In its 2001 report Crossing the Quality Chasm, the Institute of Medicine (IOM) recommended that health care must be made safe, efficient, effective, timely, patient centered, and equitable. By many measures, the health care system has made progress on the first five of these six aims, with much work left to do. But the final aim — equity — lags behind the others.
In 2002, the IOM published Unequal Treatment, documenting substantial racial and ethnic disparities in access to services, clinical care, and health outcomes. Such disparities persist today, as multiple studies have shown, and often have stark financial consequences for the affected individuals and the health systems that care for them.
The inequities linger largely because remedies often focus only on reducing disparities in clinical care and not on the social determinants of individual and population health. Many of the pertinent factors — education, poverty, housing, racism, and others — affect people far upstream from their interactions with the health care system, leaving many of us in health care unsure what lies within our sphere of influence or, occasionally, doubtful that our role in improving people’s health is more than a minor one.
At the Institute for Healthcare Improvement (IHI), we believe that health care professionals can — and should — play a major role in seeking to improve health outcomes for disadvantaged populations. To be sure, many health care organizations have taken important steps in that direction, such as increasing access to clinical services, working to improve cancer screening and survival, and closing disparities in the management of myocardial infarction. At IHI, we think it’s essential to take these efforts to the next level — by leveraging the economic, social, and political power of the health care industry and of each organization within it.
An Industry-Wide Imperative
Health care accounts for roughly 18% of the U.S. economy, employs roughly 12% of the workforce, and is expected to grow faster than any other industry in the next decade. By no means is it a niche industry. It touches every patch of the social fabric, making it a duty for health systems to act accordingly.
Since 2015, IHI has studied the workings of 23 health systems (21 spread throughout the U.S. and 2 in Canada) that have taken a comprehensive approach to improving health equity. These systems ranged from academic institutions to community hospitals (both for-profit and not-for-profit); five were safety-net health systems, and two were children’s hospitals. IHI’s research team used a standard interview guide in conversations with, typically, one to three leaders from each institution — and also gathered and analyzed results from local efforts to improve equity.
The health systems we studied recognize that health care is often the dominant employer, the biggest business, and a major economic engine in their communities. They therefore know it’s essential to conduct their operations with a focus on equity. Specifically, they redirect some of their financial investments to community initiatives and needs; offer career-development opportunities to employees, some of whom live at or close to the poverty level; carefully weigh options about where to build facilities, and who constructs and supplies them; support local businesses by hiring staff and leadership from the community; and strive for ethnic, racial, and socioeconomic diversity in all of their decision-making.
In short, these organizations recognize that health equity must be a strategic priority and that their leadership teams must champion it. We explore examples at specific organizations in the next section.
Five Ways to Make Health Equity a Core Strategy
Health systems vary in the communities they serve, the local challenges they face, and the infrastructures they inhabit. But from our examination of health care systems working to improve equity, we identified five concrete actions that any health care organization, regardless of its unique challenges, can take to improve health equity in its community.
- Make health equity a leader-driven priority. This step may sound simple, but senior management must not only articulate the vision, but also act on it by building it into all high-level decision-making. That direction-setting from the top puts the strategy directly into practice and sets the tone for the entire organization. In short, all employees must understand that advancing equity is not a charitable afterthought but critical to the organization’s mission — and workers must see their leaders behaving in ways that reflect that vision. For example, in 2012, Robert Wood Johnson University Hospital in New Jersey launched a 3-year strategic plan to improve equity and increase workforce diversity. Beyond efforts in hiring, the plan focused on community engagement, achieving greater equity in patient care, and corporate alignment; together, these areas constituted 15% of the dashboard of measures for determining executive compensation. Ethnic and racial minorities now constitute 22% of the board of directors and 34% of executive leadership.
- Develop structures and processes that support equity. To advance equity, health systems must dedicate financial and information resources accordingly, as well as set up a governance structure that oversees and manages this work across the organization. At Henry Ford Health System in Detroit, leaders have established a Center for Healthcare Equity under the stewardship of a senior vice president. One effort at the center is ongoing operational and financial investment in the Women Inspired Network, which uses a peer-support system and group prenatal care model to reduce infant mortality rates in the city of Detroit. Early results show that among 200 women enrolled in the program who have given birth so far, there have been no infant deaths (compared with an expected infant death rate in Detroit of 16 per 1,000 [3.2 per 200] live births).
- Take specific actions that address the social determinants of health. An organization must first identify the health disparities that exist in its community, learn about the precise needs and assets of the people who face the disparities, and then come up with concrete actions that aim to close the gaps. With respect to employment (an important social factor in health), in 2014 Wake Forest Baptist Health in North Carolina decided not to outsource its housekeeping services but instead to keep that contract local, thereby bolstering employment in the community. In addition, WFBH’s leadership converted four housekeeping positions into what they called “supporters of health” — employees tasked with following the most complex and vulnerable hospitalized patients back home into the community. Early results show a 16% reduction in costs of care for a preliminary cohort of 132 patients. Leaders are now bolstering the program by training most of their environmental services staff to anticipate, recognize, and address social needs among WFBH patients.
- Confront institutional racism within the organization. Racism, whether implicit or overt, is an independent driver of poor health and continues to corrupt our health systems. The structures, policies, and norms that perpetuate race-based advantage in health care, discriminatory care practices, and implicit bias in patient and staff interactions must be explicitly identified, addressed, and dismantled. In New Orleans, the inadequate response to Hurricane Katrina in 2005 scarred the community, leaving people deeply distrustful of the very institutions that were supposed to serve them. In response, just 6 weeks after the storm, St. Thomas Community Health Center reopened its doors, mandated anti-racism training for its staff, and declared dismantling systemic racism one of its core priorities in improving health in the community. St. Thomas measures its success not only in clinical areas (such as diabetes and hypertension), but also by whether leaders emerge from the community to become future health care providers in that community.
- Partner with community organizations. Health care and community organizations must collaborate if they are serious about addressing health equity in the populations they serve. The Health Improvement Partnership of Santa Cruz County, California — a coalition of 26 health care and community organizations — has worked on multiple joint initiatives since 2004. The result: a 75% reduction in uninsured residents as provisions of the Affordable Care Act took effect. Multi-sector collaboration also led to the securing of long-term funding to grow the safety-net clinic’s capacity by 10%, which has yielded corresponding declines in ER use by low-income infants, families, and Medicaid patients.
Fifteen years ago, the Institute of Medicine made a moral case for promoting health equity. Given that people with the most-complex social and health needs often incur the greatest costs of care, it makes both moral and financial sense for health organizations to develop and implement a comprehensive, strategic approach to addressing health equity in their communities. We hope that our suggestions and examples help organizations start on that path or bolster the steps they are already taking.