Implicit Racial Bias Among Health Care Professionals Discussion

WHITE PAPER Achieving Health Equity: A Guide for Health Care Organizations AN IHI RESOURCE 20 University Road, Cambridge, MA 02138 • ihi.org How to Cite This Paper: Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org) AUTHORS: Ronald Wyatt, MD, MHA: Patient Safety Officer and Medical Director, Office of Quality and Patient Safety, The Joint Commission Mara Laderman, MSPH: Senior Research Associate, IHI Laura Botwinick, MS: Director, Graduate Program in Health Administration and Policy, University of Chicago Kedar Mate, MD: Chief Innovation and Education Officer, IHI John Whittington, MD: Senior Fellow and Lead Faculty for the Triple Aim, IHI Acknowledgements: The authors are indebted to those who provided critical review of the white paper throughout the writing process: Ronald Copeland, MD, Senior Vice President, Diversity and Inclusion Strategy and Policy, and Chief Diversity and Inclusion Officer, Kaiser Foundation Health Plan; Cheri Wilson, MA, MHS, Director of Diversity and Inclusion, Robert Wood Johnson University Hospital; Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health and Equity, and Chief Wellness and Diversity Officer, Henry Ford Health System; Carol Beasley, MPPM, Senior Vice President, IHI; Don Goldmann, MD, Chief Medical and Scientific Officer, IHI; Alex Anderson, Research Associate and Co-Chair, Diversity and Inclusion Council, IHI; Amy Reid, MPH, Director and Co-Chair, Diversity and Inclusion Council, IHI; and Ann Whittington. We also thank Jane Roessner and Val Weber of IHI for their support in developing and editing this white paper. The authors assume full responsibility for any errors or misrepresentations. The Institute for Healthcare Improvement (IHI) is a leading innovator in health and health care improvement worldwide. For more than 25 years, we have partnered with a growing community of visionaries, leaders, and frontline practitioners around the globe to spark bold, inventive ways to improve the health of individuals and populations. Together, we build the will for change, seek out innovative models of care, and spread proven best practices. To advance our mission, IHI is dedicated to optimizing health care delivery systems, driving the Triple Aim for populations, realizing person- and familycentered care, and building improvement capability. We developed IHI White Papers as one means for advancing our mission. Implicit Racial Bias Among Health Care Professionals Discussion

The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and early results where they exist. Copyright © 2016 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. Contents Foreword 4 Executive Summary 5 Introduction 5 The Business Case for Health Equity 9 A Framework for Health Care Organizations to Achieve Health Equity 10 Measuring Health Equity 23 Conclusion 27 Appendix A: Interviews and Site Visits 28 Appendix B: Case Study 29 Appendix C: Health Equity Assessment Tools 31 References 37 Institute for Healthcare Improvement • ihi.org 3 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations Foreword In 2001, the Institute of Medicine described “Six Aims for Improvement” in its influential report, Crossing the Quality Chasm: A New Health System for the 21st Century. The “Six Aims” called for health care to be safe, effective, patient-centered, timely, efficient, and equitable. In the 15 years since the Chasm report, health care has made meaningful progress on five of the six aims (though there is much more work to be done on all). But progress on the sixth — equity — has lagged behind. Forward-thinking organizations have made strides, and pockets of excellence are emerging, but the lack of widespread progress leads some to call equity the “forgotten aim.” At IHI, we took steps to keep all six aims top of mind — we even printed them on our hallway walls. Despite this daily reminder, as a leader of IHI, I have to admit to a frustration with our failure to help move the needle on health equity. I know I share this frustration with all of my IHI colleagues, and with so many of you. We hope this IHI White Paper can help lay the foundation for a true path to improving health equity. Hope, of course, is not the same as a plan. So, this white paper offers practical advice, executable steps, and a conceptual framework that can guide any health care organization in charting its own journey to improved health equity. The framework stresses the importance of making health equity a strategic priority at every level of an organization, especially at the top. The framework emphasizes a systems view of how we’ve arrived at health inequities, and how they can be mitigated. And it urges us to work both within our walls, dismantling the institutional racism and implicit biases that hold us back; and beyond our walls, creating and nurturing new partnerships in our communities that can make an impact on all the social determinants of health. More than anything else though, the framework and all of the innovative and passionate work described in this paper demand that we expand our understanding of how health care can improve health equity. Improving only what we’re doing now isn’t enough; real improvement will require broadening and deepening our connections to our staffs, our patients, and our communities. The United States has a unique history of racism that has resulted in disparate and unjust health outcomes. Indeed, institutionalized racism operates all over the world. At the same time, the more we learn about how race, gender, ethnicity, sexual orientation, age, mental health, disability, geographic location, and other factors contribute to health inequities, the more our determination to make a difference grows. This IHI White Paper is part of a larger call to all of you to bring your unique skills, knowledge, passion, and good ideas to those who need them most. Thank you for reading. Derek Feeley President and CEO Institute for Healthcare Improvement Institute for Healthcare Improvement • ihi.org 4 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations Executive Summary Significant disparities in life expectancy and other health outcomes persist across the United States. Health care has a significant role to play in achieving health equity. While health care organizations alone do not have the power to improve all of the multiple determinants of health for all of society, they do have the power to address disparities directly at the point of care, and to impact many of the determinants that create these disparities. Implicit Racial Bias Among Health Care Professionals Discussion

