Strategic Improvement Plan

The Department of Family Medicine at the University of North Carolina was established in 1970 in response to the need for high-quality primary medical care to the people in the state. Over the first 50 years of its existence, the department grew tremendously and is recognized nationally as a leader in clinical work, education, and research. The department was established on the premise of the provision of health care for all.

This noble mission and years of well-intentioned hard work have not spared the department from the societal challenges of health inequities among the people of the state of North Carolina. Recent events, including the COVID-19 pandemic, have brought about a much-needed awareness of factors influencing the health of marginalized populations and have spurred the department to reflect on our mission of caring for all the people we serve, from patients to employees, and to reconcile the discrepancy between our stated ideals with the reality of our department’s history and current workplace community.

This plan highlights current efforts and outlines our plan to address disparities and create equity in healthcare, education, and research, by creating a culture that is collaborative and respectful. It will be used in conjunction with ongoing work with stakeholders to institute administrative actions that align with our mission to improve the health and wellbeing of all North Carolinians.

In 2018, the department issued a strategic plan that broadly outlined aspirations to lead the nation in innovative patient care, teaching, and research. The plan stated, “Our learners, faculty, and system leaders should reflect the diversity of the patients we serve.” Other stated goals included the development of models that support staff growth and wellbeing, targeting student pipeline programs towards those likely to work in underserved communities, expansion of residency training into rural communities, and diversifying our faculty to better reflect the demographics of our state. The plan included an intention to partner with community organizations to solve issues such as food and housing insecurity and other initiatives to reach underserved populations. At the same time, our research program listed health equity as one of its three priority areas of excellence, meaning faculty research, funding initiatives, and mentorship would prioritize work in health policy that evaluates race, ethnicity, and gender-based disparities in health outcomes.

The UNC School of Medicine (SOM) continues to move forward in addressing health equity by training future physicians equipped to serve all North Carolinians. Within North Carolina, there are many communities which suffer disproportionately poorer health outcomes. The factors involved in health disparities are multilayered and intersectional. Health disparities have been shown to be associated with key factors such as inadequate access to health care, poverty, educational inequalities, behavioral factors, and environmental exposures. Historically marginalized groups are at greatest risk for health disparities due to their experience of discriminatory practices within many aspects of society.  In 2021, The Department of Family Medicine developed a strategic plan to examine how the department can continue to promote health equity and support advances in research, teaching, patient care, and workforce development that will have a positive impact on the health of the communities we serve.

The members of the department committed emotional energy and self-reflection to these painful realities, with multiple efforts to move forward. The most formal of these efforts was the creation of the Health Equity Advisory Group (HEAG), under the direction of Alexa Mieses Malchuk, MD, MPH, who was already serving in the role of the department liaison from the SOM. The HEAG met regularly as a large group, with four subgroups dedicated to specific strategic priorities leading to the creation of themes, strategies, and metrics. The framework of these proposals was presented to the Chair’s Advisory Committee in late spring 2021, where the draft was enhanced with other ideas and strategies that were already underway. The HEAG report was foundational to the development of the department’s strategic plan, catalyzing the consolidation of the department’s activities into a comprehensive vision that meets the department’s stated commitment to social justice across its mission of providing equity in healthcare, education, and research. We view this as a living document as we continue to understand more about the changes required to improve our department.

The UNC Department of Family Medicine is committed to a work environment supportive for all people who work in the department and in our family medicine centers where everyone feels valued and engaged, with opportunity for personal and professional development. The department acknowledges that the medical environment in which we learn, work, and research has a history in hierarchy, division, that has resulted in harm. Physicians and those in power have a history of being held to different standards and avoiding accountability for their injustices. Those in lower levels of power and pay have many times been overlooked, not seen for their true value. When systems are forced to recognize their need for change, they lack the skill and tools necessary to create meaningful structural change. We acknowledge that it does not have to be this way, and pledge to educate, grow and change as individuals and a collective department. We seek an environment where employees feel appreciated and supported through a relational value structure as opposed to the traditional hierarchal model. We value people and are instituting a structure to promote a cohesive, encouraging, and fulfilling climate in which to work.

Objective 1.1  

Invest in policies and practices that promote belonging, community, and transparency throughout the Department of Family Medicine community.

Recommendations

• Support the position of Director of Education and Community Engagement, which includes the community of people who work in our department, as well as the greater community.
• Engage the UNC Family Medicine Center community to build and sustain a culture of belonging. This work includes continuous improvement projects which bring together faculty, residents, and staff.
• Establish ongoing personal and professional development programs that are supportive of all people who work in the department and family medicine centers.
• The department will support training to better understand historical factors that influence the health of marginalized populations.
• Create a system for reporting challenges that occur in the clinic or elsewhere with well-trained leaders to promptly address any such events.

