Every clinician strives to comprehensively address patient’s individual biopsychosocial needs. In a perfect world, delivering on this commitment would result in equitable care that meets all patients’ needs. And yet, ample evidence indicates that disparities in care delivery and outcomes persist at the point of care.
This unwarranted variation in care is often the result of pervasive systemic and societal challenges that go far beyond any particular caregiver, setting, or health system. In light of the stark patient population disparities revealed by Covid-19 and the national dialogue around historical and modern-day inequities, every health care organization has a renewed mandate to address disparities.
Many organizations are invested in advancing health equity, diversity, and inclusion within their organizations and communities. Their efforts to date have typically focused on increasing workforce diversity and staff training.
The theory behind increasing workforce diversity is: a workforce that more closely matches the demographics of a local population may be able to provide more culturally sensitive care. Staff with more diverse backgrounds may better understand patients’ realities and identify organizational blind spots.
The goal of training is to help staff recognize their own innate biases, thus enabling them to provide culturally sensitive care to all patients, especially those whose background and culture are different. Typical training topics include diversity and inclusion, implicit bias, and patient care guidance for specific non-dominant populations.
The clinical executive’s role in reducing disparities at the point of care must go beyond increasing workforce diversity and staff training. These initiatives are important but not sufficient to close the massive disparities that persist in our industry.
Increasing workforce diversity to match local community demographics will take years, if not decades. It is a worthy ambition that will yield dividends: more diverse and inclusive teams have a 17% increase in team performance, 20% increase in decision-making quality, and a 29% increase in team collaboration. But organizations can’t afford to wait to achieve “ideal” workforce demographics before turning to additional strategies to reduce disparities at the point of care. And even if an organization achieves a diverse workforce that perfectly mirrors the local patient population, this diversity alone won’t solve health disparities. Systemic issues within organizations and pervasive inequities beyond the point of care will persist.
Thoughtful training can help staff become more aware of disparities and their own innate biases. But even the most rigorous, widespread training will not eradicate systemic issues contributing to disparities. Organizations must go beyond workforce initiatives to make progress in reducing disparities.
Since this work will require additional investment, all clinical executives must be able to make a strong business case for reducing disparities, in addition to the moral and mission-based arguments for equitable care.
Consider one example of a disparity at the point of care: inconsistent and inadequate language services (such as interpretation and translation) for limited English proficiency (LEP) patients. Language barriers often prevent meaningful communication between clinicians and patients, which compromises care quality. When compared to English-speaking patients, LEP patients have a higher risk of adverse medical events, longer hospital stays, and higher readmission rates.
One study found that LEP patients who did not receive professional interpretation services at admission or discharge had an increase in their length of stay of up to 1.47 days. By providing comprehensive interpretation and translation services to LEP patients, organizations can begin to reduce the disparity and provide a more equitable experience.
There are additional financial benefits for the organization. To demonstrate the effect of reducing this particular disparity, the table below shows the number of “new” beds in virtual capacity that can be added by eliminating the excess length of stay for LEP patients.
Based on the model, reducing the average length of stay for LEP patients by 1.47 days generates over $923,000 annually for a 100-bed hospital. And that number grows with bed size: $4.8 million for a 500-bed hospital, and almost $2 billion across the country.
This analysis is one of many examples of how eliminating disparities can simultaneously improve both care quality and efficiency.
Data-driven examples such as the analysis shared above can rally stakeholders around the need to address health disparities. We recommend that all organizations looking to reduce disparities build their strategy around the following dimensions.
We recommend executive teams use our maturity model for reducing health disparities to assess their current level of maturity for each of these dimensions.
Clinical executives should take an active role in helping to set strategy and drive implementation across several, if not all, of these dimensions. However, reducing health disparities is a massive, long-term, multidisciplinary challenge, so it’s important to identify exactly where clinical executives should prioritize their personal efforts. This publication details where clinical executives should focus.
Clinical executives must focus disproportionally on four strategies. These are areas where they can have an outsized impact on organizational strategy, either through direct leadership or advocacy.
Reducing health disparities is every clinician’s and every health system executive’s responsibility. However, the scale and scope of this challenge demand clear and specific accountability. Every clinical executive needs to be able to answer the question: Who owns health equity issues at the organization?