This white paper provides guidance on how health care organizations can reduce health disparities related to racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. To inform this work, IHI reviewed selected literature, interviewed numerous experts, and conducted site visits to exemplary health care organizations working to improve health equity in their communities. The result, presented in this white paper, is a framework for health care organizations to improve health equity in the communities they serve. There are five key components of the framework:  Make health equity a strategic priority;  Develop structure and processes to support health equity work;  Deploy specific strategies to address the multiple determinants of health on which health care organizations can have a direct impact, such as health care services, socioeconomic status, physical environment, and healthy behaviors;  Decrease institutional racism within the organization; and  Develop partnerships with community organizations to improve health and equity. The white paper also describes practical issues in measuring health equity, presents a case study of Henry Ford Health System, and includes a self-assessment tool for health care organizations to assess their current state related to each component of the framework. The framework is a continuation of IHI’s work, which began in 2007, on the Triple Aim: improve the individual experience of care, improve the health of populations, and reduce the per capita costs of care for populations. Health equity is not a fourth aim, but rather an element of all three components of the Triple Aim. The Triple Aim will not be achieved until it is achieved for all. Introduction Tommy Cannon died at the age of 62. A black American, he lived his entire life on Highway 29 in Perry County, near Marion, Alabama, in a region known as the Black Belt. He was deeply religious, a hard worker, honest, and generous. In his late 50s, he was diagnosed with type 2 diabetes. Like many other older black Americans, then and now, he had no source of regular preventive health care. One day in 1973 when Tommy became very ill, he waited hours in a segregated doctor’s office waiting room trying to receive care.  When he was finally seen, the physician told him to go to a hospital 50 miles away because he was so sick. Implicit Racial Bias Among Health Care Professionals Discussion

Tommy Cannon died the next day at age 62 from sepsis due to a ruptured appendix at a hospital in Selma, Alabama, without ever being seen by a physician.1 Institute for Healthcare Improvement • ihi.org 5 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations In 2013 the life expectancy at birth for men in Perry County, Alabama, was 67.4 years2 — compared to 76.3 years, the national average for males in the US for the same year.3 Perry County is rural, very poor, and its citizens are primarily black. Geography, income, and race are three important determinants of health in the US. Men in Perry County should be living longer today, and Tommy Cannon’s death in 1973 might have been prevented if he had received care sooner. Figure 1 shows that, even with improvements over time, life expectancy for black Americans has lagged behind that of white Americans since 1950; indeed, life expectancy of black Americans in 2010 was equal to that of white Americans in 1980. Figure 1. Life Expectancy of Blacks and Whites in the US (1950-2010)4 85 80 Life Expectancy (in Years) 75 70 65 60 55 50 45 40 1950 1960 1970 1980 White 1990 2000 2010 Black Health disparities are not limited to race and ethnicity. Figure 2 shows the gradient of relative risk of mortality for different income levels among US households. Compared to households with annual incomes greater than $115,000 (referent), households with lower incomes have a higher relative risk of mortality, which increases with decreasing income. Institute for Healthcare Improvement • ihi.org 6 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations Figure 2. Relative Risk* of All-Cause Mortality by US Annual Household Income Level5,6 3.5 3.03 3 2.49 Relative Risk 2.5 2 2 1.45 1.5 1.36 1 1 0.5 0 < $25,000 $33,000 $50,000 $82,000 $115,000 > $115,000 US Annual Household Income (Converted to 2013 US Dollars) *NOTE: Relative risk is defined as a measure of the risk of a certain event happening in one group compared to the risk of the same event happening in another group. Even in 2016, significant disparities in life expectancy and other health outcomes persist across the United States.7 These health inequities are observed across many intersecting demographics. Implicit Racial Bias Among Health Care Professionals Discussion