Objective 1.2  

Sustain an environment of inclusivity and acknowledgment in communications in the department and family medicine centers.

Recommendation  

• Ensure that the UNC Family Medicine internal newsletter is inclusive of personal professional milestones for everyone who works in the department (e.g., new positions, promotions, graduations, etc.).

Objective 1.3  

Support the professional advancement of our clinical and administrative staff.

Recommendations

• Managers create performance and development plans for staff members so they can advance their careers in the family medicine center, department, or health care system.
• Encourage staff participation in the annual Workspace Engagement Survey with close examination of the results, seeking high rates of satisfaction and addressing any issues that are reported as concerns.

Objective 1.4

Encourage and support dissemination activities regarding departmental work addressing health disparities.

Recommendation  

• Department faculty will submit proposals for peer-reviewed papers, local and national presentations, and other dissemination activities, regarding work on developing and sustaining health equity and social justice in an academic setting.

Objective 1.5

Reach out to the greater department community including alumni and friends, informing them of departmental work addressing health disparities and inviting them to participate in supporting the department as we move forward together.

Recommendations

• Offer opportunities to donate to the Health Equity Fund in the department.
• Include departmental work addressing health disparities news in the online newsletter sent to friends and alumni.

 

The department is committed to a faculty that better reflects the population of the state we serve. This means we are purposeful in recruiting faculty from all backgrounds, including those traditionally underrepresented in medicine.

Objective 2.1  

The department seeks to recruit an exceptional group of faculty at all levels of rank and experience to create a faculty that reflects the demographics of North Carolina.

Recommendations

• Marketing and outreach to national groups like the National Medical Association, National Hispanic Medical Association, and other connections that increase the visibility of our department for traditionally underrepresented groups.
• Update our social media presence and website, including posting this strategic plan.
• All faculty selection committees have diverse representation.
• Formal exit interview process for any faculty who leave the department.
• Track recruitment and retention success of all faculty.
• Systematically assess and advance current recruitment and retention initiatives’ effectiveness in creating a sense of belonging and connection and fostering equity in achievement across populations.

The Department is committed to the equitable recruitment, professional development, and career success of its faculty. Faculty development is a key component to fully realizing the variety of skills and talents that our faculty members bring and will help empower more future leaders in medicine who will be better able to lead the next generation of physicians and researchers.

Objective 3.1

The department will provide opportunities for professional development that contribute to a high rate of retention and/or growth and opportunities for leadership positions in the Department, in the School of Medicine, in UNC Health, and at the state and national level.

Recommendation

• The Department will ensure that recruitment efforts for the faculty development fellowship reach a broad pool of qualified candidates who are representative of the communities they serve.

Objective 3.2 

The department will support new and junior faculty in the establishment of a viable career plan that allows meaningful engagement as a member of the department and the School of Medicine.

Recommendation

• Support the ongoing development and implementation of the Leadership in Academic Medicine Program (LAMP). The Department supports the time of the Associate Chair for Faculty Affairs and the Associate Director of Educational Programs for their work in this regard.

Objective 3.3

The department will support the promotion of faculty from all backgrounds to the associate and full professor level.

Recommendations

• Faculty from underrepresented communities have promotion subcommittees consisting of faculty with commitment, training, and experience in career mentorship and promotion.

Objective 3.4

The department supports the leadership development of faculty from all backgrounds.

Recommendations

• Department leadership will seek, encourage, and promote leadership opportunities for all faculty members in the School of Medicine, UNC Faculty Physicians, UNC Health, and state and national leadership opportunities.
• Leadership opportunities are discussed at annual reviews.
• Measure and monitor leadership in the department (Chair, Vice Chair, Training Program Directors, Clinic Directors, Service Line Leaders, etc.).
• Nomination of department faculty for leadership training through the School of Medicine Faculty Affairs and Leadership and Professional Development programs.

Objective 3.5 

The department will ensure equality and equity in salaries.

Recommendations

• Diverse representation on the department’s compensation plan committee.
• The department Chair and Vice Chair of Administration reviews salaries at least annually with reference to well-established analyses of compensation (Medical Group Management Association, Association of American Medical Colleges) to ensure fairness and equity.

Objective 3.6

Promote awareness among faculty in issues related to social determinants of health and health equity.

Recommendations

• Faculty are encouraged to participate in bystander training.
• Faculty are emboldened to show allyship for a more welcoming environment with pins or other open support.
• Faculty are encouraged to participate in REI training.

The department will continue to support curricula, structures, training, and educational culture which fosters a learning environment where learners feel engaged, respected, valued, and safe.

Objective 4.1

The department supports initiatives that promote underrepresented resident recruitment with the goal of recruiting and training a physician workforce that reflects the demography of North Carolina.

