The AHA’s vision is of a just society of healthy communities, where all individuals reach their highest potential for health. With COVID-19’s disproportionate impact on Black, Latino, Native American and other communities of color being the latest in a long history of health inequities and health disparities affecting racial minorities in our society, the AHA believes we must confront and eradicate structural racism, which is clearly a serious public health threat. As such, achieving health equity is among AHA’s top priorities for hospitals and health systems nationwide. Read AHA President and CEO Rick Pollack’s July 16, 2021 Perspective column for more about AHA’s mission and commitment to achieving health equity.
Providing culturally and linguistically appropriate services is key to advancing health equity, improving patient safety and quality of care and eliminating health disparities. This literature overview provides a series of resources intended to guide and empower efforts to reach this critical milepost.
This supporting document is intended to provide empirical and theoretical foundation for AHA’s investment in the Health Equity Transformation Model and its Six Levers of Transformation component (more on this below). This is not an extensive literature review, rather a brief synthesis of the literature to provide insight into each lever.
Health Equity Transformation Model
AHA’s investment on behalf of its members supported the development of the Equity Roadmap, a tool designed to support members and the health care field in dismantling structural barriers and advancing equitable health outcomes and systems in the communities they serve and accelerate health equity. The roadmap consists of three components — 1) the Health Equity Transformation Model, 2) the Health Equity Transformation Assessment and 3) the Health Equity Action Library.
The Health Equity Transformation Model is foundational to the Equity Roadmap. It features Six Levers of Transformation, each of which was explored and developed to provide technical and operational direction to the Equity Roadmap. Health care organizations and those taking the health equity journey make a deliberate choice to “pull the lever,” thereby acting to dismantle structural barriers (i.e., racism, sexism, etc.) and mobilize to advance health equity.
The six levers represent operational practices familiar to health care organizations when it comes to assessing performance, improving patient health outcomes and community collaboration. They are critical markers for measuring success and evaluating where improvements can be made.
- Equitable and Inclusive Organizational Policies
- Collection and Use of Data to Drive Action
- Diverse Representation in Leadership and Governance
- Community Collaboration for Solutions
- Systemic and Shared Accountability
- Culturally Appropriate Patient Care
Concurrent within each of these levers, participating hospitals and health systems can gauge where they stand — or how they may improve — on a continuum of progress. Some may be considering the initial stage of exploring, while others may already be in advanced continuum stages of committing, immersing, affirming or — at the highest level — transforming. The continuum represents opportunities for continuous quality improvement.
The following are web-linked citations to detailed literature and examples supporting how each of these levers plays an essential role in supporting the overall journey toward advancing health equity and eliminating health care inequities within communities.
The Six Levers of Transformation
Literature and Resources
Patient care is central to patient safety and outcomes. The HHS Office of Minority Health is the first citation for resources and studies providing guidelines for health care organizations:
- Learn more about the history, supporting reports and literature at Think Cultural Health: https://thinkculturalhealth.hhs.gov/clas/health-equity-timeline
- Cultural Competence Education for Health Professionals: Assesses the effects of cultural competence education interventions for health professionals on patient‐related outcomes, health professional outcomes and healthcare organization outcomes. (Cochrane Library Database, May 2014)
- Building a framework for inclusion in health services research: Development of and pre- implementation faculty and staff attitudes toward the Diversity, Equity, and Inclusion (DEI) plan at Mayo Clinic: “To mitigate the impact of racism, sexism, and other systemic biases, it is essential for organizations to develop strategies to address their diversity, equity and inclusion (DEI) climates.” (Cambridge University Press, January 2021)
- Culturally and Linguistically Appropriate Hospital Services Reduce Medicare Length of Stay. The study tested whether culturally and linguistically appropriate services reduced length-of-stay. The study’s results supported the idea that patient outcomes are responsive and often tied to receiving culturally appropriate services (Ethnicity & Disease, 30(4), 603–610).
- Improving Cultural Competence to Reduce Health Disparities. This review examines appropriate interventions and benefits of providing care with cultural humility. (Agency for Healthcare Research and Quality, 2016).
In order to advance equity, a hospital or health system’s mission, vision and value statements should include a focus on DEI. The policies and practices of health care organizations are critical to achieving sustainable change. Executive-level decisions and policies must apply a DEI lens to strategic planning and governance oversight influencing internal staff and surrounding communities.
- Health Equity as a System Strategy: The Rush University Medical Center Framework: How Rush University Medical Center, a Chicago-based academic health system, initiated a health equity strategy to address racial health inequities. (NEJM Catalyst Innovations in Care Delivery, Vol 2, No. 5, May 2021)
- A Measure of the Potential Impact of Hospital Community Health Activities on Population Health and Equity: How to develop and apply a measure to categorize and estimate the potential impact of hospitals’ community health activities on population health and equity. (Journal of Public Health Management and Practice: September/October 2018 - Volume 24 - Issue 5 – pp. 417–423)
- The Path Forward: Using Metrics to Promote Equitable Work Environments. This article explores the ways in which hospitals and health systems can utilize metrics to understand and address structural inequities. (Pediatrics, Office Journal of the American Academy of Pediatrics: Vol. 148, Issue Supplement 2, September 2021).
- Building a Movement, Transforming Institutions: A Guide for Public Health Professionals. Designed as web-based tool to grow health equity leaders, this resource provides guidance on organizational capacity and leadership building.
