Mobilizing toward health equity: Action steps for health care organizations

Research findings

Health equity is a top priority for many organizations

Health system and plan executives agree that health equity is important, and many of them have made it a strategic priority for 2021. Half of the health care CEOs we surveyed said health equity was among their top three organizational priorities for 2021 (figure 1). Six respondents said that DEI of the workforce—which we define as one of the dimensions of health equity—was among their top three priorities.

During our interviews, health care executives told us their leaders were having real conversations, many for the first time, about systemic racism, social justice, and the implications of each on health equity. They described organizationwide townhalls and board/leadership meetings dedicated to the topic. They said they believed their leaders were truly listening to problems, looking at data, and designing solutions. According to the executives, this contrasts with past discussions at their organizations that were more narrowly around quality of care or hiring, and solutions rarely incorporated direct feedback from those impacted.

Organizations are at different stages in their journey

While some health care executives have been working to improve health equity for years, others are just beginning to define what it means for their organizations and the populations they serve.

Some organizations have (or are getting) infrastructure and governance in place. Seventeen out of 20 surveyed CEOs said they have a dedicated team, task force, or committee and budget focused on health equity (figure 2); 10 CEOs said they have a C-suite leadership role dedicated to health equity. Among the interviewed executives, a small number said they have a chief equity officer leading their organization’s effort. Other executives have a chief diversity and inclusion officer or chief medical/population health officer leading their efforts. Some executives discussed creating specific board committees dedicated to health equity and/or leadership/board retreats focused on the topic.

More organizations are beginning to invest in health equity. Several interviewees said their organizations have recently made investments in health equity. Some organizations have publicly announced efforts, which include monetary pledges, new program initiatives, and appointments of executives who will lead these efforts.⁹

Some executives discussed investment commitments in terms of dollar amounts, while others cited commitments as a percentage of revenue. One executive said her organization is investing US$10 million per year, a significant increase from its prior investment commitments. Another executive said that her organization for the first time had a declared percentage of the budget committed to equity. Others said financial commitments toward health equity accounted for between 1% and 5% of total budgets. Most executives saw the dollar investments as a firm commitment and starting point toward something bigger.

The specificity and number of goals varied widely. Strategies to address health equity and methods for measuring progress vary widely. Most organizations are still defining their focus and goal. Organizations that were furthest along in their health equity strategies had set specific goals for measuring change such as improving a health outcome by a specific percentage or increasing workforce diversity by a certain percentage by a specific date. Organizations that are just beginning to address health equity are looking to see what other organizations have done. They are interested in which measures might work best and are trying to identify potential partners/stakeholders both internally and externally.

Leaders are taking many different approaches

All interviewees agreed on the importance of addressing health equity, but they sometimes differed on:

• The definition of health equity for the organization and the communities they serve

• Impact of DEI efforts for the workforce

• Strategies to address existing inequities

Defining health equity. Nearly all interviewed executives agreed that equity does not mean equal treatment. They agreed that rather, it means that some individuals need additional or different support or interventions due to the effect of racism on institutions, the drivers of health, and the multiplier effect of those factors. Some executives defined health equity as providing opportunities for individuals to achieve health and well-being. The executives discussed the importance of communicating this difference to their boards, leadership, staff, and the communities they serve.

Two key takeaways from the executives regarding the definition of health equity:

1) Equity goes beyond equal access to quality care. It should also include efforts to improve health outcomes through the drivers of health and combating the systemic racism that leads to disparities.

2) There is no one-size-fits-all or cookie-cutter approach to address the challenges. Initiatives and goals should be customized to the community.

Because of the complexity, one organization took a step back and worked together to be intentional and define what exactly DEI each mean to their health system and community. The executives also discussed the importance of embedding health equity within the “organizational DNA” and looking at all strategies, processes, and data through a health equity lens. Many executives discussed the importance of being intentional and taking a holistic approach by developing health equity strategies and goals within their workforce, patients, and the community.

The impact of workforce DEI efforts. Interviewees acknowledged that workforce DEI strategies should intersect with their health equity agenda but had different views on how they fit. Some view health equity as the umbrella under which DEI sits. For example, some executives saw a strong connection between improved diversity and inclusion within the workforce and improved health equity outcomes among patients. A diverse and inclusive workforce can help to improve trust, empathy, and the connection with communities. Some executives said that championing equity for their workforce could help to improve health equity within the communities they serve. For example, ensuring equal pay/benefits for their workforce, including contractors, could benefit the community. Others had separate leadership and efforts for workforce DEI and health equity with little apparent alignment.

Identifying strategies that can have a meaningful impact is challenging.Improving health equity is a complicated, multidimensional problem. Some executives said it is challenging to determine where they can have the most impact, sometimes to the point of paralysis, because it is so nuanced and local. So many factors, including the drivers of health, impact health outcomes, and executives discussed how they struggle to determine areas to invest. They described not having detailed data or not being able to directly connect specific efforts to outcomes. Executives from organizations that have been focused on health equity for several years were clear and specific about their near-term and long-term goals and visions. They also described having the “strength of leadership” to move forward with “enough data.”

