Advancing equity in the workplace: Five questions health system boards should ask leaders

The pandemic increased awareness of how equity, diversity, and social drivers impact healthcare experience, access to care, and health outcomes. It also highlighted gaps in workforce engagement, well-being, productivity, and trust.¹ Rather than addressing the issues separately, an organization’s strategy to improve health equity for the community must go hand-in-hand with cultivating equity in the health system’s own workforce. 

Healthcare leaders who have identified opportunities to integrate workplace health equity into their overall strategy and operations are seeing results on both fronts. When organizations prioritize their workforce's health and representation of the community, they are supporting their organizational goals of improving the health and health outcomes of the populations they serve.²  

The board of directors should help advance the health system’s health equity strategy both inside and outside the organization. As members of the community, board members bring a heightened awareness of the organization’s ability to improve the lives of the communities served.

Understanding the answers to five key questions can help board members influence their organization’s focus on creating equity and inclusion for the workforce.  

1. How do we build partnerships to increase our pipeline of under-represented talent and improve health equity for the populations we serve? 

Healthcare workforce diversity plays a significant role in advancing health equity. The medical community is struggling with severe workforce shortages and an inadequate number of slots in health professional programs to meet future demand.³  

The Supreme Court of the United States’ decision on affirmative action will make it even more challenging to increase the number of minority physicians and healthcare professionals.⁴ Enrollment by individuals of color in undergraduate and professional advanced degree programs is impacted when legislation targets scholarship funding and diversity recruitment efforts.⁵ The decision also could have longer-term impact on succession planning and talent development.

A recent study found that in the absence of affirmative action, organizations can enhance workforce diversity by pursuing an anchor institution strategy that incorporates social and economic disadvantage and addresses social drivers of health.⁶ Partnering with educational institutions (including community and vocational schools, high schools, and even middle schools) or other community-based organizations to hire from local and under-resourced demographics can help facilitate entry points for diverse talent.  

Prioritizing the recruitment of individuals who have the skill, knowledge, and interest in promoting health equity can also drive improvement. Providing access to healthcare experts in the form of education or clinical resources to support community health and prevention can help advance interest in health professions. These relationships create opportunities to build connections in ways that can support and strengthen community alignment and engagement, and extend the organization’s talent pipeline for generations to come. 

2. How does the organization utilize talent management systems to define achievable targets for increasing under-represented ascending leaders at all levels?  

Increasing diversity, equity, and inclusion at all levels of the organization helps hospitals and health systems reflect the communities they serve and, most importantly, reduce healthcare disparities. These priorities also increase employee engagement and attract talent.  

However, more often than not, stark differences exist in workforce distribution by race, especially at management and senior leadership levels. In a recent engagement, Chartis identified that the racial diversity gap increased significantly at the manager level and above, with only one member of the executive team identifying as a person of color. In a 2021 analysis, Chartis looked at 100 leading U.S. hospitals and found that 54% of these hospitals did not have a single Black leader in a C-suite role. Only 18% had a Black leader in one of the most common C-suite roles (i.e., chief executive officer, chief financial officer, chief operating officer, chief medical officer, and chief nursing officer).⁸ 

As part of its assessment activities, the Chartis Center for Health Equity & Belonging evaluates diverse representation by job classification. As highlighted in the example below, this type of assessment can help organizations quickly identify gaps and opportunities to inform targets and new pathways for developing ascending under-represented leaders. 

Example workforce distribution by job classification by race and ethnicity

Establishing a baseline target for achieving diverse representation is critical and should be measured at all levels, including the board. By doing so, organizations can assess the impact of providing employees equal opportunity for career development and progression.

The board can help influence attainment of diversity goals by inquiring about how the organization builds visibility and engages in development practices that accelerate representation of under-represented individuals at all levels of leadership.  

Just as organizations measure for gender in representation, organizations should evaluate equity of communities who are under-represented in workforce-related policies (including hiring, retention, compensation, performance, and succession planning). Leaders can measure the impact of these efforts through an annual review of diversity, equity, and inclusion goals and by monitoring metrics tied to those goals.  

3. Which quantitative and qualitative workforce key performance indicators (KPIs) are being used to compare our performance on workforce metrics to benchmarks?

Organizations can help identify equity gaps in under-represented populations by using demographically segmented quantitative and qualitative KPIs (such as quarterly reports on retention, turnover, and promotion) stratified by demographics such as gender, age, race, and ethnicity. Employees "vote" with their feet, and turnover is often a lagging indicator.  

The board should understand methods that the organization uses to benchmark current workforce diversity and the recruiting and hiring practices deployed to address gaps. Employee engagement surveys, burnout surveys, and stay interviews can help assess the possibility of employee turnover, which may be a leading indicator of systemic issues (e.g., racism, sexism, and homophobia). Measuring turnover rates pre- and post-interventions can help to build and sustain desired outcomes.