An organization that designates a specific leader to set and drive its health equity strategy is better positioned to make meaningful progress in reducing disparities. A single leader with the seniority to convene their executive counterparts can align the organization’s strategy around addressing specific disparities and ensure each department’s strategic plan supports equity goals. Progressive organizations generally have a chief health equity officer who reports to the chief executive and/or board with adequate funding to staff projects and implement interventions. At a minimum, we recommend designating a single leader, ranging from Director to Executive level, whose purview and responsibilities are solely over issues related to health equity. This ensures the minimally viable seniority and funding to begin to make meaningful progress.
In the absence of a dedicated leader, we recommend that the chief nursing and medical officers form a dyad leadership model to set strategy and coordinate implementation. Such a partnership will help ensure that health equity rises to the level of a true organizational priority, on par with clinical quality and safety.
One challenge for organizations with a designated leader over health equity is making sure all clinical executives also engage in the work to achieve equity. When there is a single leader who “owns” most of the work involved in reducing disparities, other leaders may actively or passively disengage from wrestling with thorny health equity issues.
Even if every leader at the organization agrees that they all have a responsibility to reduce disparities, it is easy to see addressing health equity issues as “someone else’s job.” Leaders must address this pitfall proactively.
Clinical executives must articulate how their department’s priorities advance the organization’s broader efforts to reduce disparities. A close, collaborative partnership between clinical and formally designated health equity leaders is essential. Executives should have regular one-on-one meetings with their counterpart over health equity to ensure that they align their strategic priorities and they are taking advantage of synergies whenever possible.
Identifying disparities at the point of care requires thorough data analysis. But figuring out what to do about identified disparities requires a more qualitative approach. Clinical executives typically oversee a wide variety of mechanisms for collecting input from patients, community members, and staff. These channels can help source ideas for reducing disparities and are also an important way to further embed ownership of health equity throughout the organization. Most organizations can get the feedback they need by making moderate adjustments to existing channels for listening to patients and staff. Some organizations will decide to invest in new infrastructure to gather feedback specifically on targeted interventions to reduce disparities.
Patient and family advisory councils
The time-tested patient and family advisory council is an effective way to solicit the qualitative input you need to design culturally sensitive and effective interventions to reduce disparities.
Some provider organizations invite community leaders to serve on the institution's board of directors. Other organizations invite local leaders to serve on special "community boards," which report to the chief executive or board of directors. These community boards have budgetary power. These positions should be filled by diverse leaders who have the trust of local communities.
Make sure these listening channels reflect the diversity in the organization’s community. Clinical executives should push their organizations to seek out the hardest feedback to source, recognizing that this is the feedback they likely most urgently need to hear. For example, clinical executives should make a point to engage with LEP patients and community members through an interpreter.
Meeting logistics should facilitate rather than hinder the participation of underrepresented voices. Unless specifically addressed, meeting logistics can easily pose a real barrier to their involvement. Key details to consider include:
We recommend establishing, at the facility level, multidisciplinary governance councils to advance health equity. Best practice shared governance councils have executive-level sponsorship and representation from a wide variety of staff, both clinical and non-clinical.
Some organizations already have a role-specific shared governance infrastructure—such as nursing or physician shared governance councils. If that’s the case at your organization, consider creating role-specific health equity councils that report up to a multidisciplinary, organization-wide equity council.
Employee resource groups (ERGs)
Some organizations have employee resource groups (ERGs) for underrepresented identity groups and their allies—such as people of color, Black, or LGBTQ employees. If these groups exist at your organization, invite them to participate in equity councils and create opportunities for them to provide ongoing feedback to help shape council strategy.
An organization’s infrastructure for listening to patients, community, and staff will only be as effective as the power and voice they have in decision-making for the health system. To maximize the positive impact of these listening channels, ensure they receive executive-level sponsorship and the resources to effect meaningful change.
Screening patients for social determinants of health is an essential part of reducing disparities at the point of care and ensuring that every patient receives culturally sensitive care.
The World Health Organization defines social determinants of health (SDOH) as “the conditions in which people are born, grow, live, work and age.” These non-medical factors have direct impacts on health. For example, researchers estimate that 60% of a patient’s overall health is determined by SDOH and individual behavior, while only 30% is determined by genetics, and 10% is determined by the care they receive. Left unaddressed, these SDOH can drive avoidable utilization and unnecessary spending. Patients with unmet social needs have 10% higher annual health care expenditures, approximately $2,400 per year.
