HSO

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Advancing health equity through organizational change: Perspectives from health care leaders Julia A. Doherty • Margaret Johnson • Heather McPheron

Background: Published literature on health care administration, management, and leadership and its impacts on health systems’ programs to address health care inequities is limited, as is information about how organizations integrate health equity in their cultures, missions, and strategic plans. Purpose: The aims of this study were to identify the key components necessary for health systems to implement systematic organizational change to promote health equity and to describe approaches organizations have implemented. Methodology/Approach: We conducted an environmental scan to identify central principles for implementing lasting change in health systems and experts working to advance health equity through organizational change. We interviewed 19 experts in health equity andhospital executives in 2020. Using iterative thematic analysis, we identified common themes. Results: Consistent with the literature on organizational change, interviewees described a variety of systematic approaches to change, all of which involve the following core components: (a) committed and engaged leadership; (b) integrated organizational structure; (c) commitment to quality improvement and patient safety; (d) ongoing training and education; (e) effective data collection and analytics; and (f) stakeholder communication, engagement, and collaboration. Conclusion and Practice Implications: There is no “one-size-fits-all” approach to advancing health equity. Decisions about which components require the most attention vary depending on an organization’s internal and external environment. Understanding those environments and identifying which levers will be most effective are essential. As provider organizations strive to develop more strategic and systematic approaches to addressing disparities, long-term vision and commitment are necessary to achieve sustainable organizational change.

Key words: disparities, health equity, health system, hospital, organizational change, provider

D isparities in health that exist across communities are evidence of differences in health care access and treat- ment, and the social conditions and physical environ-

ments in which people live. More specifically, race, ethnicity, socioeconomic status, age, sexual orientation and gender iden- tity, disability, and geographic location are examples of char- acteristics that influence health outcomes (Baptiste-Roberts et al., 2017; Meade et al., 2015; Singh et al., 2017).

In 1979, the federal government released the first Healthy People initiative, a large-scale public health strategy presenting

Julia A. Doherty, MHSA, Senior Research Director, L&M Policy Research, LLC, Washington, DC. E-mail: [email protected]. Margaret Johnson, MBA, Director, L&M Policy Research, LLC, Washington, DC. Heather McPheron, MPH, Director, L&M Policy Research, LLC, Washington, DC.

The opinions expressed in this article are the authors' own and do not reflect the view of the Centers forMedicare &Medicaid Services, the Department of Health and Human Services, or the U.S. government.

This study was conducted under contract with the Centers for Medicare & Medicaid Services, Office of Minority Health (Contract HHSM-500-2011-00019I/ 75FCMC19F0003). The content of this article reflects the terms and provisions of the contract under which the work was performed and technical direction provided by the U.S. government. Mention of trade names or organizations does not constitute endorsement by the U.S. government.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.

DOI: 10.1097/HMR.0000000000000326

Organizational Change to Advance Health Equity

national health objectives and goals for disease prevention and health promotion among Americans (Centers for Disease Control and Prevention [CDC], 1989; Healthy People, 2020b). By 1990, the national strategy, then titled Healthy People 2000, cited disparities reduction as one of its three overarch- ing goals (CDC, 2009). The intervening decades saw new public health problems emerge that exposed and exacerbated health disparities. Acknowledging the evolving challenges, Healthy People’s improvement agenda not only retained a fo- cus on disparities but also expanded to “eliminating dispar- ities, achieving health equity and improving health of all groups” (Healthy People, 2020a; Koh et al., 2011).

AlthoughHealthy People 2020 clearly articulates the twin goals of reducing disparities and achieving equity, the pub- lished literature on individual hospitals and health systems’ programs to address health disparities and persistent ineq- uities is relatively limited (Bourgois et al., 2017; Horwitz et al., 2020). Until recently, there were few examples in the literature of the approaches that hospitals and health systems have used to prioritize health equity in their institutional cul- tures, missions, and strategic plans, much less lessons learned. In the past 5 years, multiple organizations, including the Insti- tute for Health Improvement and the Healthcare Anchor Network, have undertaken initiatives and developed guid- ance to support health systems in working to advance health equity (Ubhayakar et al., 2017; Wyatt et al., 2016). These and other efforts reflect an increasingly active role some health care organizations are taking to identify and implement strategies

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to advance health equity and address disparities. Hereinafter, we use “provider organizations” to refer to hospitals, health systems, and other provider entities delivering health care services.

