Governance
10 Questions Boards Can Answer to Advance Equity
Now is the time to take a step back and look at COVID-19’s impact
By Somava Saha, M.D., Dora Barilla and Karma H. Bass
COVID-19 has served as a wake-up call to the inequities experienced by underserved and historically marginalized populations.
As some of the world’s most accomplished clinical experts continue to develop therapeutics, treatments and vaccines for combatting the pathogen, health care leaders need to plan for the long road to recovery and resilience in their local communities. Now is the time to step back, take a long, hard look at the impact of COVID-19 and ask: How did we get here, and what needs to change?
Shifting Community Stewardship
Resolving inequitable health outcomes requires health care organizations to shift their focus within the community to make sure they are providing care services and contributing to community conditions in a manner that is equitable — not equal — for all populations. COVID-19 has forever changed our communities and should compel governing boards to understand the nuances of inequities in their communities, broaden the reach and resolve of their organizations, and restore trust in their organizations.
This means a governing board should understand the pandemic’s impact on all populations within its community, the efficacy of its organization’s response, and the organization’s capacity for improving that response.
Here we outline 10 questions that can serve as critical conversation starters for trustees in directing organizations toward actions that lead to genuine, systemic and sustainable positive change for populations that have suffered the most from health care inequities.
The Impact of COVID-19
1 In what ways did health inequities show up among the populations within our community, and what drove those inequities?
It is important to know the COVID-19 infection and mortality rates for all populations within your community — stratified by race, age, gender, location and such. This information also should include the type of care these populations received. Who is hospitalized, and who is not? Who received treatment in the intensive care unit? Who was put on a ventilator? It also is important to examine the differences in the outcomes among these groups and their root causes.
2 How has COVID-19 affected different segments of our workforce?
Early on it became clear how the virus was affecting the physical and mental well-being of the health care workforce. For good reason, much attention was placed on the toll the pandemic was taking on front-line workers — mainly physicians and nurses.
But is important to know how the pandemic has affected all employees’ overall well-being. Housekeeping, maintenance and food service staff, for example, also were working extra shifts and may have had increased expenses, such as for child care, because of the additional work. It is important to ask about workers who are struggling, get to know their stories and what support they are receiving, and find out what it will take for them to thrive.
3 What did we learn about the needs of our community and how will we use this information to strategize and shape our efforts to advance health equity?
Beyond effective medical care, the pandemic has revealed other unmet needs — especially with food and housing — of community members disproportionately affected by the pandemic. This kind of information on community needs should be incorporated into reports distributed regularly to the board to better inform decision-making about community benefit and other community investments. The ongoing dashboard of data that boards regularly review should identify community members disproportionately affected and organizational initiatives and investments that positively affected these populations. The data also should inform decision-making that leads to decreased health inequities.
Organizational Capacity to Address Health Inequities
4 To what extent does the composition of our board, administrative leadership and workforce reflect the populations within our community that are experiencing inequities?
To better understand and meet the needs of its community, a health care environment should include people who truly represent that community and bring that lived experience into day-to-day operations and strategic planning in all areas, including governance, leadership and workforce.
It is important to understand, however, that diversity is not solely about having people from diverse racial and ethnic backgrounds join your board. Trustees should be valued not only for their age, gender, color of their skin or any other demographic characteristic, but also for what they can offer to advance equity and well-being in your community. They should view equity as a core value of any work and be able to persuade others that change is needed.
5 Is our governance process truly equitable, and do we have the culture to enable genuine change?
Diversity efforts are not complete when diverse board members are seated. The board itself has to be ready to embrace equity and understand what contributed to inequitable systems and what it takes to achieve equity. Diverse members who understand what causes inequities should have genuine influence within the board to effect change.
Decision-making processes, board leadership appointments and board culture should be transparent, foster inclusion and allow everyone to add their voice. Processes should facilitate honest conversations that leave room for dissent. This type of learning journey requires each trustee, no matter their original viewpoint, to support and advocate for health equity, even if it feels uncomfortable. We cannot facilitate change without being willing to be changed.
6 What board competencies are required to advance equity?
Competency to advance health equity is twofold: understanding your organization’s history of being trusted or mistrusted in the community, and having the skills to confront those community perceptions and address any lasting impact.
