Racial and Health Equity: Concrete STEPS for Health SystemsTranslate Your Commitment to Racial and Health Equity Into Action in Your Health System

This toolkit will help you prepare your organization for vital conversations about health equity, racial equity, racism, and anti-racism. It describes how to engage leaders, administrators, clinicians, patients, and other stakeholders in these conversations. The toolkit provides practical steps to collect system-wide data and advance racial and health equity in your health system.

What is Health Equity?

The World Health Organization defines health equity as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. ‘Health equity' or ‘equity in health' implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”¹ Another valuable definition comes from Paula Braveman: “Health equity is the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions. …Health equity means social justice in health (ie, no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged).”² Ultimately, health equity means optimal health for all, and is a goal all health care organizations, big and small, can work toward through their day-to-day work.

How Can Health Systems Advance Health and Racial Equity?

As the commitment to advance health equity and racial equity grows across many sectors, motivated physicians in medium and large health systems—ranging from physician groups and integrated delivery systems to hospital-affiliated outpatient practices and emergency and inpatient settings*—may wonder how best to pursue these goals through their day-to-day work.

Now more than ever, you and your colleagues might be asking questions like:

• Do preventive screening rates, treatment recommendations, or other measures of the quality of our patient care differ by race, ethnicity, and/or language?

• Does everyone in our practice and health system understand how institutionalized racism shapes clinical practice, patients' health outcomes, and the health of the community? How can we better understand or deepen our understanding?

• Do all patients feel equally welcome by our employees and comfortable in our clinic?

• Does our health system's payer mix reflect or even exacerbate institutionalized racism?

Leadership may desire to improve internal diversity, equity, and inclusion (DEI) initiatives, asking questions like:

• Do all employees feel equally welcome and comfortable at work?

• Do our recruitment and hiring practices consider diversity within our organization?

• Are our recruitment and hiring practices bringing in individuals who represent the patient population we serve?

• How do internal DEI efforts for employees relate to our pursuit of health equity and racial equity for our patients and community at large?

Since health equity and racial justice are not only desirable outcomes but also ongoing interrelated processes, this toolkit adapts a practice transformation framework to offer 5 STEPS that can help motivated leaders move health systems forward to embed racial justice in their practices and advance health equity for clinicians, for patients, and for the communities served. Recognizing that the path to equity and justice is a dynamic, long-term journey, this toolkit focuses on initial catalytic STEPS and associated resources to translate that commitment to equity into action and make meaningful improvements that can produce concrete benefits to patients, clinicians, and other colleagues in their health systems. These recommended STEPS are part of a larger cycle of continuous learning, improvement, and accountability envisioned in the American Medical Association's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity that seeks to advance equity through transformation efforts at the patient, organizational, community, and societal levels.

“As health care organizations, payers, and others focus on social determinants and population health, we have a responsibility to ask: To what degree are our approaches grounded in a framework that addresses structural racism and equity? If we can't answer that question with rigor and candor, even our most innovative solutions might perpetuate inequity and illness, not prevent it.”³

—Rishi Manchanda, MD, MPH; President and Chief Executive Officer, HealthBegins

For leaders who wish to disseminate a focused toolkit to specific departments or divisions, or individuals wanting to learn how to implement racial and health equity strategies in a smaller or solo practice, visit the related AMA STEPS Forward™ toolkit, Racial and Health Equity: Concrete STEPS for Smaller Practices.

• For the purposes of this document, we use the term “health system-affiliated practice” to describe care delivered by a team of health care professionals within or closely affiliated with mid and large health care delivery settings. These settings range from large physician groups, clinically integrated networks, and integrated delivery systems to large hospital-affiliated outpatient practices and emergency and inpatient settings.

1. Commit as a Health System to Do the Work

2. Start Shifting Organizational Norms and Practices by Learning About What You Don't Know

3. Get a Handle on Your Data

4. Develop a Shared, Clear, Compelling Vision and Goals for the Entire System

5. Launch Targeted Improvement Efforts Across the System

Like every organizational transformation effort, advancing racial justice and health equity requires leadership. It also requires courage—courage to approach this work with genuine respect, to facilitate and create a safe space for difficult conversations, to find comfort in discomfort, and to commit to meaningful action.

Committing to do the work—and then actually doing it—may start with you, whether you are a C-suite leader of a major health system, the manager or medical director of a division or department, or a frontline clinician within the health system.

Health system commitment occurs in 2 phases that could take place simultaneously or sequentially.

