In these weeks of mourning, anger, fear and courage, we have been heartened by the many statements of support and solidarity with demands for racial justice from so many health care organizations. We hope that these words will translate into concrete and practical actions to address racism and injustice in all of its forms. Here, we offer some initial actions for health systems to take, in the hope that these offerings will spur conversation and action, and amplify local advocacy efforts such as those through the #ActionsSpeakLouder campaign, and community partnerships (see examples from Cleveland and Chicago).
Creating a just health care system is not the work of one person or organization, nor of weeks or months, but can only be built in community and with deep ongoing commitment over time.
1. Listen to your community.
This is the time, more than ever, to engage with your community, through formal and informal channels for input. This engagement should explicitly seek to reflect the diversity of your community, in terms of race/ethnicity, disability status, gender identity/sexual orientation, socioeconomic/insurance status and primary language. Meaningful engagement needs to be accompanied by a willingness to shift the balance of power, to validate the experience, expertise and value of community members, and to acknowledge the painful historical legacies of discrimination and exploitation by the health care system. These efforts require a commitment to act on community recommendations that will require investing resources, shifting priorities and ceding power. Our team has over the years delved deeply into how to authentically engage patients, families and communities, and offer resources to assist in this effort, including a change package and a framework for engagement.
2. Embed equity as a core component of your quality and safety programs.
The disparities in deaths and illness from COVID-19 have laid bare the stark health disparities affecting Black, Brown and Indigenous communities. Equity should be firmly embedded in a health system’s quality and safety program, so that equity efforts are robustly resourced and sustained as a core business function of the health system. Identify and address disparities in patients’ health outcomes, but also subtler effects of race such as how physician ratings can be affected by racism and discrimination. Renaming quality and safety to “quality, safety and equity” would be a start; living up to that name by addressing equity in all ongoing quality and safety efforts should be the ongoing commitment.
3. Decrease the use of force by your own security staff.
The number of armed security guards in health care settings has increased over the last several years. This is the moment to review your own use-of-force and security policies, including the size of your security force and whether you need armed security at all. Decrease reliance on security personnel by establishing a crisis response team similar to mobile crisis teams in the community, that are staffed by an outreach worker or peer with a clinician (social worker or behavioral health specialist). Examine incident data to see if security personnel are disproportionately engaging with Black people, other people of color, and people with disabilities. Regularly debrief security incidents to analyze opportunities to reduce the use of force. Ensure that all hospital staff, including security staff, are trained to recognize how implicit bias and racism influence their interactions with patients and visitors, and provide training in de-escalation strategies. To protect immigrant patients, ensure that you have clear policies and procedures regarding interactions with immigration officers.
4. Pay a living wage and diversify your workforce at every level.
Health systems have powerful economic effects in their local communities. As employers, health systems should implement the following:
- Commit to paying staff a living wage and increase the minimum wage paid to $15 an hour. Ensure adequate health insurance, retirement and paid leave benefits.
- Recognize that employees are often also patients in your health system and may be subject to harmful billing and collections processes. Work to reduce or forgive employees’ medical debt.
- Commit to ensuring that your workforce at every level reflects the racial diversity of community served. Ensure that your hiring practices promote this goal, such as by reviewing job descriptions carefully to see if they may be inadvertently excluding certain types of candidates, and implementing a blinded resume review process. Be open to hiring fully qualified individuals with arrest and conviction records into appropriate positions.
- Promote early exposure to health and science careers for Black youth and other youth of color to create a pipeline for a diverse health care workforce.
5. Stop aggressive collections practices and reduce the burden of medical debt.
Unaffordable health care and medical debt prevents patients from seeking needed care and is a key driver of bankruptcy. Aggressive collection practices inflict damage on families and further disadvantage people of color, particularly Black Americans, who are more likely to be burdened with medical debt. Three immediate actions are:
- ceasing collection action for any COVID-related testing or treatment;
- analyzing legal actions taken against patients to examine whether they are disproportionately burdening people of color; and
- improving financial assistance and debt repayment programs
6. Hire community-based providers, such as community health workers, peer providers and doulas.
Community health workers, peer providers and community-based doulas all originate from the communities they intend to serve, share key life experiences with their clients, provide non-clinical supports and help identify relevant social supports. Evidence shows that community health workers improve health outcomes, reduce health care costs and bridge the gap in health disparities by providing culturally centered care and helping patients navigate the health system to get the care they need. A community-based workforce has also been shown to be an incredible asset during the current pandemic, as they provide critical support for populations that have been made vulnerable, particularly Black and Latinx communities, at every stage of disaster response.
7. Name and address the role of racism in clinical care.
Clinicians’ behavior and clinical decisions may be influenced by conscious or unconscious bias. Experiences of discrimination based on race, sexual orientation or disability in health care encounters – both overt and subtle – can undermine patients’ trust, satisfaction with care and provider-patient communication, and harm patients. In addition to interpersonal racism, institutional racism can lead to worse outcomes, affecting everything from what service patients are admitted to, to how long patients wait in the emergency department. Naming the role of racism and implementing anti-racism training are important steps to changing culture.
8. Advocate for your community
Health systems have a powerful voice that should be used to seek solutions and justice for the communities they serve, whether that is advocating for stronger social safety net programs or reducing violence, particularly that perpetrated against Black people and other people of color, people with mental illness, people with substance use disorders, and people with disabilities. Health systems should also advocate for policies that increase the affordability of care, including expanding health care coverage, improving access to care and eliminating surprise billing.
As organizations devoted to improving health, health systems have an opportunity and an obligation to tackle the “moral determinants of health” and to use their power to address the deep injustice embedded in our social fabric.
We invite your suggestions, commentary and input on the path ahead. Please connect with us on Twitter @ccehi or by email to firstname.lastname@example.org.
For more on more steps the health care industry can take, read this piece by Community Catalyst board members Joia Crear-Perry, MD and Anton Gunn, and Luella Toni Lewis in FierceHealthcare.