Action Plan for Advancing Diversity, Equity, Inclusion and Anti-Racism FY2023

The DEI/AR Council is proud to present our second annual Action Plan for Advancing Diversity, Equity, Inclusion and Anti-Racism for the UCSF Benioff Children's Hospitals in FY2022. This strategic plan was created collaboratively by the BCH DEI/AR Council, Senior Leadership, Executive Leadership, and the Board of Directors. Moving forward, the work must continue to be collaborative since we know that the impacts of diversity, equity, inclusion and anti-racism occur at individual, institutional and systemic levels.

This is an exciting time as we have commitments from BCH leadership to take on issues of health disparities, social justice, bias and racism. In our needs assessment, the majority of BCH employees recognized and embraced that we work in an institution that has at its core the mission to provide the best healthcare to every child. At the same time, Blacks, Indigenous and People of Color (BIPOC) and other groups (LGBTQ+) experienced disrespect and excluding behaviors most often in our workplace. And our analysis across BCH job categories shows that the most common race/ethnicity is White amongst management and professionals while BIPOC predominate among administrative support and service workers. We cannot provide the best healthcare to all children when we have such disparities in our workforce, when we perpetuate racist structures.

This is our time to build an institution that is safe for all who enter. This is our time to speak the hard truths and to hold one another accountable. This is our time to be intentional in our thinking and in our actions. Our Action Plan for Advancing Diversity, Equity, Inclusion, and Anti-Racism for the UCSF Benioff Children's Hospitals is about our behaviors and our priorities. We embarked on this journey together two years ago and have come very far. There is much further that we have to go, there is much that we have to do. And we can do it if we do it together, with courage, with spirit and with love.



Problem Statement

UCSF BCH, an anchor institution embedded in systemic racism, has made initial progress, but targeted strategies are needed to address inequities in recruitment, hiring and advancement of Black, Indigenous and People of Color (BIPOC) and other groups including LGBTQ+ communities. Equally operable is the negative impact of individual biases and their contribution to these inequities.  A problematic climate exists whereby BIPOC at BCH are less likely to feel respected and have more often experienced/ observed excluding behaviors. These workforce inequities and this problematic climate contribute to disparities thereby undermining our vision to be the best healthcare provider. While this plan is primarily focused on workforce, subsequent DEI work will assess, and address as identified, disparities in healthcare, outcomes, and patient experience


To build an institution that is rooted in justice and equity to nurture an inclusive culture and to cultivate and implement effective strategies for the just and equitable provision of education, discovery, and patient care.



To build an empathetic, supportive and equitable environment for the present and future UCSF Benioff Children’s Hospitals community.



BCH values all employees by embracing their diverse talents, perspectives, and experiences, and fostering inclusion that inspires innovation, encourages respect and promotes unlimited success.



To attract and sustain a diverse workforce by recruiting, hiring, developing and retaining high-performing employees who work collaboratively to carry out the mission for BCH.


Guiding Principles

  • Cultivate a culture that encourages collaboration, flexibility, and fairness to enable individuals to contribute to their full potential and further retention.
  • Develop structures and strategies to equip leaders with the ability to manage diversity, be accountable, measure results, refine approaches on the basis of such data, and institutionalize a culture of inclusion.
  • Assess internal talent to create a high-performance, sustainable organization to meet its strategic and operational goals and objectives.
  • Recruit from a diverse, qualified group of potential applicants to secure a high-performing workforce drawn from all segments of our society.

Areas of Priorities






  • Survey managers who have completed the Brave Spaces training
  • Development of Brave Spaces 2.0, that will include not only focus on the Our People Pillar but on the Patient Experience Pillar by incorporating Gallup, Climate Survey and Patient Experience data into team discussions.
  • 50% of the True North Board Managers will have completed the Brave Spaces training by end of FY23
  • Additional 25% of  interprofessional teams establish Brave Spaces by end of FY23


Patient Experience

  • Toolkit will include literature and evidence based best practices. A literature review of NRC, Beryl Institute, Press Ganey can determine what is available.
  • Highlight boards that are done well to provide examples
  • Projects should be developed that are evidence based and proactive à data analysis, coaching, resources, and toolkit will help in development of these actions
  • Patient Experience Champions for every TNB à Amy and Diana have a list of Focus 25. Check in with Susan regarding identifying those champions for each unit
  • Development of Patient Experience Toolkit by 3rd Quarter FY2023
  • 50% of the True North Board Managers will be trained on the toolkit by end of FY2023


Quality & Safety

  • Goal is to develop a loose structure for an oversight committee that can address DEI-AR related IR’s.
  • UCSF Health’s Incident Reporting system has a category for reporting DEI-AR related events. Under the “Professional Conduct” category there is an event titled “Discrimination/Racism from/by Employee”. Under “Diagnosis/Treatment” category there is a “Interpreter/Translation Issue” option. Under “Safety/Security” category, there is a “Discrimination/Racism from/by patient/visitor” option.
  • Establish monthly meeting with Quality & Safety
  • Increase in number of successfully submitted DEI-related Incident Reports compared to 4th Quarter FY2022 by end of FY23


Workforce Equity

  • Create communications and toolkit for the Mentorship Program
  • Strategize and develop a BCH Mentorship Program
  • Ongoing Data Review – Physician Diversity; Separations & Workforce Diversity analysis.
  • Strategize the logistics of a Mentorship Program by end of FY2023
  • Establish base level metrics for Separations by 2nd Quarter FY2023
  • Establish base level metrics for Physician Diversity Analysis by 2nd Quarter FY2023
  • Workforce Diversity Analysis Report FY22 by 2nd Quarter FY2023


Create DEI/AR Synergy Across Enterprise

Align DEI/AR activities with BCH, UCSF SOM and UCSF Health initiatives

  • Provide support to decrease MyChart enrollment disparities
  •  Assist with Code CARE roll out in the East Bay
  • Dissemination of UCSF Anti-Racism Initiative objectives and progress across BCH, throughout FY23



  • Partner in developing dashboard to increase visibility of real time data
  • Integrate Quality Built-In Kaizen with the DEI/AR Council TFTs, especially with addressing cross-bay disparities
  • Collaborate on improving translations of MyChart content
  • Identification of factors that contribute to the MyChart disparities ongoing in FY23
  • Collaboration on a toolkit for assessment and best practices in addressing cross campus disparities ongoing in FY23



  • Partner with Code CARE team to identify best practice for anti-bias education component of staff training
  • Assist with incorporation of historical context of BCH Oakland with our broader community
  • Code CARE training available for East Bay staff by end of quarter 3, FY23