The aims of this qualitative study were to identify and consider the core components necessary for provider orga- nizations to implement systematic organizational change to address health disparities and promote health equity and to describe approaches some provider organizations have im- plemented. Our findings are of particular interest to local, state, and federal health care stakeholders, seeking oppor- tunities to develop programs that support efforts to system- atically and sustainably combat disparities. In addition, the COVID-19 pandemic has both exacerbated existing dispar- ities and stimulated further discourse on the role provider or- ganizations can and should play in addressing the multitude of factors and social contributors that influence health. The pandemic’s disproportionate impact on communities of color underscores the need for swift and increased action for pro- vider organizations to assume a role in addressing the under- lying and pervasive forces driving health disparities (Artiga et al., 2020; CDC, 2020).

Theory Transforming an organization’s culture and ingraining health equity as a strategic priority necessitate organization-wide strategic and operational changes. We conducted key infor- mant interviews with health care industry experts and indi- viduals representing provider organizations to explore this hypothesis. We aimed to understand (a) their experience and expertise pertaining to moving beyond individual inter- ventions to address health disparities toward implementing a systematic, coordinated, and sustainable organization-wide approach and (2) how their organizations approached em- bedding the concept of health equity into the entity’s mission and strategy. We conducted an environmental scan to gain a better understanding of the central principles of organiza- tional readiness when embarking on widespread, systematic change in health care and used this understanding to frame the discussions with the interviewees.

The research team identified multiple well-established change models through the environmental scan. We selected Kotter’s eight-step model for leading change to guide our work given its focus on helping leaders—across industries, in- cluding health care—establish practices for creating sustained and long-lasting changes while encouraging them to think beyond a one-time change event (Kotter, 1995). To adapt Kotter’s model to the advancing health equity context, we leveraged research conducted by Eckstrand et al. (2017). Eckstrand et al. conducted a review of 10 change models fo- cused on addressing health disparities experienced by women and racially and ethnically diverse communities; they identi- fied five core and overlapping components of these change models. Using the components that Eckstrand et al. identi- fied and Kotter’s eight-step model, we developed a novel con- ceptual framework for this study (see Figure 1). The core components identified in this framework were the organizing principles for the key informant interview discussion guides.

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Core components necessary to implement and sustain or- ganizational change to address health disparities and promote health equity include the following:

• Committed and engaged leadership: To prioritize health equity, it is critical to have dedicated leaders capable of leading the organiza- tion through change. Sustaining change requires leaders to com- mit financial and human resources to ongoing change efforts and to serve as champions for the transformation efforts.

• Integrated organizational structure: An organization must have pa- tience for the work of integrating organization-wide change and commitment to identifying and eliminating internal silos.

• Commitment to quality improvement (QI) and patient safety: Both quality and safety improvement involve creating high-value and safe patient experiences across all populations. Focusing on identi- fying and narrowing gaps in quality and safety for different segments of a population is an important step, which can also serve to engage staff at all levels of an organization in advancing health equity.

• Ongoing training and education: Employees and managers often need to learn new skills and acquire a shared terminology when an organization is undergoing change. From coaching on individual self-awareness to large-scale team building activities, continuous training and education can empower staff to act on a common vision and is a vital step toward institutionalizing new approaches.

• Effective data collection and analytics: Building a data infrastruc- ture to collect patient self-reported race and ethnicity data as well as information on individual social needs can help a provider organization better understand the communities it serves. Having an understanding of how to analyze patient-level data alongside contextual information on community resources and needs is important.

• Stakeholder communication, engagement and collaboration:Ongoing, transparent communications and collaboration across stakeholder groups—employees, patients, families, and caregivers—help iden- tify, promote, and sustain change around new norms and behav- iors within the organization. Direct connection with community stakeholders and listening to their needs lay the foundation for effective partnerships that will be instrumental in facilitating change within and outside an organization’s walls.

Methods This qualitative, exploratory study was designed to synthesize published research about organizational change with the experi- ence of health care experts and executives to impart lessons learned. Following a scan of peer-reviewed and gray literature fo- cused on the key components needed to implement systematic change in a health care setting, we conducted 16 key informant interviews with 19 individuals. They represented a purposive sample of experts in health equity and executives from provider organizations whose leaders were also focusing on advancing health equity.