Recommendations

• The Department will ensure that recruiting efforts are made so that the final pool of qualified candidates for the residency reflects the broad scope of the community.
• Residents have the opportunity for one-year career development fellowships that allow for professional focus in areas of personal interest.

Objective 4.2  

Faculty and students are aware of the UNC SOM Mistreatment Policies and Reporting procedures and faculty development resources to help create inclusive and supportive learning environments. Faculty will consider biases they bring into the workplace and evaluative environment.

Recommendations

• Create a confidential system for resident reporting of micro/macroaggression with a consistent system of follow-through by residency leadership. Ensure learners are aware of this system and that a practice of feedback to facilitate an inclusive environment is developed.
• Maintain a list of mental health professionals from diverse backgrounds available to learners.
• Create a supportive network of faculty advisors and mentors with experience and training in inclusive learning environments.
• All residents are encouraged to complete safe zone training in their intern year and faculty are encouraged to join.

Objective 4.3  

Ensure that our residency curriculum and formal didactics address issues related to health equity, including social determinants of health.

 

Recommendations

• Faculty and resident education meetings incorporate integrated teaching on health equity into each session.
• Evaluation forms address the extent to which educational sessions address health equity and social justice with speakers/facilitators provided feedback on their success in this regard. Residency management team will monitor.
• First and second-year resident family medicine month rotations will contain curriculum in health equity, social justice, and community engagement.
• Integrate equity and social justice concepts into the quality improvement class projects.
• Integrated LGBTQ+ health education throughout the residency didactic curriculum, as well as introduced trainings for staff.

Objective 4.4  

Ensure that experiential learning at our clinical sites fosters our ability to serve all populations.

Recommendations

• Train faculty in inclusive teaching strategies that promote social justice and a sense of belonging.
• Ensure that clinical rotations include specific objectives related to health equity and social justice with evaluation questions that assess how the objectives were addressed.
• Ensure this applies to all learners (residents, fellows, and medical students, pharmacy, social work, physician’s assistant, or nurse practitioner school) as well as MedServe scholars.

Objective 4.5

Work with the UNC School of Medicine to recruit medical students from diverse backgrounds, and recruit students into family medicine.

Recommendations

• The department supports leadership and involvement of our faculty in the many initiatives in the UNC School of Medicine that support and promote underrepresented student recruitment, enrollment, retention, and success such as the FIRST program, Medical Education Development (MED), Carolina First Look, Summer Academy, among others.
• The department supports a faculty director of the Family Medicine Interest Group (FMIG) and the development of activities that include outreach to medical students from diverse backgrounds.

Objective 4.6  

The Primary Care Sports Medicine Fellowship Program is committed to training a diverse group of fellows as well as teaching family medicine residents the skills to provide excellent musculoskeletal care to the patients they serve.

Recommendations

• Participate in the American Medical Society for Sports Medicine Annual Meeting Fellowship Fair in-person and virtually (as applicable) to highlight our Sports Medicine team members who hail from a diverse array of backgrounds including races and ethnicities, geographic origins, and genders.
• Increase the number of weekly noon didactic lectures on Health Equity in Sports Medicine.
• Our Fellows rotate through and assist Faculty in a variety of learning environments, including North Carolina Central University and Shaw University, both Historically Black Universities (HBCUs).
• Our Fellows, Faculty, and rotating residents volunteer our medical services to provide free preparticipation sports physicals and sideline game coverage to many public schools across Chapel Hill and Chatham counties.
• Faculty members serve on and directly participate in our residency program’s Second Look for underrepresented minority residents as well as medical school movements such as the Resident Diversity Initiative (RDI).
• All faculty members within our department are encouraged to complete Bias 101 training.
• Continue to partner with the School of Medicine and the Graduate Medical Education (GME) community at UNC Health to support its trainees and promote a supportive learning environment for residents of all backgrounds.

Objective 4.7

Support the UNC Preventive Medicine Residency Program Inclusive Excellence Initiative. The Preventive Medicine Residency Program is committed to addressing the historical trauma and structural racism in our healthcare system, starting with a recruitment strategy that focuses on a holistic review of the applicants.

Recommendations

• Residents and faculty engage annually in recruitment initiatives, including the SNMA and Carolina First Look residency fairs, to increase our visibility to underrepresented minority students.
• Support open and honest communication, with residents having multiple avenues for anonymous reporting of challenges that occur within the learning environment.
• Policies are written into a professional compact and reinforced in group and individual settings.
• All residents and faculty are encouraged to attend Racial Equity Institute training. The didactic seminar curriculum includes health equity topics (examples include LGBTQ+ care, racial disparities in cardiovascular outcomes, and workforce research on underrepresented minorities in medicine).