Phase 1: Establish Where You Are by Asking Questions

A good place to start is by asking questions. Talking about racism, racial justice, or health equity in clinical practice may make some of your colleagues and other stakeholders uncomfortable. While it's important to approach conversations about racial equity with respect and candor, expect discomfort and even some degree of conflict. After all, advancing racial justice and health equity in clinical practice involves challenging norms and interrupting patterns that maintain structural disadvantages from patient-facing issues such as access to care and population health management to organizational issues such as hiring, advancement, and pay equity.⁴

One way to overcome the discomfort inherent to racial equity work is to spend some time absorbing the Learning Zone model or reviewing this guide from the Southern Poverty Law Center. With this foundation, you may gain confidence to have open, honest, and potentially uncomfortable conversations about racial justice and health equity as you lead your organization towards a more equitable practice.

Consider asking employees and colleagues questions that invite honest self-assessment within and across clinical and administrative departments:

• Do we know whether access to care, preventive screenings, treatments, quality, or outcome measures differ by patient race, ethnicity, and language?

• When was the last time, if ever, that we asked patients and employees how racism has impacted their health and the care they've received over the course of their lives?

• If we don't have a plan to identify and reduce racial inequities for our patients and community, how do we know that our practice isn't contributing to the problem?

These questions can help identify opportunities for improvement while increasing engagement and commitment among leadership and employees.

Phase 2: Identify a Champion

With the aforementioned questions in mind, the next phase of commitment is to identify champions for advancing racial and health equity work within your organization and across departmental or practice settings. Identify and convene champions across administrative departments and centers (eg, Quality & Safety, Population Health Management, Human Resources, DEI, community benefits), clinical departments, and patient support services. Champions should be trusted, respected voices who have a strong motivation and commitment to racial justice and health equity. If you're reading this, you may be one of these champions.

It is critically important for health system leaders at all levels to understand and avoid tokenism, which overemphasizes representation at the expense of authentic inclusion, and other unfair practices when identifying champions. For example, Black professionals across many industries report a common pattern in which executives appoint a junior person of color to be a “champion” or lead for racial equity-related work, provide them little or no resources, and then ask them to solve the problems of racism in their organizations that they neither created nor benefit from. In some cases, Black, Latinx, and other people of color are expected to serve as “cultural ambassadors,” which leaves them to do 2 jobs: “the official one the person was hired to do, and a second one as champion for members of the person's minority group.”⁵ Instead of giving the illusion of an organizational commitment to racial justice, health system leadership should invest time and resources to engage in this work, starting with providing authentic, meaningful support for champions.

As a reflection of the organization's formal commitment to this work, this cross-departmental group of champions should have an official charter with clear executive sponsorship and support.

Many organizations are taking their commitment a step further by establishing formal Centers for Health Equity and hiring a Chief Equity Officer. By creating an infrastructure and allocating financial and human resources to your initiatives, your organization is far better positioned to create long-term, radical change. If you need support in deciding how to begin transformation or engage your leadership, watch a few videos like this one in the AMA's Prioritizing Equity series.

Name it, frame it, explain it.

Before making a plan to improve racial justice and health equity, it's important for everyone in the health system to develop a better, shared understanding of racism. This includes developing an understanding of the 4 types of racism in medicine (structural, institutional, interpersonal, internalized)—and anti-racism. (For more on the 4 types of racism in medicine, see the AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity for definitions.) Gaining this understanding requires a combination of individual and group learning to find out what you don't know. Provide dedicated time as well as informal opportunities at work to talk with colleagues. Leadership should not only facilitate the dissemination of information but take an active role in engaging groups and individuals in the learning process.

Review the ways white privilege and white supremacy influence organizational culture. Approach conversations with respect, listen, and be open to questions in yourself and your health system, then consider how this approach may influence culture and patient care.

Learn from the experiences of others:

• Talk with other leaders and colleagues about the benefits and challenges of beginning the work

• Read about the experiences of other health systems advancing health equity and racial justice

• Read and share AMA's landmark Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity

• Share lessons from “bright spots”: other health systems, organizations, or practices that have started the journey to racial equity

• Partner with internal DEI leaders and consider hiring an experienced consultant to facilitate group conversations and normalize a commitment to racial justice and health equity

• Pursue opportunities to engage and support patients, community members, and local leaders, especially those who belong to historically marginalized communities, in this conversation

There are even some questions you can consider using during patient visits:

Advancing Health Equity: A Guide to Language, Narrative and Concepts, designed for physicians and other health care professionals, provides guidance and promotes a deeper understanding of equity-focused, person-first language and why it matters

“We must commit to finding ways to structure and standardize the collection of all types of demographic data, of information not only about race and ethnicity, but also gender identity, sexual orientation and preferred language that have made people more vulnerable to the blows of public health emergencies.”⁷

—Aletha Maybank, MD, MPH; Chief Health Equity Officer, American Medical Association

To chart a course forward on racial equity, it's essential to understand your organization's data on a granular level or a population level. Ask 2 basic questions within and across your departments:

• What does our patient data tell us about racial inequities in quality, access, health outcomes, and health-related social needs among our patients?