Sample Selection We scanned publications, news releases, reports and articles, and key organization websites to identify United States-based health system experts and provider organization executives recognized for their expertise on reducing health disparities or taking a systematic approach to advancing health equity. We defined experts as individuals with unique experiences and qualifications related to addressing health disparities and issues of health equity, including academic researchers, leaders at prominent membership organizations, and leaders at various health care organizations. Considering the experts

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Figure 1. Advancing health equity: elements required to support change.

and provider organization leaders separately, we ranked can- didates on the extent to which their individual expertise or institutional program(s) aligned with the objectives of our study. From the refined candidate list, we conducted outreach by phone and e-mail and recruited eight individual experts to participate in the study.

Concurrently, we identified provider organizations taking a systematic approach to advancing health equity. We con- ducted brief semistructured screening calls with individuals at the prospective provider organizations to confirm our un- derstanding of their body of work. From the refined candidate list, we selected eight provider organizations. We conducted outreach by phone and e-mail to recruit specific individuals based on their role as leaders in advancing health equity within their organization. These provider organizations repre- sented institutions with a diversity of organizational struc- tures, religious and academic affiliations, geographies, sizes, and degree of integration across care settings. For example, the organizations from which we recruited leaders in equity include a 750+-bed academic medical center in the Midwest, a health system with over 20 hospitals on the East Coast, and a health system representing a 30-hospital network spanning three states in the South. The names of these organizations and the titles of their respective interviewees are provided in Table 1.

The complete sample consisted of 16 interviews with 19 individuals: 8 health care experts and 11 leaders representing eight provider organizations. Each interviewee consented to be recorded during the interview and later consented to be identified and acknowledged for their participation. Table 1 provides information about each interviewee, including their organizational affiliation. A summary of interviewees’ roles is provided in Table 2.

Data Collection We conducted a total of 16 semistructured telephone inter- views during February and March 2020. Through these dis- cussions, we explored whether the framework we developed

Organizational Change to Advance Health Equity

was suitable for understanding organizational readiness to in- tegrate health equity and whether any additional core com- ponents or refinements to the framework were needed. We elicited interviewees’ insights into the facilitators and barriers organizations encounter in their efforts to advance health eq- uity, and we asked about tools and strategies organizations have employed to support enterprise-wide advancement of a health equity agenda.

Interviews delved into the core components crucial to implementing organizational change as organizations shift from individual and sometimes single initiative-based ap- proaches to strategies systematically promoting equity work across the organization. The questions were structured to elicit practical insights into what components were necessary to implement organizational change and tactics the organiza- tion used to integrate health equity into its broader patient care, patient experience, quality, and safety priorities. We also asked them to reflect on the successes and challenges their teams encountered.

All interviews were led by a senior researcher who was accompanied by a second senior researcher to assist with follow-up questions. A research assistant took transcript-style notes of each discussion. Interviews were recorded and lasted 60–90 minutes. The recordings were used to finalize the inter- view notes, which were aggregated for analysis. We developed a database to facilitate sorting of key themes and synthesis of findings.

Data Analysis We employed a structured thematic analysis that inte- grated aspects of an immersion approach (Borkan, 1999). After each interview, the research team debriefed to dis- cuss the initial findings and identify emerging trends. Sec- ondary analysis involved reviewing all the interview notes to identify additional themes and patterns. Subsequently, we used an iterative analytic process to further develop each theme. The team carefully considered and discussed each theme for its relevance across the interviews. As

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TABLE 1: Key informant interviewees

Name of institution Type of institution State/ region Interviewee title

Brigham and Women’s Hospital Academic hospital MA Medical Director of Quality, Safety, and Equity

Christus Health Health system TX Vice President for Health Equity, Diversity and Inclusion

Johns Hopkins Health System Health system MD Co-Chair, Health Equity Steering Committee

MetroHealth System Health system OH President, Institute for H.O.P.E.

