. Additionally, institution 2 reported issues assessing patient experience disparities due to limited access to patient socio-demographic data, creating a “no data, no problem” problem.

Despite these obstacles, each institution made significant progress by refining their objectives to focus on more attainable goals and fostering collaboration across departments. The success of the task forces was driven by the dedication, enthusiasm, motivation, and cross-departmental collaboration of its members. This propelled progress and energized efforts. All task forces were committed to sustaining DEIJ work through collaborative efforts, expanded engagement of clinical leadership, and improved institutional alignment.

This study is limited to the experiences of only three cancer centers clustered in one geographic area. However, sharing these lessons will be helpful for institutions seeking structural change in other institutional and geographic settings. Other clinical settings wishing to improve DEIJ can leverage our lessons learned by obtaining early leadership buy-in, integrating manageable DEIJ goals within institutional strategic imperatives, distributing tasks among task force members with the authority and capacity to advance group goals, and rewarding DEIJ work in practice through workload reductions, dedicated time, and other recognition aligned with institutional values.

While we discussed at great length whether to include patient representatives in each task force, we opted to forgo patient representatives to encourage candor around internal challenges. Yet, this does limit our perspective to that of internal team members at each cancer center. Future work should, when possible, include patient perspectives to ensure meaningful improvements align with patient needs. Future work could also consider establishing a platform for community collaboration where task force members can share resources, learnings, and best practices with community members [22]. Collaboration with external community organizations may provide valuable support and motivation to overcome challenges.

Finally, while the findings of our assessments and action plans are specific to the institutions involved in our study, the educational recordings of task force sessions and affiliated resources of sessions are published and accessible to all on the www.cancercontroltap.org technical assistance web site [16]. Resources include downloadable templates that other institutions may use to conduct their own organizational assessment and action planning.

Conclusion

Developing a multi-disciplinary task force to advance DEIJ goals created meaningful improvements in our study. However, strong institutional leadership buy-in, alignment with strategic priorities, protected time and resources, and authority to advance structural change are critical to build an inclusive organizational culture and operationalize DEIJ values into policies and practice.

Acknowledgments

In addition to the authors, the following individuals contributed to the task force efforts described above: Titilayo Akinmusuru, Victoria Atchison, Julie Barnard, Joanne Cameron, Ami Chitalia, Karen Colandreo, Jacquelyn Dunmore-Griffith, Mica Grantham, Tahneezia Hammond, Dawn Harrison, Kristen McElreath, Shantie Morgan, Oluwabukola Oluwole, Jessica Rivera Rivera, Shayla Scarlett, Cherie Spencer, Candice Tavares, Linda Taylor, and Lawanaha Townsend.