An organization’s health equity strategy should consider the unique needs and challenges within the communities they serve. Organizations should consider each community’s demographics, its culture, history of racism, and local events that might influence whether people are hesitant to seek care when needed. Every region/locality has some history (and/or current instances) of racism, which can influence how when and where community members seek care. Historical racism and existing social unrest in the region/community should be thoughtfully considered. This could help address the needs of the organization (workforce) and the health/social needs of the community.

Most of the executives we interviewed work for organizations that serve multiple communities. They agreed that it is important to have a representative from each region who can speak to the nuanced needs and challenges of their communities. These executives said they try to identify opportunities for systemwide or organizationwide initiatives, such as hiring practices, clinical pathways for quality improvement, and scorecards. They acknowledged that most of these efforts were localized to meet the unique needs of each community.

Many interviewees stressed the importance of listening to community residents when developing strategies to address health equity. This can be just as important as listening directly to consumers and listening to the physicians, social workers, and community partners who have been working on equity concerns for decades. Organizations should not dismiss the voice of the patients and provide them with a seat at the table versus just offering token involvement. According to one interviewee, “the voice of the patient leads to an understanding that will lead to change, better outcomes and loyalty.”

Strategies to drive change

Interviewed executives acknowledged that there is a lot of work to be done. Organizations that are furthest along in their journey have a commitment from top leadership and identified a connection between health equity and their business model, including their financial performance, patient satisfaction, and outcomes. Many of the executives we interviewed said health equity strategies not only need to align with organizational strategies; they also need to be ingrained within the business and measure progress to drive true change within the organization. Executives acknowledged the need for accountability to ensure that efforts sustain.

Change needs to be driven from the top

While there is momentum for organizations to address health equity, it needs to be more than just the topic of the moment. Many interviewed executives recognized that addressing health equity requires more than just dollars. All executives agreed that having a clear strategy and vision for health equity from top leadership, including the board, is essential for an organization to move forward and for sustaining it as a priority.

Some interviewed executives discussed how their top leaders identified the problem years ago and decided to take action then. Others discussed how through the use of data, compelling stories, and focusing on today’s pandemic and social justice movement, leaders recognized the problem and made health equity a priority. All agreed that efforts could not move forward without support from the top.

Sustain efforts.A mix of governance levers could help create accountability within an organization. Many executives noted that if equity is separate, or on the margins, the commitment—both in terms of leadership and financing—will go away when times get tough. Others discussed how measuring progress could create some level of accountability and staying power for the initiatives. For example, tying equity to quality could help ensure that health equity remains a priority for the CEO, board, and other top leaders. Measuring progress could also help embed measures of equity into organizations’ internal scorecards, including quality measures, to keep progress visible. Hospitals will always be accountable for quality, but embedding equity training into certifications makes it a core business requirement. Some executives also discussed tying performance reviews and compensation (of leaders and physicians) to metrics on health equity to help ensure accountability on all levels.

A shared understanding and connection to the business is critical

Health equity should be instilled in each part of the business, not an add-on measure, to help ensure accountability. Executives told us that they try to “speak the business’s language” to get their leaders on board with the drive to improve health equity. They agreed that a shared understanding of the connection between health equity and the business model (e.g., quality, outcomes, workforce) is critical.

Some interviewees said they use specific examples of taking a health equity lens to various parts of the business that resulted in improved performance and patient experience. For example:

• One executive had her data analysts investigate ER data to see what factors may be contributing to longer visit and wait times. They found that the majority of patients with longer wait times did not speak English as their primary language. By adding primary language to the intake form, they were able to shave off a three-hour difference, which improved performance and also made the ER experience more equitable.

• Another executive used data on disparities in patient experience scores to demonstrate gaps that ultimately affect revenue, as those scores are correlated with patient loyalty, likelihood to recommend, and payment in value-based models.

However, our survey results indicate that few CEOs are connecting health equity to business goals. Only four surveyed health care CEOs said their health equity goals were related to business objectives such as improved patient outcomes, satisfaction, brand, or market share (figure 3). The majority of CEOs said they are investing in health equity to help improve support for the drivers of health, social good, and to support the organization’s mission. Interviewed executives agreed and said organizations that don’t make this connection could be missing an opportunity to advance health equity while helping to achieve critical business goals.

Know your audience. To get support and resources from the CEO/board and to get buy-in from physicians, the workforce, and other stakeholders, executives discussed how the presentation may need to shift depending on who is in the audience. Many said that they found there is not necessarily a one-size-fits-all solution. One executive, said that “some are already on board with health equity investments and don’t need convincing; others need data to illustrate the problem areas or blind spots and what solutions may help, and others need to hear personal stories of employees and patients to be convinced health equity should be an investment priority.” Executives discussed how it was critical to have a stakeholder strategy that included both those who were supporters of health equity and others who need more convincing.

