Health Equity Crosses All Board Responsibilities
Proactive Steps to Take to Ensure Health Equity Remains a Key Focus
By Linda Summers
COVID-19 exposed truths that were buried below the many competing challenges of the health care industry. One significant and tragic truth is that health equity does not exist for all individuals in all communities. While most health care and public health leaders would most likely acknowledge awareness of a health equity gap, COVID-19 demonstrated how truly deep and wide that gap is. Eliminating health disparities and ensuring health equity should be the responsibility of all health care leadership, beginning with the board. How the board carries that important work through all of its responsibilities will be a crucial component of health care’s success, or lack thereof, in improving health equity.
What is Health Equity?
Health equity is care that meets the needs of patients regardless of geographic location, socioeconomic status, gender, ethnicity and other patient characteristics. Unlike health equality, which calls for equal treatment for all patients, health equity prioritizes care based on need. When health equity is missing, health disparities result. Disparities are preventable health differences experienced by people from historically marginalized communities.
While race and ethnicity are often associated with health disparities, their impact is much broader. Disparities affect a significant portion of our nation’s population and may result from inadequate access to care (particularly true in rural areas), environmental inequality such as unsafe housing or pollution, health care literacy, food insecurity, access to broadband and certainly poverty.
Ensuring Equitable Care
If equity crosses all board responsibilities, it is important to briefly review what these responsibilities are. The board’s responsibility, at its core, is to support the health and well-being of its community through the provision of quality health care.
Specifically, duties include the following: serve the mission and set strategic direction; confirm the provision of safe and quality patient care; adopt and monitor sound financial planning and performance; select and evaluate the CEO; connect with the community; adopt policies and ensure organizational integrity; and evaluate its performance.
How the board performs these responsibilities is changing—and it needs to. To ensure equitable care, the board must shift its focus away from a broad “aggregated” view of its duties, to one stratified to ensure that no one is left behind. It is no longer enough to do what we have always done and at the same time change the health equity dynamic. Boards need to focus on intentional strategies to improve health equity.
Developing an Equity Mindset
To truly achieve health equity, board members must start with an awareness and understanding of where health disparities exist. Perhaps more importantly, we as leaders must consider our own personal beliefs and perceptions regarding what health equity really means. This requires us to challenge the way we think about and consider what is truly equitable, and not simply equal. It is through the process of personal and organizational introspection and challenge that a health equity mindset can be created.
One challenge in creating an equitable mindset is to move away from thinking about health equity as a separate initiative, owned by a committee or a specific role. Real change will occur when a constant eye for equity becomes a core element of the hospital or health system’s mission. No health care mission or vision statement would ever suggest that it seeks to provide quality care only to people with means, or that its mission is to give differing levels of care based on race or ethnicity. Unfortunately, in some cases, this is in fact what health care is doing—to the detriment of far too many.
Questions to Answer
The following are important questions every board should ask and answer.
Who are we and whom do we serve?
While this may seem like a theoretical exercise, it is not. It warrants discussion and even some focused generative discussion at the board level. How do we define health and wellness? How do we define community? How are we caring for our communities? Where, how and for whom do disparities exist? There are no easy or clear-cut answers to these questions. It is up to the local community board and community together to explore and decide.
Fortunately, we have guidance. As society’s understanding of community health and health equity evolves, information and data available to address this issue are ever-growing. Every major stakeholder and agency has published some form of health equity model or framework that can assist the board in answering those questions in a structured and productive way. One resource to consider is the Centers for Medicare & Medicaid Services (CMS)’ health equity-focused measures in its Hospital Inpatient Quality Report Program.
The first measure assesses a hospital’s commitment to establishing a culture of equity and delivering more equitable health care by capturing concrete activities across five key domains, including strategic planning, data collection, data analysis, quality improvement and leadership engagement. The second and third measures capture screening and identification of patient-level, health-related social needs — such as food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety. In the near future, CMS is also interested in using measures focused on connecting patients with identified social needs to community resources or services.
Does your current strategic plan include a goal of improving health equity? If not, it should. In fact, CMS guidelines expect it and will require it.
Do we provide equitable care?
One core responsibility of the board is to ensure safe, effective, quality care.
- Does your board ensure that all people have equitable access to that care?
- Does the board look at care stratified by race, ethnicity and the social factors that influence health?
- Do service line decisions regarding where and how care will be provided routinely examine the impact on disadvantaged individuals?
Effective boards know the boundaries between management and governance. This means boards should seek aggregated information that efficiently summarizes data. However, the board also owns the responsibility of questioning management as to whether the data it reviews is stratified to reflect the needs of everyone in the community, across all socio-economic factors and determinants of health. While aggregated data might report improvement in a particular area of health, that data may not effectively identify those who might be showing a decline in that particular area.
Are we a diverse board?
The AHA’s 2022 National Health Care Governance Survey Report reveals we are progressing much too slowly in the area of diversity on hospital boards. At the current rate of the shift toward a more diverse membership, meaningful diversity will take decades. This is unacceptable. Work in this area must begin now and the boardroom is the place to begin. It cannot be delegated or tasked to the governance committee or talked about in the abstract when a board position needs to be filled.
Like all real change initiatives, work to diversify the board needs to be intentional and focused. There is much that can and should be done to create a board structure and culture that creates a seat at the table for those individuals who truly represent those you serve
How equitable is our own organization?
Hospital boards are often surprised to learn that there are internal inequities that are not being addressed. When you look across your organization’s policies and practices, do you find a structure focused on ensuring equitable treatment for all? Does your management team provide internal equity data to ensure review of current practices?
Based on data, trustees can find answers to the following questions: Is your emergency department’s use of restraints or prescriptions of narcotics influenced by race or socioeconomic status? Does your human resources department actively seek diversity across all roles and departments? Does your purchasing department seek minority-owned supply chain solutions? It is possible that the place to begin is within your own four walls.
Board members should serve as the organization’s voice for equity. Management does not actively seek to exclude or discriminate; quite the contrary. However, management roles are challenging and increasingly complex. Executive leaders need the board to hold them accountable in a rigorous process that ensures front of mind health equity not only in all policy development, but in changing the core cultures of their organizations.
Time to Act Is Now
In our work with boards and CEOs across the United States, my colleagues and I find the very individuals with the knowledge, expertise and experience needed to drive the organizational shift required. The challenge is to move away from viewing health equity as a separate initiative, but rather to view it as a core element of the hospital or health system’s mission.
Health care leaders need to develop and adopt the mindset that health equity is integral and, in fact, drives all clinical, operational and financial decision-making. For some organizations, incorporating health equity may represent a new focus or undertaking. For those further along in their quest for health equity, the pandemic may have created an even more urgent case for change.
Wherever an organization finds itself, the need to act without delay could not be greater.