This post is part of our health equity series. Please read our overview post, Why Health Equity Matters in 2022, to learn more about how you can help advance health equity.
Implementing a comprehensive strategy to advance health equity is a moral and financial imperative for healthcare organizations (HCOs).
Persistent health disparities create preventable suffering and excess costs, are fueled by social determinants of health (SDoH), and consistently disadvantage people of color. Recent studies of racial equity estimate that $135 billion could be saved annually if racial disparities in health were eliminated, including $93 billion in excess costs of care.
These issues are pervasive because they extend far beyond the traditional healthcare setting, and efforts to advance health equity must reflect a complete, organization-wide commitment. Many HCOs have voiced a commitment to achieve health equity, but taking the next steps to develop a comprehensive strategic approach can be challenging.
Effective strategies hinge on effectively identifying specific community needs, establishing trust to overcome historic racism, and embedding health equity into business processes and objectives. As a result, every organization must develop a unique strategy tailored to their population’s most pressing issues, their own internal structure and processes, and their available resources.
Achieving health equity requires making it one of your organization’s key priorities and developing a robust strategy. However, cultivating a culture around health equity and executing on equity-centered initiatives is more than adding it to a list and holding a planning meeting.
Fortunately, the Institute for Healthcare Improvement (IHI) has outlined five universally applicable ways to make health equity a core strategy. We’ll explore these five key actions below.
Health equity should be a top-level focus that is aligned with business objectives and built into every major decision. Leadership is ultimately responsible for ensuring that health equity considerations are actually put into practice, and they must make it clear to employees that advancing equity is not a charitable side project but a key, organizational focus.
To ensure accountability, your organization may also consider incorporating measures of health equity advancement in executive compensation and departmental key results. As one executive said in an industry-wide survey by Deloitte, “When equity IS our culture, just the way we do business, and NOT a special set of circumstances—that is how to keep it as essential.”
Hiring a chief equity officer is one possible approach to creating a top-down focus on health equity. This position should be accountable and responsible for the development and execution of an organizational strategy—helping to maintain a focus on health equity in leadership/board meetings. Critically, hiring an equity-focused C-Suite role should not result in siloing equity efforts within their department. Instead, they should embed equity throughout the organization.
Advancing health equity requires dedicating organizational resources to establish new programs and initiatives. In turn, this necessitates creating a governance structure that oversees and manages these programs, ensuring that resource allocation is consistent, sufficient, and not mismanaged. The scope of these programs may depend heavily on organization size and capacity, but the teams that oversee them should be able to focus their undivided attention on health equity with repeatable processes, an appropriate budget, and well-defined goals.
Henry Ford Health System’s (HFHS) Healthcare Research Disparity Collaborative is an excellent example of structural support for health equity. HFHS founded the collaborative to create an arm of their business dedicated to researching and addressing racial and ethnic health disparities with other health systems and community-based organizations (CBOs). Since then, HFHS has maintained ongoing operational and financial support through the collaborative for a variety of health equity initiatives in Detroit, such as the Women Inspired Network, which works to reduce infant mortality for women of color.
To advance health equity, HCOs must identify the disparities that exist in their communities, determine the precise SDoH affecting their members, and develop initiatives designed to meet these needs. This can be challenging because the most relevant SDoH will vary by community and individual and will generally reflect factors outside the healthcare setting. Thus, HCOs will need to collect non-medical, demographic data to identify the most actionable areas for improvement and the population subsets at the highest risk. To conduct this analysis, HCOs can distribute social needs assessment surveys, collaborate with CBOs, and draw on publicly available datasets, such as the Area Deprivation Index.
Please read our post, 3 Ways Healthcare Organizations Can Advance Health Equity by Addressing Social Determinants of Health, for more information on the importance of addressing SDoH, how to use your available data, and how you partner with CBOs.
Racial biases drive poor health outcomes and must be explicitly addressed and dismantled internally. Despite years of improvement, racial biases persist in healthcare through structures, policies, and discrimination. COVID-19 evinced this clearly; racial minorities had over three times more premature excess deaths per 100,000 than white people in 2020, reflecting increased risk of exposure to COVID-19 due to socioeconomic disparities and barriers to care.
Racial biases are not always overt, but it’s critical to identify and minimize them. People may be willing to admit that biases exist at a system level, but may be hesitant to address them or acknowledge their own biases. For example, in a recent study from the Society of Maternal- Fetal Medicine, 84% of physician respondents agreed that race-based disparities in care delivery were negatively impacting their practice, but only 29% believed that their personal biases were affecting how they cared for their patients. To help expose and unseat even subconscious racial biases, HCOs can educate staff by holding recurring unconscious bias training sessions and seminars about racial biases.
If HCOs are serious about advancing health equity, they must deeply understand the issues facing their population of interest and consider collaborating with CBOs that systematically link healthcare and social services for the people at risk of poor outcomes. Rather than designing equity programs for their communities, HCOs should strive to design them with their communities. This may help to overcome historic distrust of medical institutions, more accurately address specific issues people are facing, and provide partnerships to more efficiently carry out intervention efforts.