Benchmarking performance is also critical. In addition to evaluating internal performance, the board should consider comparing performance to regional or national benchmarks to help gauge progress. For example, the American Heart Association has released a new Workforce Well-Being Scorecard, which is designed to help employers evaluate the culture of health and well-being within their workforces to identify gaps and determine how their progress stacks up to peer organizations.¹¹  

Annual employee education on topics such as health inequity, health disparities, unconscious bias, systemic racism, and cultural humility are foundational for building a culture that embraces truth, compassion, and psychological safety. Ensuring that all employees receive education and refreshers annually and measuring understanding and impact as part of ongoing performance reviews will ensure that these tactics are not simply check-the-box exercises. 

4. Do we have a patients’ “rights and responsibilities” policy that supports a safe environment for our employees and well-communicated procedures to guide professionals in their responses to these difficult situations?  

A patient “rights and responsibilities” policy provides guidelines for accessing and receiving care.¹² It presents an opportunity to evaluate the institution’s processes for handling patients who are exhibiting behavior that is considered racist, violent, or sexually harassing against employees. The policy ensures that the system is designed to balance accountability and safety for both patients and employees.

Rates of such behavior remain high in most health systems.¹³ These episodes create emotionally charged, complex challenges for front-line workers who may find themselves ethically obligated to help patients and families who are simultaneously abusive and demeaning.  

Policies and procedures that outline patient behavioral expectations guide workers during these events and may help reduce the harmful impact of these distressing patient exposures. They also communicate to healthcare workers that the institution supports their well-being and has anticipated these issues.

Investigating the chain of events after a patient rejects a healthcare worker based on their race or after a patient sexually harasses a healthcare worker can reveal the level of organizational preparedness for these events. 

5. How is the organization identifying and addressing social drivers of health impacting our lowest-paid employees?  

Lower-paid workers in health systems often struggle with basic needs. In a recent engagement, the Chartis Center for Burnout Solutions found that among the health system’s 600 workers in food services, environmental services (EVS), and transport, 23% had difficulty affording the clothing or shoes needed for their jobs, 12% were worried about stable housing in the next two months, and 10% had had their utilities threatened to be shut off. Smaller percentages of workers were often worried about food running out before their next paycheck; had problems getting childcare; or resided in housing with water leaks, mold, or ovens that didn’t work.  

Providing living wages and social service resources to employees benefits the organization’s workforce and the community’s economic sustainability. 

Example social drivers of health for EVS, food service, and transport workers at a 14-hospital system

The workforce is more intimately linked together than most board members may recognize. A hole in one department or job responsibility due to social need factors can drive down how other members of the workforce function and create turnover.  

For instance, staffing issues within EVS (such as sterile processing or cleaning rooms) will cause a decrease in operating room throughput. Or if transport workers are burnt out or insufficiently staffed, interventional radiologists will have to transmit their own patients. Because “burnout trickles up,” there is at minimum a soft return on investment for attending to the needs of this portion of the workforce.

To ensure sustainability, the board should understand how the organization identifies employee social drivers of health in concert with the development of strategies that support long-term retention and engagement. For example, organizations that offer a tuition assistance program with local healthcare educational programs might extend this assistance program to the children of lower-paid employees. This benefit could act as a retention and recruitment tool and could be a key element of the value proposition for recruiting.  

Employers are also positioned to offer support across other areas of consumer need, such as financial literacy, wealth management, and financial tools that increase awareness and skills for building and sustaining financial stability.  

Furthermore, employer-sponsored benefits often serve as a catalyst for helping people live healthier lives. As employers, health systems play a vital role in ensuring equity in income, economic stability, and workplace benefits (such as paid time off and medical benefits). And while many employers are aware of the need to evaluate their benefits offerings to meet the evolving needs of their workforce, leaders need to consider whether benefit plans may inadvertently exacerbate inequity in social, economic, and health outcomes.

For example, many health plans require an out-of-pocket payment for nonroutine preventive care visits (such as emergency room visits). But research shows that some populations may rely on the emergency room for routine medical care. Cost-sharing efforts may worsen the outcomes for employees who are most at risk for complications.¹⁴ Asking for data to understand this impact on your health system’s lowest-paid employees can help to identify drivers and address opportunities for potential plan design changes. 

Strategic priorities for promoting health equity within the workforce  

Healthcare workers are a vital resource who collectively contribute to the well-being of patients and communities. Connecting the workforce investment to health equity is essential to ensure a more just and equitable health system. The board should evaluate these strategic efforts:  

1. Diversify the talent pipeline.  
2. Build programs to develop under-represented leaders at all levels.
3. Develop targets and regularly monitor KPIs.
4. Create psychological and physical safety for employees.
5. Identify and address social needs of lowest-paid employees.

By prioritizing and actively addressing these issues, health systems can provide more accessible, inclusive, and culturally appropriate care for all individuals—ultimately improving health outcomes and reducing disparities in healthcare delivery.