• What does data from our community tell us about these patient and community-wide inequities?

One commentary proposes a 4-tiered sequential pragmatic framework that your health system and/or department could use to begin to assess for patterns of inequity among your patients (Figure 2).

As more accrediting and oversight organizations focus on health system commitments to identify and address health inequities, it is important to routinely collect and analyze patient and department-level performance data, as well as employee data, by race, ethnicity, and primary language (REAL).

The COVID-19 pandemic has revealed that many hospitals and health care systems, as well as state and federal governments, fail to consistently capture REAL demographic information about patients. The omission of data on race, ethnicity, and language is just one-way institutionalized racism manifests in health care. Support patient self-recording of race, ethnicity, and language data through the use of patient-facing tools online and/or at the point of service in your practice.⁸ As your department begins to collect and analyze REAL data, leverage other data such as age, sexual orientation and gender identity, income, and occupation as “filters” to help discover additional hidden patterns of inequity. This is also a good moment to discuss and consider whether the data algorithms and software your health system uses for risk stratification, predictive, and/or prescriptive analytics are perpetuating institutional racism. Consider requesting or conducting an equity audit of your algorithm, and review and discuss emerging recommendations for ethical approaches to issues of algorithmic bias in machine learning.

To help identify additional social and structural drivers of these health inequities, apply aggregate-level patient-level data on health-related social needs, such as food insecurity or housing instability, to your analysis. Where feasible, leverage internal and external expertise to geocode and analyze EHR data to identify geographic patterns or clusters of health inequity. Compare the insights from that analysis of patient data with community-level data to further understand these inequities as they manifest within and outside the walls of your health system.

Many large health systems conduct Community Health Needs Assessment (CHNA). These assessments are typically performed every 3 years in collaboration with local public health departments and community input. The report is publicly available on the website of each hospital and includes information about the population served and identifies disparities and prioritized health issues of concern.

With a focus on a few key actionable measures, the next STEP is to create a shared vision and goals to reduce or eliminate racial inequities in care delivery and performance, both within your department and across the entire system.

There are 2 components to remember.

1. First, under the auspices of an enterprise-wide group of leaders who represent various administrative departments and centers, clinical departments, and patient support services (eg, a “health equity and racial justice task force or workgroup”), each department should develop its own equity-focused, quality improvement-based project charter. One leader in each department should serve as their department team's executive sponsor, with direct reporting requirements to the taskforce and C-suite executives, who in turn provide resources and communicate why this work aligns with the mission and values of the entire organization.

   Keep racial justice front and center as you develop your department's team charter. A key element of being an anti-racist health system is “centering the margins.” This means “making the perspectives of socially marginalized groups, rather than those belonging to the dominant race of culture, the central axis around which discourse on a topic revolves.¹¹ To center your team charter in “the margins,” invite and support individuals from historically marginalized groups. With trusted and trained facilitators, invite and provide financial support to patients, employees, and community residents to discuss and review your charter and to validate or invalidate your health system's approach and ideas about how to reduce racial inequities.

   Here are 2 examples of how different health systems are using charters and task forces in their endeavor to become anti-racist organizations:

   • Leaders at Brigham and Women's Hospital designed a program—called the Healing ARC (acknowledgment, redress, and closure)—and centered Black and Latinx patients and community members most impacted by unjust heart failure management to inform clinical interventions as well as institutional restitution for historic patterns of racial inequity in the health system's own care and treatment of heart failure patients.

   • Mt. Sinai Health System created a task force created to address racism in the wake of George Floyd's murder and the surge of support for the Black Lives Matter movement. The task force includes 51 team members across all levels of the organization. With input from all departments, the task force developed a road map to advance 11 institutional strategies. Founding the Institute for Health Equity Research and expanding leadership development opportunities are among the changes the system has already implemented.

2. Second, each department should draft a quality improvement-based project charter, including SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals based on your data analysis and identified inequities. Using our example of patients with early-stage lung cancer, a racial equity team based in a health system's oncology department could define a project charter with the following SMART goals.

