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Health Equity

Boards Must Address Equity Competencies

Health leaders’ attention, connection and empathy will help guide difficult conversations

By Maria Hernandez, Dora Barilla and Karma H. Bass

According to the Institute for Healthcare Improvement, in 2019 only 25% of hospital leaders ranked health equity as one of their top three priorities. By 2021, that number soared to 58%. Undoubtedly, the harsh realities of the global pandemic made it impossible to ignore that our health care system only works for some people, some of the time.

Although health care systems pride themselves in providing the best quality of care to all, the pandemic’s disproportionate impact on Latinos, African Americans and people of color made it clear this ideal must be more than a mission statement. Even though health inequities have been documented for over 120 years, the tragic events surrounding the pandemic and the murder of George Floyd have forced a new round of conversations in the board room and the C-suite: How do we respond to the social, political and economic inequities that impact health outcomes? What can a health system do to reach historically marginalized members of the community? How can we make health care work for all?

Developing the Mindset

Leaders at every level must bring to the workplace a mindset that can navigate conflict and intervene appropriately. At the core of every inclusive leader’s challenge is how to build the foundation for a workplace that remains psychologically safe for all staff. It’s that sense of belonging that leads to engagement, innovation, and productivity — the source of organizational excellence.

In one of our consulting practices, we have introduced leaders to the ACE Mindset: attention, connection and empathy — a path for engaging in difficult conversations that are required to intervene and interrupt biased behaviors and reduce its negative impact. It reflects three important skills we consider foundational: First, leaders need to pay attention to the broad context of what a person may be experiencing to understand how they are perceiving what is being said or done. Next, they need to foster an authentic connection with the individual to hear their story, their perspective or concern. Third, leaders must have empathy for the individual — see the situation from their perspective and acknowledge their emotions.

Ground Rules for Inclusive Meetings

One way that boards can create psychological safety to effect more meaningful discussion is through a set of ground rules that guide how meetings are conducted and individuals interact. This might include behavioral norms, such as agreeing to be on time and coming prepared to meetings, speaking respectfully, listening with an open mind and adhering to the written agenda’s timeframes.

Some boards even ask their members to sign a code of conduct every year, similar to the requirement that board members complete annual conflict-of-interest disclosure forms.

No single set of agreements will work for every board. The power of ground rules is derived, in part, by the fact that those agreeing to them participate in their development. The specific rules will depend on the group’s own culture, dynamics and priorities. The goal is to foster ownership among board members for the caliber of their deliberations and group dynamics. Ground rules are ineffective unless board members are willing to follow and hold each other accountable to them.

We offer these rules as a sample. Boards will want to develop their own.

  • Be willing to “lower the water line” and discuss how group dynamics are impacting the discussion at hand.
  • Be honest and kind.
  • Take space, make space: invite the quiet members in the room to provide commentary.
  • Declare and take the role of “Patient’s Advocate” by representing what a patient might feel or think about a change, policy, or the issue on the table.
  • Avoid side conversations.
  • Be fully engaged and agree to turn off laptops and cell phones.
  • Ensure all agreed-upon actions are assigned.
  • Agree to use a “parking lot” for issues the board will come back to later so the discussion can stay focused.
  • Keep the back-and-forth conversations in the boardroom confidential and agree to talking points of what can be shared at the meeting’s conclusion.

Imagine a leader has witnessed when the only person of color, the only woman or the only non-clinician in a meeting gets repeatedly interrupted by one participant. As the meeting proceeds, despite efforts to make room to hear all participants, this one person has shut down.

It’s a scene that plays out constantly in the workplace. A leader can “ACE the conversation” with both the person who stopped participating and the domineering person. It may seem odd to suggest that we demonstrate empathy with the one person interrupting others in a meeting, but showing empathy doesn’t mean we agree with the person’s motivation or emotions --- it is the ability to see a situation as the other person sees it. It builds the trust needed to then help the individual see why that behavior needs to change.

This mindset for approaching difficult conversations is just one of the many skills — learned behaviors — that define inclusive leadership. It’s key to remind ourselves that these skills are part of a lifelong journey to effective leadership.

Developing Leadership and the Workforce

With the field of health equity and social determinants evolving, the healthcare ecosystem has had challenges in finding qualified competent individuals to place in these positions within health systems. Public health is a great entrée for preparation but such experience often falls short in understanding the niche of a health system in addressing health equity and improving community health.

The ability to recognize bias in all its forms and to bring equity into the design of services throughout the care continuum will require a willingness to challenge the status quo, which translates into effective change management strategies. Through it all, leaders will need to get comfortable with being uncomfortable. The age of health equity is disrupting health care for all the right reasons.

Another competency leaders need to cultivate as part of an organization’s culture is to use equity as a required standard for all policies, practices and programs. We often hear the most well-intentioned leaders say they will look at a program or initiative “through the lens of equity” to ensure it is free of bias or works for all. This sounds temporary and optional.

