Institutionalizing Racial Equity in Health System Performance

Christopher J. King, PhD, FACHE Associate Professor, Health Systems Administration Georgetown University Email: [email protected]

Readiness Assessment

Audience and Purpose: As hospitals and health systems strive to integrate social factors in clinical care and eliminate racial differences in health outcomes, it is important to reflect on history and examine the intersection of racial injustice, the structural environment, and health status. This tool is designed for board members and senior executives who wish to assess their organizations and uncover opportunities to move upstream to make a more meaningful difference in the health of the communities served. Realizing each enterprise is on a different place on the continuum, the purpose is to stimulate dialogue and identify opportunities to strengthen the organization's capacity to function with a racial equity lens.

Racial Equity: An outcome in which “race no longer determines one’s socioeconomic outcomes. As a process, we apply racial equity when those most impacted by “structural racial inequity” can fully participate in the development of “institutional policies and practices that impact their lives.” Center for Social Inclusion

Governance and Management

●     Does the board of directors reflect the racial and ethnic character of the community served?

WHY IS THIS IMPORTANT?

According to the American College of Healthcare Executives, persons of color represent only 14% of board members, nationally. Boards that reflect the racial and ethnic composition of the community enable the creation of policies, practices, and institutional norms that are inclusive and culturally nuanced. This commitment also mitigates risks associated with unconscious bias and poor decision-making - compromising patient safety and community perception.

●     Are HR policies in place to ensure staff and leadership represent the racial and ethnic character of the communities served?

WHY IS THIS IMPORTANT?

Staff and leadership that reflect the racial and ethnic character of the community enriches internal dialogue and sharpens the institution’s capacity to best meet the needs of its patient population and service areas. This commitment also helps overcome sentiments of distrust of the healthcare system due to a history of unethical medical research imposed on persons of color. As a means of promoting quality of care and patient engagement, a workforce the reflects the character of the community mitigates risks associated with unconscious bias and poor decision-making.

●     Does the board, leadership and staff have organizational space, time, resources, and structure to discuss and respond to issues of racial justice within and outside of the organization?

WHY IS THIS IMPORTANT?

Conversations around racial injustice and the root causes of such injustices are sensitive, complex, and emotionally difficult. Protected time is necessary for cultivating a culture of openness and trust. Afterwards, a shared philosophy can be achieved and supported by common language and messaging that is internally and externally explicit. 

●     Is there shared understanding of how racial justice advances the organization’s mission and population health strategy?

WHY IS THIS IMPORTANT?

Since mission statements guide all organizational decisions, it is important to express how this commitment supports the mission and population health goals. All messaging – internal and external – should reflect the connection.

●     Is there motivation to learn about the history of the community served and the conditions that have contributed to racial inequality and poor health outcomes?

WHY IS THIS IMPORTANT?

Each community has a unique history that has contributed to segregation, inequality and other inequities. Awareness of the community’s history and the hospital’s historical position is key for racial healing and developing a roadmap for the future.

Even today, hospitals and health systems are not immune to the effects of systemic manifestations of racial injustice. In fact, inequitable conditions are likely to exist within the institutions themselves. Allocating protected time and resources to identify internal vulnerabilities, explore unfairness in external structures and systems, and explore promising solutions are prerequisites for improving the patient experience, as well as the conditions of the local community.

●     Is there awareness of the importance of defining terms (i.e. racial equity, structural racism) and socializing such language across the enterprise?

WHY IS THIS IMPORTANT?

Interpretation of terms vary based on each individual’s lived experience. Shared understanding of terminology promotes alignment and minimizes risks of miscommunication. Moreover, institutions that can  operationalize how concepts such as privilege and power play out in their local communities are a step forward in building a short- and long-term strategy.

●     Is there motivation to explore how to redeploy assets as a means of building the community’s capacity to address racial inequities?

WHY IS THIS IMPORTANT

As anchor institutions in their local communities, hospitals and health systems have the capacity to use their voice and resources to improve the structural conditions of historically marginalized communities of color. Mechanisms include, but are not limited to: volunteering services to strengthen the capacity of organizations with a racial equity mission, advocating for changes in zoning or resource allocation to promote more equitable distribution of resources, and developing purchasing and procurement guidelines to prioritize local businesses housed in distressed neighborhoods.

●     Does the hospital have racial equity metrics for tracking performance, monitoring progress and ensuring accountability?

WHY IS THIS IMPORTANT?

Since it is important for this work to be integrated throughout all functions of the enterprise, metrics related to areas such as Patient Experience, Human Resources Management, Purchasing and Procurement, and Strategic Partnerships promote accountability and a balanced approach towards progress.

●     Does the hospital have mechanisms in place to stratify utilization patterns and health outcomes by race/ethnicity and/or neighborhood?

WHY IS THIS IMPORTANT?

Tracking patient utilization patterns by disease condition, age, race/ethnicity, and neighborhood helps pinpoint opportunities for intervention and strategic partnerships. Furthermore, a substantial body of literature suggest the prevalence of unconscious bias in patient experiences and clinical decision-making. Mechanisms to monitor clinical outcomes and patient perceptions by race/ethnicity, insurance, and income are critical for population health improvement.

External Support and Engagement

●     Does the hospital have relationships with community stakeholders so that honest, bidirectional information flows in support of partnerships, programs, and projects that address racial and health injustice?

WHY IS THIS IMPORTANT?

The external conditions that shape the experiences of where people live, work, eat and play are dynamic and constantly changing. Therefore, it is important for the organization to have relationships with community-based organizations to stay abreast of existing or impending policies, practices or inequitable resource distribution that may disproportionately burden communities of color. With such knowledge, the hospital is empowered to mobilize resources and respond accordingly.

●     Does the organization have access to racial justice facilitation experts, curricula, resources, and other tools to educate and support dialogue among staff, board, and volunteers?

WHY IS THIS IMPORTANT?

It is unlikely that organizations have the internal expertise to initiate an institutional approach towards racial equity. In fact, organizations on the journey have vocalized the importance of enlisting the support of external expertise at the start– mainly due to the complexity and sensitive nature of the work. An experienced professional can help team members establish boundaries and achieve a unified philosophical voice – ultimately establishing an approach that best suits capacity.

●     Does the hospital have affiliations with community-based entities with missions grounded in racial justice?

WHY IS THIS IMPORTANT?

It is unlikely that organizations have the internal expertise to initiate an institutional approach towards racial equity. Hospital leaders can accelerate their learning curve by developing cross-sectoral affiliations with community-based entities that have missions grounded in racial justice. Such interactions are likely to shed light on former and current policies and practices that disproportionately affect the health and wellbeing of communities of color.  

●     Does the hospital have access to grassroots advocates who can serve as key informants or advisers in a journey towards racial equity?

WHY IS THIS IMPORTANT?

Grassroots advocates and those directly impacted by racial and social injustice bring lived experiences that shed light on health implications and health outcomes. Their level of engagement is likely to foster a deeper sense of compassion and empathy and their narratives are instrumental for shaping how the hospital will approach the work and interface with various sectors of the community.