To what extent has race, place, income and other historical drivers of health inequity played a role in any mistrust that your community may have for your organization? Does your board understand how the organization may have contributed to this legacy of mistrust? Has your board gone through a process of understanding its own history and relationship with the community?
Understanding the community conditions that affect health is key to addressing health equity. Does your board have public health and social needs expertise complementing traditional board competencies such as finance, legal and real estate? Have you examined data to address inequities in your organizational policies?
7 Do the reports that our board regularly reviews include data that has been stratified to reveal the inequities that exist in our community?
Community needs data that is stratified by age, race, place (census tract or zip code), gender, income level and other factors will help to delineate the inequities various populations are experiencing. Boards should have a process to evaluate this data, set strategic goals based on the data, and regularly review the data at meetings as part of the board’s core quality improvement process, because equity is a key component of quality.
The Response
8 How can our organization’s time, resources and talent be used to advance equity?
Organizations that are forward-thinking in advancing equity use their resources to reverse the impact of historic discriminatory practices in their communities. Practices such as exclusionary zoning, or “redlining,” placed on certain populations by government and private entities resulted in disinvestment in these communities and ultimately led to some inequities, such as in income and education, which we see today. Advancing equity requires a commitment to understanding such past discriminatory practices and fostering practices that will reverse their impact.
For health care organizations, this means investing in their communities beyond care delivery, and into workforce, hiring and purchasing pipelines that bring dollars back into the community. These kinds of investment, known as anchor strategies, bring direct benefits to historically underserved populations. How are operating dollars at your organization being used to invest strategically to advance equity, including providing living wage jobs, sourcing vendors who are local to the community, locating a facility where it can best serve those in need and hiring low-income, minority workers from the community?
9 Which community organizations have been most effective in responding to the community needs heightened by the pandemic, and how is our organization partnering with them?
In many ways, COVID-19 has served as a stress test, exposing the weak and strong points in our social systems. Which organizations within your community stepped up to fill in the gaps to meet immediate needs? Who had and built trust with local communities? It is important to partner with community organizations that provide services that help fill immediate needs. Likewise, it is important to form partnerships with organizations that provide similar or related services or input that will have a longer-term, sustainable impact on conditions within a community that resulted in such need. A food pantry will supply groceries to fulfill immediate needs, but a retailer might offer a program to hire community members, or a local bank might facilitate a small business loan for a woman-owned or minority-owned local business.
Investing in equity means investing in programs that address short-term needs and that contribute to the long-term health of your community. Who are these partners? What do they need from your organization to be successful in providing short-term services and long-term investments that support underserved populations and enable the community to thrive?
10 How is our organization using the lessons from COVID-19 to strengthen its long-term resilience against the next crises?
After a crisis, resilient organizations take the time to retool, institute changes that mitigate weaknesses and better prepare for the next crisis. How has your organization used what it has learned from the pandemic to develop a strategy that builds capacity, not just for mitigation and preparedness, but for long-term resilience that includes built-in protection for underserved populations? Have you mapped out and modeled the strategic investments that could most improve health equity in the short, medium and long term as you would any other business plan?
As your board reflects on the impact of COVID-19 and your organization’s response, consider how the choices your organization makes today might build the vital conditions all communities need to be resilient in facing the next shock that comes. These vital conditions include belonging and civic muscle, access to humane housing, reliable transportation, basic needs for health and safety, and access to lifelong learning and a thriving natural environment.
Advancing Health Equity
The COVID-19 pandemic has illuminated and exacerbated health inequities. If those inequities were once partially shielded by ignorance, misguided decisions and overt racism, the pandemic has pulled pack the curtain entirely to reveal a system that leaves far too many people vulnerable to poor health and life outcomes.
By asking the right questions, health care boards can help their organizations enact changes that foster healing, restore trust, advance equitable care and pave the way to better health and well-being for all individuals in their communities.
Somava Saha, M.D., (somava.saha@weintheworld.org) is founder and executive lead at Well-being and Equity (WE) in the World and based in Pelham, New Hampshire. Dora Barilla (dorabarilla@hc2strategies.com) is president and co-founder of HC2 Strategies, Rancho Cucamonga, California. Karma H. Bass (kbass@viahcc.com) is founder and senior principal at Via Healthcare Consulting, Carlsbad, California.
Please note that the views of authors do not always reflect the views of AHA.