The Health Improvement Partnership of Santa Cruz County is an excellent example of the impact HCOs can have when partnering with other health systems, CBOs, and community representatives. Since its founding in 2004, the coalition of HCOs and CBOs has successfully reduced the rate of uninsured residents in the county by 75%.
The Center for Health Care Strategies has also compiled a repository of resources to help organizations streamline CBO collaborations, including a partnership assessment tool. This tool is designed to help partners “understand progress toward benchmarks characteristic of effective partnerships, identify areas for further development, and guide strategic conversations.”
Developing a strategy that adheres to these five actions will foster more equitable health outcomes and will help to ensure that the pursuit of equity remains a central focus. However, creating an effective strategy to prioritize health equity and putting it into practice are two different things. Once your organization has established advancing equity as a guiding principle, it’s important to consider how you plan to drive long-term program success.
Rush University Medical Center is an excellent example of an organization that successfully prioritized health equity and launched an effective, long-term initiative to improve outcomes. In 2016, the health system rolled out their strategy to address race-based life expectancy gaps in Chicago.
The city has the largest racial mortality gaps among the 30 largest U.S. cities, and Rush identified that a significant portion of premature mortality is caused by chronic conditions in racially segregated neighborhoods. In fact, there is a 14-year life expectancy disparity between neighborhoods just two metro stops away, and Rush identified that economic factors are partially responsible for this disparity. Downtown Chicago has a median household income of $107,000, whereas Garfield park, a nearby, predominantly Black neighborhood, has a median household income of $22,000.
To address the SDoH factors that contribute to this health disparity, Rush adopted an organizational health equity strategy centered on eliminating structural racism and economic deprivation in their community. Their strategy incorporated the IHI’s five key actions despite being developed independently. Rush launched the strategy with support from a dedicated senior executive team, collaborated with the community and local organizations, looked internally to confront biases, developed measurable goals, and listened to the people most negatively affected by SDoH to drive the initiative.
In 2017, Rush began to execute on their strategy by hiring, purchasing, investing, and volunteering locally to help ameliorate the financial pressures they had identified as driving mortality. As one of the largest employers in west Chicago, their first mission centered on using their business units to promote economic activity, wealth-building, and community health. Moreover, they aggressively targeted financial inequities that existed within their organization, as many of their employees resided in economically disadvantaged communities and were experiencing financial hardships.
To ensure the success of their overall health equity strategy and their initial, economic-focused initiative, Rush created an employee resource group and held regular discussions with employees and community members. This had the effect of embedding a focus on health equity in the heart of the organization, ensuring it represented more than a one-time effort, and helping to guide internal practices. Since the strategy was adopted, Rush has:
Rush also launched several initiatives to address SDoH and ensure their impact on achieving health equity was transparent, measurable, and consistently increasing. To this end, Rush established a multidisciplinary health equity oversight committee that provides input on organizational performance improvement projects involving race, ethnicity, gender, and age-related inequities. They also introduced new screening tools to capture SDoH data, such as food and housing security and access to transportation.
With measurement and an internal oversight committee guiding their efforts, Rush began an ambitious project to tackle SDoH, eliminate the life expectancy gap, and advance health equity: the foundation of a coalition that enlisted every health system and community-based organization on Chicago’s west side. West Side United (WSU) was created to standardize goals and processes related to health equity and share best practices across these organizations.
The organization was founded with input from local residents, continues to be driven with their guidance, and follows a key principle: Chicago’s disadvantaged neighborhoods know best about the challenges they face. Every WSU project is designed and executed collaboratively with input from the community it is intended to benefit, and the organization carefully avoids dictating change from a position of power. As one resident put it, “Don’t make top-down decisions and then invite everyone to something that’s already been decided.”
WSU has made remarkable progress towards eliminating health inequities and uniting healthcare organizations and community members behind a shared goal. In the first three years since its foundation, WSU has:
Rush developed a set of five overarching recommendations for successfully putting a health equity strategy into practice that they base on their experience combating structural racism, improving health outcomes for underserved communities, and collaboratively founding the WSU. For other HCOs aspiring to tackle inequities, they recommend:
These guidelines share the IHI’s focus on responsible leadership and supporting initiatives throughout the organization, but Rush also emphasizes the importance of measurement, clear goals, and accountability. Without explicit equity goals that leaders value as highly as key financial and performance metrics, initiatives may fall by the wayside. As Ruch states, “tackling systemic racism, economic inequities, and other social and structural afflictions...is simultaneously a necessary and daunting long-term task.” Success is dependent on resolute commitment.
Finally, everyone has a vested interest in creating a more just system, and Rush credits their progress thus far to following the guidance of their local communities. They share that “listening sessions in the community and a commitment to share decision-making with community leaders are foundational to [their] strategy and necessary to overcome historical mistrust. Rush’s community efforts are guided by the voice of the community: ‘Nothing about us without us.’”
For more information about developing a strategy to prioritize health equity and partnering with local communities, please check out the American Public Health Association’s health equity resource page. They provide an excellent series of fact sheets that detail everything from COVID-19’s impact on housing instability to combating environmental health disparities for children.
This post is part of our health equity series. If you’re interested in learning more about health equity and what can be done to achieve it, please check out our comprehensive overview post, Why Health Equity Matters in 2022, and our other posts on health equity:
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