- Health Equity and Leadership. Prepared for the Colorado Trust, this document presents action steps for health care organization leaders charged with promoting health equity, focusing on cultural competency and humility as drivers for change.
In order to address health issues in patient populations or communities, hospitals must accurately collect patient data, using culturally appropriate methods and stratify data findings to paint a more accurate picture of where improvements can be made to mitigate health disparities and generate positive outcomes.
- The Institute of Medicine released Race, Ethnicity, and Language (REaL) Data: Standardization for Health Care Quality Improvement Report Released, which underscores the importance of REaL data collection to identify, examine and ultimately address health disparities.
- Inventory of Resources for Standardized Demographic and Language Collection: Building an Organizational Response to Health Disparities. (Centers for Medicare & Medicaid Services: March 2021)
- A Framework for Stratifying Race, Ethnicity and Language Data: A five-step framework for hospitals and health care systems on stratifying patient data to identify health care disparities. (Health Research and Educational Trust: October 2014)
- Collection of Data on Race, Ethnicity, Language, and Nativity by US Public Health Surveillance and Monitoring Systems: Gaps and Opportunities: Provides evidence that complete and accurate data collection is beneficial for patients and healthcare providers. Highlighting the important role data collection plays in eliminating health disparities and paves the way for innovative solutions. (Public Health Rep. 2018 Jan/Feb)
This underscores ways an organization can create pathways that lead to diversifying leadership ranks to reflect the populations and communities served. It’s vital that senior health care administrators, executives and board trustees represent the various populations that are served. The broader picture of diversity includes, but is not limited to, race/ethnicity, age, gender, ability and sexual orientation. System leadership that represents the cultural nuance of communities and staff are important to operational decision making.
- The Future of Diversity and Inclusion in Health Services and Policy Research: Recommendations on providing national leadership by taking five visible steps to promote workforce diversity and inclusion. (AcademyHealth.org report: September 2015)
- University of Michigan Medicine, Diversity Equity and Inclusion Year 2 Plan: University of Michigan Office for Health Equity and Inclusion (OHEI) mission, vision and priority plan. (University of Michigan Health – Michigan Medicine, September 2017)
- How and Why to Increase Board Diversity: follows the experiences of hospital and health system leaders charged with increasing board diversity and representation. It provides first steps and important questions for discussion for those engaged in building out diversity, inclusion, and equity strategy. (American Hospital Association, July 2015)
- Board Diversity Lessons Learned: How three AHA member health systems achieved board diversity: Provides case examples from hospitals and health systems with demonstrated success in increasing board diversity and representation. Examples highlight bright spots and areas for improvement. (American Hospital Association, 2021)
- Creating Accountability for Inclusive, Responsive Leadership: Leaning on the important relationship between DEI work and infrastructure, this blog maps out ways internal stakeholders can identify and bridge gaps in workforce. (SHRM Executive Network, 2020).
Strong and sustainable hospital-community partnerships – which are defined by equitable planning, implementation and evaluation; transparent communication; and strong, collaborative leadership – are key to addressing needs and improving the health of communities and patients.
Activities include redressing power imbalances, strategically aligning and sharing resources to advance health equity and collaboratively fostering healthy communities.
- Beneficial guidance for tax-exempt hospitals to conduct community health needs assessments for meeting federal requirements.
- How Should Health Care Organizations and Communities Work Together to Improve Neighborhood Conditions? How to reconcile public health improvement with local autonomy in decision making so as to express respect for community members’ on-the-ground experience – one children’s hospital story. (AMA Journal of Ethics, March 2019).
- Collaborations Between Health Systems and Community-Based Organizations: Results and examples of the 2018 environmental scan conducted by the Association of State and Territorial Health Officials (ASTHO) which illustrates strategies for overcoming early challenges to developing new community health partnerships. (ASTHO Report, January 2020)
- Community-Based Participatory Research: A Capacity-Building Approach for Policy Advocacy Aimed at Eliminating Health Disparities. Demonstrates the value of community-based research and lessons learned from organizations utilizing this method to engage with community members to address health inequities. American Journal of Public Health 100, no. 11 (Nov. 1, 2010)
- Making the Case for Collaborative Community Health Improvement (CHI). Reviews the ways in which some hospitals and health systems have engaged in innovative practices to improve the health of patients and their communities. (Center for Disease Control and Prevention, 2016).
To sustain DEI work across departments and service lines, establishing the infrastructure to maintain accountability is crucial. Examples include creating councils, designating DEI champions, and clearly communicating and involving employees, patients and communities at varying levels in DEI activities.
- Northwell Health, Center for Diversity, Inclusion and Health Equity Report: Northwell Health’s commitment from leadership on continued DEI improvements, including the establishment of a Diversity and Inclusion Workforce Council. (Northwell Health, 2017)
- University of California San Francisco (UCSF) Benioff Children’s Hospitals Action Plan for Advancing Diversity, Equity and Inclusion: “We cannot provide the best healthcare to all children when we have such disparities in our workforce, when we perpetuate racist structures. This is our time to build an institution that is safe for all who enter.” (UCSF Benioff Children’s Hospitals, September 2020)
- Rush System presents their 2020 DE&I report demonstrating the evolution and foundation of their internal and external approach to DEI (Rush System, 2020).
- Atrium Health offers a variety of experiences for colleagues and community members to join in building a culture that fosters diversity, equity, and inclusion from toolkits oriented toward team members to system resource groups. (Atrium Health, 2021).
Note: This document will be updated as new literature relevant to these topics becomes available.