Contributor: Journey to Launching a Meaningful Health Equity Strategy

On June 4, 2020, during an on-campus rally for racial justice at Stanford University (SU) School of Medicine (SoM), Lloyd Minor, David Entwistle, and Paul King “knelt in silence for 8 minutes and 46 seconds—reflecting on George Floyd’s last moments on Earth” and stated:

As the three leaders of Stanford Medicine, we come to this time of tragedy, unrest, and reckoning with a pledge: We will not be silent. We will use our influence to effect change. Today, we say that enough is enough. Racism and discrimination in all its forms are a direct affront to Stanford Medicine’s most cherished values: they have no place in our society.

These 3 leaders sponsored SoM’s Commission on Justice and Equity (henceforth Commission), led by Terrance Mayes. The Commission’s primary objectives involved conducting an end-to-end assessment of systems and structures of SoM and Stanford Health Care (SHC); policies and practices; workforce (staff, faculty, and leadership); care delivery settings, using a diversity, equity, and inclusion (DEI) and health equity (HE) lens; and recommending strategies to strengthen DEI and HE systemwide.

In its final spring 2021 report, the Commission presented 4 recommendations to advance DEI and HE, including leadership commitment and accountability, workforce diversity, creating a culture of belonging, and health equity integration.

SHC is not immune to challenges involving DEI or HE. In 2020, reflecting on the inequitable impacts of the COVID-19 pandemic, SHC prioritized 3 HE strategies to specify: who should be involved, how HE should be defined, and where the HE team should start.

Along with my colleagues, I met with over 200 SHC frontline staff during their DEI design-thinking research and heard staff input expressing a strong desire to improve HE. These DEI demonstration projects led to strategic discussions regarding HE between David Entwistle and Dale Beatty.

Following these discussions, the HE program was launched informally in late spring 2021. The SHC HE program subsequently implemented a research division providing DEI in the workforce (staffed by PhD research scientists, social workers, public health advisors, research associates, and project managers), coupled with a research implementation program to improve disparities in health care delivery and outcomes.

SHC’s Health Equity strategy team grew organically from these DEI project discussions beginning in spring 2021 and formally launched in January 2022. Since launching the HE program, SHC has focused on both increasing DEI in the workforce and improving disparities in outcomes, especially for patients at higher risk. I launched the HE award to recognize and support a diverse workforce in providing culture-based patient care that effectively addresses discriminative structures and processes affecting inequality in outcomes.

The Venn diagram below reflects the overlap between workforce DEI and HE, which aligns with the SHC strategy. However, it is acknowledged that although these 2 equity areas share several attributes, they are not the same thing and they do not address the same problems.¹

Workforce DEI and HE Venn Diagram

HE is an essential element of health care quality as the Institute of Medicine defines it.² Extensive research has documented disparities in health and health care rooted in modifiable factors (eg, socioeconomic status including education, income, health insurance, neighborhood, health literacy; English proficiency) as well as biological attributes and social constructs (eg, race, ethnicity, sexual orientation, gender and gender identity, and ability, etc).

Health inequity presents an important gap in care quality, which also could compromise health system finances (eg, readmission rate penalties, under/over-utilization of resources). HE can be attained with societal efforts to address modifiable factors addressed above and through collaborative actions across various stakeholders in health care as suggested in Healthy People 2030.³

Eliminating disparities and achieving HE is SHC’s strategic and operational priority to become a national HE leader among health care delivery systems. Key measures of achieving HE include: 1) embracing HE in culture, leadership strategy, and operating domains; 2) improving health inequities in becoming the “best at getting better”; 3) leading the nation’s health care delivery system to advance HE.

The HE strategic framework presented below is developed based on SHC’s vision and mission and plans to develop priority areas across 3 strategic pillars—strategy and culture, governance and alignment, and community.

SHC Health Equity Strategic Framework (Draft)

SHC is now taking the next steps to set HE priorities, define each priority’s timeline, develop governance structures to support efforts, develop key metrics to measure success, and formalize the community partnership subgroup, among others.

References

1. Crews DC, Collins CA, Cooper LA. Distinguishing workforce diversity from health equity efforts in Medicine. JAMA Health Forum. 2021;2(12):e214820. doi:10.1001/jamahealthforum.2021.4820

2. Institute of Medicine. 2001. Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: The National Academies Press. doi:10.17226/10027

3. Health equity in healthy people 2030. Health.gov. Accessed January 19, 2023. https://bit.ly/3XrmITg