In September, Harvard Medical School’s Center for Bioethics hosted a new installment of their Organizational Ethics Consortia, Can an Institutional Commitment to Equity Help Restore the Moral Core of Medicine?
Bringing together Dr. Vikas Saini (the Lown Institute), Dr. Katherine Peeler (Boston Children’s Hospital), Dr. Omar Lateef (RUSH University Medical Center), and Dr. Thea James (Boston Medical Center), the discussion focused on the role of hospitals in addressing problems like moral stress and burnout and how a commitment to equity fits into their resolution. Watch the video of the event and read some of the highlights from the discussion.
The dilemmas facing hospitals
Panelists emphasized the conflicting incentives for health systems between prioritizing equity and keeping the lights on. “The more right you do in health care, the more wrong your operating margin will report at the end of the year,” said Dr. Lateef.
He shared how RUSH University Medical Center’s strategy during COVID-19 of taking as many patients from safety net hospitals as possible was an energizing force for physicians who saw the difference they were making in their community, but it created financial issues for the hospital. “Because we had lost so much money, we were going to fall below our debt covenant. We couldn’t pay our loans …. We had unprecedented losses through the pandemic,” he said.
Another key challenge for hospitals is making sure that the C-suite and frontline hospital staff are on the same page. “Hospitals often say they have a plan, but physicians who are in the trenches often don’t see this plan,” Dr. Peeler explained. “If hospital’s systems that support equity… aren’t clearly communicated, physicians find themselves in the tough position of not knowing how to actually access the resources in their own hospital to deliver the care their patients deserve,” she said.
And for hospital workers who had been trying to call attention to structural racism for years, it seemed suspect that leaders were vowing to improve equity only after it became popular to do so. “I couldn’t understand that while people don’t recognize inequity when it’s clearly in plain sight all day long, how can all of the sudden people have this commitment to equity?” said Dr. James.
How equity metrics help hospitals “do the right thing”
In order to bolster the contents and actionability of hospitals’ health equity plans, hospitals have to measure what matters and do so in a transparent way. “If we’re going to reframe what it means to be a great hospital, we need new metrics,” said Lown Institute President Dr. Saini. This goal is what drove the creation of the Lown Institute Hospitals Index for Social Responsibility, which evaluates hospitals on equity and value as well as outcomes.
“Let’s measure things that aren’t currently being measured. Let’s do it in a way that’s transparent, and let’s measure things that would be really hard to game.”
Dr. Vikas Saini
However, it’s not just enough to measure health disparities or community investment – institutions have to be willing to internalize and act upon these results, said Dr. Lateef. That can be tough when the results bring feelings of discomfort and frustration for hospital systems. “We all feel like we’re doing an incredible amount of work and no one wants to hear that they’re not doing enough,” he said.
Equity-related measures in particular can provide a critical opportunity to increase the efficiency and impact of hospitals’ plans in the long-term, but only if hospital leaders take them to heart. “Metrics that look at equity should be discussed in boardrooms and when you’re doing that … you’ll drive change, said Dr. Lateef.
For Dr. James at BMC, to make strides on equity it was important to “look inside our own house,” she said. Their “Health Equity Accelerator” program started with hospital leaders meeting monthly in working groups to identify the biggest health disparities in their own patient population. Using this model, BMC has been able to reframe their approach to medicine by putting the identification and resolution of the root causes of ill-health at the forefront of their operations.
It’s not easy to remove health inequities that are baked into the system, but having health systems, researchers, and policymakers working together is a start. “In the same way that multiple forces led us to this moment over many decades, multiple economic, social, and political forces are going to be necessary to get us out of it and that means multiple solutions, different initiatives, multiple domains – all working together if we’re going to pull ourselves out of this tailspin,” said Dr. Vikas Saini.