The department has a nationally renowned research program with researchers who recognize that inequitable health outcomes result from a host of interconnected factors including, but not limited to, structural and institutional racism, implicit biases, stigma and discrimination, cultural, linguistic, and socioeconomic barriers, and geographic disparities in access to healthcare. Given the pervasive nature of health inequities, our researchers’ work intersects with these challenges. For example, our faculty work to understand key factors in healthcare workforce development; how to identify determinants of disparities in tobacco use; how to address disparities in the management of chronic diseases; and understand the role of social determinants of health, insurance coverage, and sources of care as causes of health inequities.

Objective 5.1

Recruit researchers from diverse backgrounds and provide support through the many programs available.

Recommendations

• Research faculty seek minority supplements to federal grants, to support junior faculty from underrepresented groups.
• The Department will seek supplements to federal grants to support junior faculty who have a proven track record of demonstrating a commitment to serving underrepresented populations.
• Provide mentorship of young researchers from a variety of backgrounds.

Objective 5.2

The Department is committed to research and health policy work that addresses health inequities, including disease prevention and health promotion.

Recommendation

• Prioritize research in health policy that evaluates race, ethnicity, and gender-based disparities in health outcomes.

Objective 5.3

Continue to support the National Research Service Award (NRSA) Primary Care Research Fellowship at UNC.

Recommendation

• Train primary care researchers to address the health care needs of the people which includes mentorship with research opportunities in community interventions, access to care, health workforce, rural health, health literacy, new models of care, and other topics relevant to improving health disparities.

Objective 5.4

Continue to develop the North Carolina Network Consortium (NCNC), a practice-based research network.

Recommendation

• Ensure that medical research takes place in the communities where people live to ensure a population-based understanding of illness and disease. This is foundational for health equity research.

The department is committed to the provision of clinical services, population health management, and community outreach to improve the health of all people.

Objective 6.1

The Department will lead the provision of health care services at Chatham Hospital, which is a critical access hospital serving the population of Chatham and nearby counties.

Recommendation

• The department will continue to provide faculty and resident physician staffing to the Chatham Hospital emergency room, hospital inpatient service, and maternity care center.

Objective 6.2

Continue partnership with Piedmont Health Services (PHS) in the provision of care to rural and underserved communities. PHS is the organization that leads the region’s federally qualified health centers (FQHC). FQHCs are health care organizations that qualify for funding under the federal Public Health Service Act to serve an underserved area or population. The department has been a partner to PHS for more than 40 years.

Recommendations

• The department continues its commitment to training residents to work with underserved populations, including through our rural residency track program with Piedmont Health Services.
• Through Carolina Health Net, the department partners with UNC Hospitals and Piedmont Health Services in the provision of primary care to 25,000 uninsured people in the region.

Objective 6.3

The department partners with community organizations and public health agencies to improve the health and well-being of people who live in our communities.

Recommendation

• Continue to support a position of Director of Community Health Initiatives who will manage relationships with multiple community stakeholders, including the Town of Chapel Hill, Piedmont Health Services, Rockingham County Primary Care Initiative, among others.

Objective 6.4

The department continues its longstanding partnership with the Orange County Health Department (OCHD) in the provision of direct patient care to an underserved population as well as overseeing the public health of all people who live in the county. This role remains critical in the response to the COVID-19 pandemic.

Recommendation

• Continue to provide the medical directorship to Orange County Health Department.

Objective 6.5

Address factors that disproportionately contribute to health inequities by improving quality of care for everyone.

Recommendation  

• Our population health team establishes metrics for high-quality care along with processes to improve that care. Metrics include demographics (race/ethnicity, gender, sexual orientation, insurance status, etc.) that identify health disparities.
• Clinical Systems Improvement (CSI) team sends focused data monthly on metrics related to social determinants of health.
• Leverage success of the statewide department and I3 to share best practices that reduce health disparities and promote equity.

Objective 6.6

The department is committed to the care of vulnerable populations, including migrant farmworkers, those without insurance, and those who are underinsured.

Recommendation

• The department continues to provide medical directorship for the North Carolina Farmworkers Program and the Student Health Action Coalition (SHAC).

“Our department is committed to the successful implementation of this strategic plan. We have created a dashboard that measures and monitors these objectives and recommendations, which will be reviewed quarterly by the Chair’s Advisory Committee and reported to the members of our department, alumni, donors, and other interested parties on a regular basis. We aspire to be true to our mission of providing equitable health care to the people of North Carolina in an inclusive environment where everyone feels valued and where our faculty and residents reflect the population of our state. I am proud to be a member of a department full of talented, committed, collaborative people who are prepared to fulfill this mission.”
– Chair Margaret Helton, MD