Most health systems have extremely high expectations about patient safety and ensuring it is a part of all program or policy decisions. Equity must hold the same status. The transformation of our health systems to serve all will require equity as an embedded strategy or framework that is consistently expected. Some institutions are beginning to use equity impact assessments — a structured process for identifying whether a policy, program or practice has negative impacts on one group of people. This assessment involves asking key stakeholders about the impact of a policy or program to bring their lived experience into the design of programs. The process involves assessing available data and then identifying root causes of inequities and sets forth a strategy for addressing and removing bias.

Many health systems and other organizations around the country with innovative health equity initiatives are finding it hard to fill positions with a qualified workforce. Workforce pipelines for improving community health and health equity are desperately needed to address the gaps in competencies and achieve the results needed within our health systems and their collaborative partners.

An example of an innovative strategy to address this need can be found at The University of Providence in Great Falls Mont., which is affiliated with Providence, one of the largest health systems nationally. The school recently developed a specialized Community Health Investment Certificate* to prepare the workforce in addressing health equity, improve health related social needs and to develop a broad understanding of community health opportunities for health care providers and community-based partners.

The industry has a long way to go in preparing the workforce to be skilled in health equity. Creating partnerships with higher education will be a critical component in developing our future leaders.

Developing Governance. Achieving health equity cannot be seen as a separate initiative or program in health care. Equity should be part of everything we do — the way we approach our work, the questions we ask, how we form decisions and how we define our strategy. Effective governance that advances health equity requires three key competencies among trustees: self-awareness, cultural humility and transparency. When these are exercised, the board engenders trust and sets a foundation for innovation that creates opportunities for authentic collaboration among trustees, executives and among key community stakeholders.

Self-Awareness. Effective leaders know their strengths and limitations. They understand their role and their impact on others. The ability to recognize how their actions can set the tone for a meeting or a conversation is essential to support the productive relationships among the trustees. With self-awareness comes the ability to accept you don’t know what you don’t know. There is a strong willingness to learn and explore the issue from every angle; to hear every perspective. Some of the approaches to inspire greater self-awareness include conducting board self-evaluations or finding a coach that can support professional growth. Collective self-awareness should involve an annual self-assessment that includes asking board members how well they feel the group is doing at being diverse, equitable and inclusive. Conducting a confidential written survey and paying attention to the distribution of responses (not just averages) is an effective way to unearth real and constructive feedback or areas for improvement for individual trustees and collectively for a board.

Cultural Humility. An overwhelming percent of hospital boards are not diverse. This means that white men and women need to recognize that the perspectives and experiences of historically marginalized communities are not in the room. When they hold discussions about how to better serve Latino, Black, Asian or LGBTQ communities, they must be willing to accept that those lived experiences need to be understood. This understanding can be accomplished by inviting patient advisory groups, community advisory committees or guest speakers who can raise the board’s level of awareness about the issues these communities face.

Many white people think it is noble to say, “I don’t see color or race. I treat everyone the same.” Some will say to a diverse person, “I don’t think of you as Black or Latina. I see you as my colleague.” These remarks ignore the fundamental truth that unconscious bias is human nature. They suggest that in working with others it is okay to ignore key elements of a person’s identity. There is enormous privilege that comes with being part of the mainstream culture and recognizing that another’s experiences may differ from your own and that both are valid, both need to be respected. This is core to valuing the cultural plurality that is foundational to American ideals.

Transparency. Boardroom magic happens when trustees come together to deliberate, discern and decide together on a direction for the organization. This willingness to listen carefully and be influenced by management, clinicians, patient advocates and each other before deciding on the really big issues is a hallmark of truly effective governance. These key discussions require the ability to “say what you mean and mean what you say” so that trustees can stand behind decisions being made.

Robust debate, even conflict at times, is essential when navigating the high-stakes, complex issues facing today’s health care organization. Learning to disagree without being disagreeable is an advanced-practice governance competency.

The result of developing these competencies is a significant path towards effective governance that can set a foundation for the board to advance health equity.

The Inclusion Journey

If some remain skeptical of why they should work to advance equity, as is still heard articulated in some boardrooms, it is important to explain that equity improves decisions, fosters more nimble and effective leadership and creates resilient organizations capable of navigating the unforeseen challenges of the future.

As we in health care continue to build our health equity competencies, we should perhaps most importantly demonstrate the competency that represents a core value: the ability to call people in, rather than call people out. All stakeholders must be invited to the table to graciously have the hard conversations in a way that is not threatening or evokes the defensive mechanism.

The work of health equity will always be an inclusive journey on which everyone is welcome to learn.

Editor's Note: In her previous role as Vice President of Community Health Investment for Providence, co-author Dora Barilla helped develop the Community Health Investment Certificate.

Maria Hernandez, Ph.D, (maria@impact4health.com) is president and COO, Impact4Health, in Oakland, Calif. Dora Barilla (dorabarilla@hc2strategies.com) is president and co-founder, HC2 Strategies, Rancho Cucamonga, Calif. Karma H. Bass (maria@impact4health.com) is managing principal, Via Healthcare Consulting, in Carlsbad, Calif.

Please note that the views of authors do not always reflect the views of AHA.

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