The goal of this white paper is to provide guidance on how health care organizations can reduce health disparities related to “racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”8 These factors are, of course, closely linked. Populations are often separated into distinct groups: heterosexual or LGBTQ; black or white; women or minorities. Making these distinctions is important for understanding differences between various populations. However, these distinctions present a significant problem, as individuals simultaneously possess many characteristics. Women who are Hispanic and LGBTQ are, at the same time and with the same significance, women and Hispanic and LBGTQ. Thinking about an individual through only one of those lenses does not capture a complete understanding. This idea is called “intersectionality” — a framework for understanding how “multiple social identities such as race, gender, sexual orientation, socioeconomic status, and disability intersect at the micro level of individual experience to reflect interlocking systems of privilege and oppression.”9 A growing body of research examining the relative effects of different sociodemographic characteristics on health (for example, the relative effects of race and socioeconomic status on risk of mortality) will continue to elucidate the joint and independent effects of various characteristics on health outcomes.10 For now, understanding the relative impact that, for example, race/ethnicity has over socioeconomic status, or gender has over race, or income has over gender, remains an open question for researchers. Evidence suggests that health care’s proportional contribution to premature death is only approximately 10 percent, with the remainder due to multiple, non-medical determinants: behaviors (40 percent); genetic predisposition (30 percent); social circumstances such as employment, housing, transportation, and poverty (15 percent); and environmental exposure (5 percent).11 These factors do not exist in isolation; for example, the ability to engage in healthy behaviors (e.g., healthy eating) is determined by an individual’s social circumstances (e.g., access to affordable, healthy food). Health care organizations alone do not have the power to improve all of the multiple determinants of Institute for Healthcare Improvement • ihi.org 7 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations health for all of society, but they do have the power to address disparities directly at the point of care, and to impact many of the determinants that create these disparities. Health care has a significant role to play in achieving health equity. Implicit Racial Bias Among Health Care Professionals Discussion

The intent of this white paper is to provide guidance for health care organizations to make health equity a strategic priority, create the governance structure and processes to support this work, tackle the multiple determinants of health on which these organizations can have an impact, recognize and decrease institutional racism in their own organizations, and build partnerships with others in the community to improve health equity. Definitions It is important to establish clear definitions of the terms used in this white paper: population health, social determinants of health, health equity, health disparity, health inequity, and health care disparity.  Population health: Defined in a 2003 article in the American Journal of Public Health by David Kindig, MD, PhD, and Greg Stoddart, PhD, as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”12 Health care organizations generally define population in two different ways: either the communities in their geographic service area or the patients actually seen in their organization.  Social determinants of health: Defined by the World Health Organization (WHO) as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”13  Health equity: To define health equity, we turn to the work of Professor Margaret Whitehead, head of the WHO Collaborating Centre for Policy Research on the Social Determinants of Health. Most countries use the term “inequalities” to refer to socioeconomic differences in health — that is, health differences “which are unnecessary and avoidable but, in addition, are also considered unfair and unjust.” Whitehead goes on to state that, when there is equity in health, “ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, no one should be disadvantaged from achieving this potential, if it can be avoided.”14 This is the definition IHI uses to guide our work on improving health equity.  Health disparity and health inequity: Health disparity is defined as the difference in health outcomes between groups within a population. While the terms may seem interchangeable, “health disparity” is different from “health inequity.” “Health disparity” denotes differences, whether unjust or not. “Health inequity,” on the other hand, denotes differences in health outcomes that are systematic, avoidable, and unjust.  Health care disparity: Defined by the Institute of Medicine as “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”15 This white paper focuses on disparities in health outcomes rather than the provision of health care; however, the equitable provision of health care is essential to reducing disparities in health outcomes. Health care organizations have a significant opportunity to improve health equity in the communities they serve. As Antony Sheehan, former president of the Church Health Center in Institute for Healthcare Improvement • ihi.org 8 WHITE PAPER : Achieving Health Equity: A Guide for Health Care Organizations Memphis, Tennessee, said in an interview, “Health services should be a conduit to mitigating the social determinants that stand in the way of health and wellbeing.” Methods As part of our effort to understand how health systems can impact health equity in their communities, IHI led four 90-day Innovation Projects on health equity in 2015.16 The purpose of these sequential 90-day cycles was to design and test a framework for health systems to impact the multiple determinants of health and make significant improvements in health equity in the communities they serve. IHI developed the framework described in this white paper based on the work of these Innovation Projects, which included scans of the current published literature on health equity; more than 30 expert interviews, including interviews with patients; site visits; and learning from exemplary health care systems on the cutting edge of working to improve health equity in their communities (see Appendix A). Implicit Racial Bias Among Health Care Professionals Discussion

The Business Case for Health Equity In addition to the moral argument for achieving health equity and the fact that improving health care quality and population health will require reducing health disparities, there is a strong business case for accelerating this work at the national, state, and individual health system levels. Health disparities not only result in poorer heal … Implicit Racial Bias Among Health Care Professionals Discussion