To improve health outcomes and reduce disparities at the point of care, overall health care must encompass the social factors that influence health. Yet there remains a high degree of variability in how organizations are screening for and addressing SDOH. This variability is due to three underlying barriers that prevent organizations from screening for SDOH at the point of care: funding, screening logistics, and clinician discomfort.
Barrier 1: Funding
72% of hospitals do not have dedicated funds to address patient social needs
There are two main funding challenges. The first is reimbursement. The fee-for-service payment for SDOH screening is minimal. Additionally, there is not a universally accepted SDOH screening tool that organizations can use to meet the billing requirements. Second is justifying the investment in screening. Many organizations hesitate to adopt SDOH screening practices out of concern that it is difficult to address the social issues identified. It’s easier to screen patients for SDOH if an organization has organization- or community-led resources to direct patients to. But to justify the investments or partnerships those resources require, organizations need data to make the financial case. The clinical executive’s role here is to help the organization identify which data points will make the most compelling case.
Barrier 2: Screening logistics
70% of hospital electronic medical records do not screen for patient’s social and behavioral needs
Once an organization commits to SDOH screening, the next barrier is overwhelming screening logistics. A common initial instinct is to collect as much information as possible—leading to very long questionnaires that take too much time to complete. Focus the screening process on the social factors that:
Sample SDOH screening tools
Barrier 3: Clinician discomfort
80% of providers feel uncomfortable addressing their patient’s unmet social needs
The third barrier clinical executives must directly address is clinician discomfort with talking about SDOH. Many frontline clinicians feel ill-equipped to address patients’ social needs. This discomfort can stem from:
The clinical executive’s role here is to directly acknowledge this potential discomfort, while reinforcing how critical social determinants are to overall health. With proper training in communication on what can be sensitive topics and the rationale behind the data collection, staff can feel well equipped to screen for and discuss SDOH with patients.
Most organizations currently lack a data-driven approach for identifying disparities at the point of care. Clinical executives should help their organizations establish an infrastructure to identify and address disparities.
Start with collecting complete and accurate patient demographic data. Use this data to stratify clinical outcomes and process-of-care metrics to identify opportunities to reduce disparities at the point of care. (This organization-specific data can also powerfully reinforce the case for focusing on disparities.)
We recommend all organizations aim to collect REGAL data:
Use a self-reporting methodology whenever possible so patients feel comfortable providing the information and are reporting the most accurate data, free of outside influence or assumption. Leverage the patient portal to push such questionnaires to patients ahead of planned care or at the beginning of an interaction with the health system. If self-reporting is infeasible, we recommend assigning data collection responsibilities to registration staff or a similar role present across care settings. Choosing a role standardized across settings allows for streamlined training and rollout of the demographic data collection protocol across a system.
Once the data is routinely collected, you can begin to proactively identify disparities occurring at the point of care. We recommend stratifying outcomes and process-of-care metrics at least twice a year, focusing on the organization’s top clinical morbidities and nursing-sensitive indicators. Disparities in nursing-sensitive indicators are some of the clearest examples of disparities at the point of care. Disparities in these indicators show that unwarranted care variation is occurring and resulting in inequitable patient outcomes, including adverse events and hospital-acquired conditions.
Examples of data to stratify in this way include:
For more on institution- and community-oriented metrics, access: Health disparity metric picklists.
Beware of “analysis paralysis” at this stage. You may uncover many more disparities than you can possibly begin to tackle. Identify one or two significant disparities to focus on in the short term.
Ask the following questions for each disparity to determine which to prioritize across the clinical enterprise.
Identifying one or two disparities to focus on system-wide should not preclude local service line leaders from establishing additional, area-specific goals. However, we urge all leaders to prioritize making meaningful progress on reducing one to three disparities rather than spreading their efforts thinly across so many disparities that little progress is made.
Reducing disparities at the point of care is a critical first step toward providing better care for everyone. But an organization won’t make real change in the community unless its leaders commit to addressing the structural root causes of SDOH: poverty and inequity. Addressing these root causes is an essential commitment for any organization that embraces its role as an anchor organization in their community. Anchor organizations invest in long-term health equity by considering what business, workforce, and culture changes they must make to address the root causes of SDOH. These organizations actively reinvest in their communities to improve their socioeconomic status. This involves advocating at the local, state, and federal level for policies that address structural barriers to health care access, socioeconomic advancement, and equity, as well as investing in local economies to build sustainable and equitable wealth.
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