The Clinical Executive's Role in Reducing Disparities at the Point of Care

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.

Community boards
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:

• Compensation: Do you compensate advisors for their valuable time and input?
• Meeting time: Can someone who does not work a traditional 9-to-5 job attend?
• Digital divide: Can someone without access to home internet easily communicate with organizers? Do you provide the necessary technology for virtual meetings (e.g., computer, Wi-Fi, webcam) for those who need it?
• Transportation: Is the meeting location easily accessible for someone who does not own a car? Do you cover transportation expenses?
• Language: Do you make language services available for advisors with limited English proficiency (e.g., in-person interpretation)?

Shared governance
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:

• Have an outsized impact on a patient’s health status (e.g., housing, food security)
• Are already known to be present in the community and contributing to patients' health status
• Will help you build the case for partnerships or homegrown initiatives to address the need

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:

• Lack of or insufficient resources to address patients’ social needs
• Discomfort discussing issues that feel too personal
• Lack of training or tools to identify or discuss social issues with patient
• Lack of education and/or fluency around social determinants of health

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:

• Race
• Ethnicity
• Gender identity & sexual orientation (commonly referred to as ‘SOGI’ data)
• Age
• Language preference

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:

• Quality performance indicators (e.g., LOS, admissions, readmissions) 
• Outcomes (e.g., experience data, PROMs, top clinical morbidities)  
• Delivery of preventive services (annual physical, mammogram) 
• Department-specific indicators (e.g., nursing-sensitive indicators, instances involving use of physical or chemical restraints, activation of security)
• Process of care measures (e.g., time to admit, ED wait times)

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.

• Is the disparity clinically significant?
• Is reducing this disparity a priority of the community we serve?
• Are there solutions within our sphere of influence?
• Will addressing this disparity drive value for our organization (e.g., lower costs of care)?
• What investments in new technology, roles, or community supports are needed to address the disparity?

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.