Identify allies. Improving health equity can require tremendous effort and a long-term commitment. However, there are fast-start opportunities in the short term that can help build momentum. These include identifying allies for health equity among other leaders within the organization. Such allies can include physicians or operations leaders.

• For example, one executive has had success by identifying “ambassadors” who were operations leaders and may see synergies in their initiatives to pilot efforts that would improve care delivery. These allies can help build relationships with other leaders within the organization and can help ensure efforts gain broader attention and support.

• Another executive said a physician leader was inspired to add “equity” into the performance reviews of her physician team. The leader used this as an opportunity to discuss data and patient experiences with her physicians and to point out potential blind spots and share their learnings with other physician leaders.

Change needs to be funded and supported

Interviewed executives discussed how adding depth and action to commitments is critical. Some organizations have good intentions but only gain soft commitments, such as promises and messages without specific goals, investments, or detailed actions. Many organizations include equity in their missions and have been working to improve the health of their communities. However, some executives discussed how past experiences show that in tough times, health equity initiatives can fall in priority or lose funding. Firm commitments from leadership can reduce the chance of this happening. This means setting goals, having accountability, and developing measures of all the efforts behind the dollars. Commitment and support from the top (CEO and board) and an organized plan can also be essential. Organizations also should answer some tough questions:

• Where can our efforts have the most impact?

• How do we ensure our efforts will endure?

Answering those questions upfront can help sustain the initiatives and hold stakeholders accountable.

A chief equity officer role and a clear governance structure should be created

More immediately, health care CEOs should consider a chief equity officer role to demonstrate the organization’s commitment to health equity. The role could report to the CEO and present frequently to the board. This leader ensures accountability and execution on health equity strategies for the organization. Organizations that have had a lengthy focus on health equity had such a leader in place. More importantly, this leader was given resources (dollars and people) to support efforts and a seat at the executive table to align the organization.

Many interviewees also highlighted the importance of having a clear governance structure and dedicated infrastructure, including a leader, to support these initiatives. With multiple internal and external/community partners, the initiatives should require a clear governance and accountability structure to help ensure sustainability and success.

Data, analytics, and measurements are essential

While health care executives acknowledge that data is critical, some struggled with how to use data to measure the impact of their health equity efforts. Some had specific tactical goals and clear measures to track progress related to improved quality, outcomes, drivers of health, and the workforce. Others were still defining their goals and measurements.

Data can be a powerful tool for gaining broader organizational support. Many executives discussed how their organizations or physicians had never looked at their data by race before simply because they had never been asked to. By looking at their data in new ways, many described the experience as eye-opening. Data that demonstrates how patient outcomes differ by race can demonstrate the importance of addressing health equity. Data can also show where well-intentioned efforts are falling short. For example:

• One health system executive used data to show that Black mothers and infants had a mortality rate that was three times higher than other races. This information was presented to the board/CEO and used to create a clear baseline. The organization set a goal to reduce it by a certain percentage.

• Another health system executive said doctors pride themselves on being inclusive and sensitive to health equity. However, the data showed that Black women were far less likely than white women to receive mammograms. One doctor was puzzled because she treated all patients the same—by giving them the same reminder to get an annual mammogram. “That’s the problem,” the executive said. “For someone who have never had a mammogram, a reminder might not work. They might need a discussion on the importance of mammograms and help with identifying where to get one that is convenient. Different patients need different messaging.”

In both cases, data paved the way for tactical and impactful discussions for improving inequities.

Many executives also discussed the difficulty of developing scorecards specific to their communities and in measuring long-term initiatives. Although, there is a lot of academic research and data on health inequities and clinical data, one executive said she had no publicly available template for building her initiatives around business metrics. Although every community has unique needs, many health care organizations face common challenges such as chronic-condition disparities or consider common approaches such as investment in the drivers of health. A lack of transparency among health organizations can stall progress if each organization has to learn through trial and error versus learning from one another.

In addition to collecting and measuring data, many executives said it is helpful to hear real-life examples from people who have experienced inequity and discrimination. Executives discussed sharing these stories with their leaders. For example, one employee recalled how a patient recoiled when they tried to give them a vaccine, because the patient didn’t want a Black man to touch them. A nurse explained that she changed her name on a resume because it was “too Black” sounding. Once she changed it, she had an influx of job offers.

Conclusion

Health equity strategies that address multiple dimensions can be most effective and when every leader within the organization understands their role and takes action to achieve health equity. Leaders should consider the following questions across the following four dimensions:

• Organization: How can we reimagine our approach to diversity, inclusion, and belonging to advance equity among our workforce and address its unmet social needs?

• Offerings: How can our products and/or services more effectively meet the needs of our patient population across demographic groups?

• Community: How can we serve our local communities as health equity leaders?

• Ecosystem: How do we strategically amplify our positive impact through our vendors, partners, and public platform?

Achieving health equity requires leaders to deliberately design and build systems toward this purpose. Executives should recognize that it is a long journey but there are near-term opportunities that can lead to real change. Health care leaders should consider a long-term commitment—not just of dollars but also of leadership, resources, and accountability.