   Within 12 months, this department will work with key stakeholders, including patients and individuals from historically marginalized communities, to:

   • Achieve at least 20% increase from baseline in curative treatment rates among all adult patients, including Black men and women;

     and

   • Decrease inequities in curative treatment rates between Black men and women and other groups by at least 20% from baseline.

Instead of simply identifying and accepting that racial health inequities exist, the preceding STEPS will help everyone in your health system to develop a shared understanding of why they exist and a shared commitment and plan to eliminate them. The next STEP in system transformation is for teams within and across departments to launch focused quality improvement (QI) campaigns that explicitly and specifically aim to advance racial justice and health equity.

Several studies have demonstrated the positive impact of equity-targeted quality improvement on improving racial equity in care delivery and practice performance.¹³ For example, in the landmark national Health Disparities Collaborative, community health centers used quality improvement to reduce racial, ethnic, and socioeconomic disparities in care over the short-term (1 to 2 years) and key health outcomes over longer, 2- to 4-year periods.¹⁴ Similarly, health systems have also deployed disparities-targeted quality improvement to reduce racial health disparities for a range of issues, from COVID-19 care to cancer treatment. The key is not to use a “one-size-fits-all” approach in which quality improvement interventions are broadly targeted to the general population. See below for an example of how to develop equity-focused quality improvement goals and interventions.

Here are some vanguard examples of health system-based initiatives to embed racial justice and advance health equity.

• The ACCURE Trial identified and intervened to improve racial equity in 5 cancer centers across the US, nearly eliminating existing inequities in treatment and outcomes for Black patients with early-stage lung and breast cancer. This intervention was the inspiration for the illustrative examples described in this toolkit.

• Northwell Health created the Center for Diversity, Inclusion and Health Equity and leveraged existing departmental structures to help identify health inequities and integrate equity into daily functions across the health system. For example, the Center reviews and updates the system's Language Access Plan to improve equity for persons who have limited English proficiency. In 1 year, the system provided more than 260 000 language interpretation calls.

• NYC Health + Hospitals recently launched the Medical Eracism initiative, led by its Office of Quality & Safety and its new Equity & Access Council. The initiative has already prompted the health system to discontinue the use of 2 race-based clinical assessments for kidney function and vaginal delivery after C-sections to help reduce racial biases in care.

• In 2016, UW Medicine formed a multidisciplinary committee to advance health care equity. The following year, the committee released an enterprise-wide Healthcare Equity Blueprint. By 2019, the committee expanded the use of health care equity dashboards system-wide. This year, health system leaders merged this and other efforts and created an Office of Healthcare Equity to advance this work.

These 5 STEPS are meant for motivated leaders ready to work with their health system colleagues, patients, and communities to advance racial equity. These STEPS can help you develop shared understanding and commitment, set data-driven goals, and embark on a journey of continuous learning and improvement for racial justice and health equity.

Journal Articles and Other Publications

Race, racism, and equity: General

• Learning for Justice (formerly Teaching Tolerance). Let's talk: discussing race, racism and other difficult topics with students. Accessed April 10, 2021. https://www.learningforjustice.org/sites/default/files/general/TT%20Difficult%20Conversations%20web.pdf

• The Eliminating Disparities in Child and Youth Success Collaborative, the Coalition of Communities of Color, and All Hands Raised. Tool for organizational self-assessment related to racial equity. October 2013. Accessed April 10, 2021. https://nhchc.org/wp-content/uploads/2019/08/organizational-self-assessment-related-to-racial-equity_oct-2013.pdf

• Jones K, Okun T. White supremacy culture. In: Dismantling Racism: A Workbook for Social Change Groups. ChangeWork; 2001. http://www.cwsworkshop.org/PARC_site_B/dr-culture.html

• Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000;90(8):1212-1215. doi:10.2105/ajph.90.8.1212

• Wilkerson I. America's enduring caste system. New York Times. July 1, 2020. Updated January 21, 2021. Accessed April 12, 2021. https://www.nytimes.com/2020/07/01/magazine/isabel-wilkerson-caste.html

• Saad LF. Do the work: an anti-racist reading list. The Guardian. June 3, 2020. Accessed April 12, 2021. https://www.theguardian.com/books/booksblog/2020/jun/03/do-the-work-an-anti-racist-reading-list-layla-f-saad

• Kijakazi K, Schwabish J, Simms M. Racial inequities will grow unless we consciously work to eliminate them. Urban Wire: Race and Ethnicity, the blog of the Urban Institute. July 1, 2020. Accessed April 12, 2021. https://www.urban.org/urban-wire/racial-inequities-will-grow-unless-we-consciously-work-eliminate-them

