Why It Matters
"Talking about equity has little meaning if — when faced with real-time examples of inequities — we avoid digging deeper."
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Addressing Equity Starts by Looking Inward

By Elias Miranda | Wednesday, March 3, 2021
Addressing Equity Starts by Looking Inward Photo by Andrew Ling | Unsplash | Minneapolis skyline at sunset

There is a lot of discussion in health care these days about the need to make care and our workplaces more equitable, but are we always as open to addressing these issues as we should be?

The following experience, shared by Taj Mustapha, MD, Assistant Professor of Internal Medicine and Pediatrics at the University of Minnesota, may seem familiar to many:

A Black trainee in a graduate medical education program tried to advocate for a Black patient. She believed that bias may have been playing a role in how her patient’s case was being handled. Though the pushback was subtle, she got the distinct impression from unit staff that they didn’t welcome her raising the possibility that racial stereotyping was influencing decision-making.

The experience left her deflated. She had thought that everyone would want to do everything they could to provide excellent care. Though she was a senior resident, and close to the top of the care delivery team hierarchy, she felt marginalized.

Talking about equity has little meaning if — when faced with real-time examples of inequities — we avoid digging deeper. This has become especially important for health care improvers as the COVID-19 pandemic continues to disproportionately affect people of color and low-income communities.

Some organizations are determined to go beyond good intentions. For example, in the aftermath of the killing of George Floyd in Minneapolis, Fairview Chief Executive Officer James Hereford and Jakub Tolar, MD, PhD, Dean of the University of Minnesota, created the HOPE (Healing, Opportunity, People and Equity) Commission. Its purpose is to recommend ways to transform M Health Fairview into an anti-racist and inclusive academic health system while also attaining more equitable outcomes and creating inclusive environments and experiences for their patients, employees, and communities. (Note: M Health Fairview represents the collaboration between the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services, a member of the IHI Leadership Alliance.) In their words, the HOPE Commission is, “an acknowledgement that M Health Fairview must improve itself to produce more equitable health care outcomes for all of our patients.”

During a recent Leadership Alliance Roundtable call one of the leaders on the HOPE Commission described the role of health systems in healing communities. Taj Mustapha, MD, who shared the story above, talked about the necessity of looking inward to learn how the health system can address their contributions to inequities.

To improve outcomes for their patients, M Health Fairview decided they first needed to provide equitable outcomes for their staff. Health systems are often among the largest employers in their communities. Addressing the health care needs of everyone within their walls — including their staff members — means they can have a direct impact on the social determinants of health in their communities.

During their review, M Health Fairview found that most of their staff had health insurance thanks to their employee benefits and the robust safety net programs that exist in Minnesota. However, issues like lack of home internet service or difficulty navigating and advocating for oneself through the health system were barriers to care. In response, M Health Fairview is taking a holistic approach by looking at the roles they play as a corporate citizen, employer, health care provider, and academic institution.

There is also some evidence that the HOPE Commission is helping to raise staff morale. For example, the senior resident who tried to advocate for her patient told her story to the Commission. “She illustrated the concrete but also subtle differences in care given to her patient and described the marginalization of staff that try to speak up against bias," Mustapha said. “Sharing her experiences with leaders in the health system has renewed her vigor to engage in work to reduce health disparities.”

Where to Begin

If you are wondering where to begin in the work of equity both in your health system and community, Mustapha has offered three key pieces of advice:

  • Align equity efforts throughout your organization — Recognize that all elements of how your work is organized should be arranged to support transformation into an anti-racist, multicultural, and inclusive institution. Though this takes coordination up front, the investment in time and effort is crucial if you hope to succeed.
  • Embrace a Truth, Racial Healing & Transformation (TRHT) process. According to the W.K. Kellogg Foundation, TRHT is “comprehensive, national, and community-based process to plan for and bring about transformational and sustainable change, and to address the historic and contemporary effects of racism.” This is not a linear process. Mustapha compared it to building an airplane as it is being designed and flown. TRHT is a complex and intertwined process and engagement needs to be strong in all three pieces of the work.
  • Set both near-term and long-term goals. There is sometimes a tendency in equity work to shy away from dreaming big, but Mustapha believes it’s necessary to lay out a vision of achieving justice — not just equity — in health and health care to motivate everyone involved to achieve better outcomes. Concurrently, it is important to devise incremental steps that can be taken on the road from the current reality to a vision of justice for the future.

Strength in Numbers

M Health Fairview’s HOPE Commission is one example of the work being done by participants in the IHI Leadership Alliance to combat health inequities and provide more equitable outcomes for patients and communities. The Alliance is a dynamic collaboration of executive leaders from over 50 health systems who share a goal to work with one another to deliver on the full promise of the IHI Triple Aim. Members taking part in the Alliance’s Equity Workgroup have committed to working alongside each other to address two specific aims: 1) Dismantling institutional racism within their organizations and 2) addressing inequities in care outcomes among the communities they serve.

Health systems can take this time of unprecedented change to examine how they can actively address unequal systems, and amplify the voices of marginalized people. There is no quick fix to a problem of this size and scale, as M Health Fairview has acknowledged by making the HOPE Commission a multi-year effort. But wherever you and your organization are in your journey, know that there are others who understand that equity is essential to quality, and are committed to learning and sharing with others along the way.

Elias Miranda is an IHI Associate Project Manager.

You may also be interested in:

Achieving Health Equity: A Guide for Health Care Organizations

Improving Health Equity: Guidance for Health Care Organizations

Why Anti-Racism Work Is (and Isn’t) Like Addressing Patient Safety

A living wage for healthcare workers is essential to achieve health equity

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