Race, racism, and equity: Health care

• American Medical Association. Organizational strategic plan to embed racial justice and advance health equity, 2021-2023. Accessed September 27, 2021. https://www.ama-assn.org/system/files/2021-05/ama-equity-strategic-plan.pdf

• American Medical Association and Association of American Medical Colleges Center for Health Justice. Advancing health equity: a guide to language, narrative and concepts. 2021. Accessed November 16, 2021.https://www.ama-assn.org/system/files/ama-aamc-equity-guide.pdf

• Commonwealth Fund Task Force on Payment and Delivery System Reform. Advancing racial equity in health care. November 2020. Accessed September 27, 2021. https://www.commonwealthfund.org/sites/default/files/2020-11/CMWF_DSR_Task_Force_Equity.pdf

• Sivashanker K, Duong T, Resnick A, Eappen S. Health care equity: from fragmentation to transformation. NEJM Catalyst. September 1, 2020. Accessed September 27, 2021. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0414

• Sivashanker K, Gandhi TK. Advancing safety and equity together. N Engl J Med. 2020;382(4):301-303. doi:10.1056/NEJMp1911700

• Endo, JA. Addressing race in practice. Institute for Healthcare Improvement blog. September 27, 2016. Accessed April 10, 2021. http://www.ihi.org/communities/blogs/addressing-race-in-practice

• Williams JC. Double jeopardy? An empirical study with implications for the debates over implicit bias and intersectionality. Harv J L & Gend. 37;2014:185-242. https://repository.uchastings.edu/faculty_scholarship/1278/

• Southern Jamaica Plain Health Center. Liberation in the exam room: racial justice and equity in health care. Institute for Healthcare Improvement. Accessed April 12, 2021. http://www.ihi.org/resources/Pages/Tools/Liberation-in-the-Exam-Room-Racial-Justice-Equity-in-Health-Care.aspx

• Vaidya A. NYC Health + Hospitals drops use of two race-based clinical assessments. MedCity News. May 18, 2021. Accessed September 27, 2021. https://medcitynews.com/2021/05/nyc-health-hospitals-drops-use-of-two-race-based-clinical-assessments/

Other

• AHRQ Quality Indicators Project Toolkit. Instructions: project charter. Agency for Healthcare Research and Quality (AHRQ). Accessed April 12, 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d2-projectcharter.pdf

Videos and Webinars

Race, racism, and equity: General

• Gross T. A ‘forgotten history' of how the U.S. government segregated America. NPR Fresh Air. May 3, 2017. Accessed April 12, 2021. https://www.npr.org/2017/05/03/526655831/a-forgotten-history-of-how-the-u-s-government-segregated-america

• ABC7 News Bay Area. What are structural, institutional and systemic racism? July 9, 2020. Accessed April 10, 2021. https://www.youtube.com/watch?v=GtOOj5YvMyc

• Race Forward YouTube page. Accessed April 12, 2021. https://www.youtube.com/user/racialjustice

Race, racism, and equity: Health care

• American Medical Association. Prioritizing Equity video series: The root cause & considerations for health care professionals. June 17, 2020. https://www.ama-assn.org/delivering-care/health-equity/prioritizing-equity-video-series-root-cause-considerations-health

• American Medical Association. Prioritizing equity video series. https://www.ama-assn.org/delivering-care/health-equity/prioritizing-equity-video-series-root-cause-considerations-health

Websites

Race, racism, and equity: General

• Smith D. The 10 R's of talking about race: how to have meaningful conversations. Net Impact. June 3, 2020. Accessed April 10, 2021. https://www.netimpact.org/blog/talking-about-race

• ThemPra Social Pedagogy. The learning zone model. Accessed April 10, 2021. http://www.thempra.org.uk/social-pedagogy/key-concepts-in-social-pedagogy/the-learning-zone-model/

  • The model's “comfort, stretch, panic” framework assumes that to learn and improve, we all have to venture out from our comfort zone, where familiar norms and practices remain unchallenged, into a learning zone, where we can make new discoveries. That's essential for racial health equity, which is a continuous learning process.

  • Racial Healing and Reconciliation Project. The work. http://www.racialrec.org/work/

Race, racism, and equity: Health care

• American Medical Association. AMA Center for Health Equity. Accessed April 10, 2021. https://www.ama-assn.org/topics/ama-center-health-equity

• Mount Sinai. A road map for action. July 2021. Accessed September 27, 2021. https://www.mountsinai.org/about/addressing-racism/road-map