Northwell Health Integrated delivery network

NY Senior Vice President and Community Health Investment Officer

Rush University Medical Center Academic medical center

IL Senior Vice President for Community Health Equity

Rush University Medical Center Academic medical center

IL Co-Director, Center for Community Health Equity

Sutter Health Health system CA Chief Medical Officer Health Equity Program Manager, Office of Patient Experience

University of Pittsburgh Medical Center

Academic medical center; health plan

PA Program Administrator, Center for High Value Health Care Director of Government and Business Relations

Accreditation Council for Graduate Medical Education

Accreditation body National Chief Sponsoring Institution and Clinical Learning Environment Officer

American Hospital Association Health care association

National Senior Vice President and Chief Medical Officer

Association of American Medical Colleges

Health care association

National Senior Director for Health Equity Research and Policy

Institute for Healthcare Improvement

Quality improvement institution

National Director, Pursuing Equity Initiative

University of California San Francisco

University National Director, Social Interventions Research and Evaluation Network

University of Chicago and Robert Wood Johnson Foundation

University; philanthropy

National Quality Improvement and Care Transformation Strategist, Department of Diversity, Inclusion and Equity, University of Chicago Medicine and Biological Sciences Co-Director, Advancing Health Equity: Leading Care, Payment, and Systems Transformation

University of Michigan University; policy center

National Director, Institute for Healthcare Policy and Innovation

University of Wisconsin University; policy center

National Professor, School of Medicine and Public Health Director, Center for Health Disparities Research

needed, we returned to the primary data to verify or better understand the subject matter.

Results The six components in our study framework were confirmed by experts and provider organization executives alike as the core components an organization needs to have in place in order to implement systematic change to address health disparities and advance health equity. Our analysis of the discussions with the interviewees did not elucidate differ- ent core components to integrate into the framework. The approaches and lessons learned that the interviewees

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associated with prioritizing health equity in their institu- tional culture, missions, and strategic plans offer meaning- ful additions to the literature.

Advancing Health Equity Requires Leadership Commitment and Resources All but one executive with whom we spoke asserted that institutionalizing a “culture of equity” means leaders at the highest level (i.e., the C-suite) must be dedicated to ensuring that equity-focused values are integrated into all aspects of provider organization operations. The one “outlier” interviewee

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TABLE 2: Distribution of interviewees by role

Distribution of interviewees by role n

Senior executive or physician leader at provider organization

7

Project director/programmanager at provider organization 3

Other leadership role at provider organization 1

Expert at academic or research institution 4

Expert at quality improvement institution 1

Expert at accreditation body 1

Expert at national health care association 2

Total interviewees (some interviewed together) 19

reaffirmed leaders’ essential role in articulating equity as an organizational priority, though this executive asserted that having the support of key patient safety and QI leaders and a chief medical officer can be sufficient to bring about signif- icant and positive change. Interviewees also noted that a hallmark of engaged leadership is supporting strategic priori- ties with the necessary financial resources, infrastructure, and staff to systematically advance programs and activities that align with the stated goals.

Integrated Organizational Structure and Accountability Most interviewees emphasized the importance of building and supporting processes that actively facilitate integration of equity work into a provider organization’s existing workflows; doing so can mitigate resistance to broader organizational change. They cautioned that, in any provider organization, there is a risk of unintentionally limiting equity-focused work to designated departments or entities at the expense of foster- ing a broader culture of equity and a sense of joint responsibil- ity throughout the organization.

Most of the individuals we interviewed in provider organiza- tions have an office of diversity and inclusion and/or an office focused on health equity; in some instances, these organizations also have separate offices focused on community-facing activi- ties. Based on their firsthand experience, interviewees empha- sized the need for integration of equity work across functional departments, such as patient safety, quality, population health, communications, and clinical leadership (e.g., nursing and emergency departments). Broad, cross-cutting work promotes collaboration within the organization while also reducing the fragmentation associated with having separate, uncoordinated equity initiatives underway within the organization. Breaking down “silos of excellence” within a mission-driven organiza- tion also mitigates barriers to advancing an organization-wide culture of equity.

Governance structures designed to support health equity can bolster a provider organization’s focus and accountability and, at the same time, encourage integration across divisions

Organizational Change to Advance Health Equity

and departments. Such mechanisms are particularly significant given that provider organizations’ health equity programs often span different functions of the organization, including aca- demic and research arms, population health, and community outreach. Executives we interviewed described different types of oversight and governance structures that were designed to create accountability and ascertain progress toward meeting goals. One large provider organization requires that each of its divisions, including its health plan, reports to a community-facing in- clusion board. As part of its organizational change strategy, another provider organization established a health equity committee of leaders from its medical divisions, QI, nursing, administration, and one of its major community health cen- ters to provide direction and ensure accountability. A third provider organization created a center for health equity that included a research arm, as well as a health equity steering committee, to guide the entire organization’s work.

Culture Change Through QI and Patient Safety Multiple interviewees affirmed that, for organizations with quality as a core value, embedding health equity work within the QI and patient safety structure is a “natural fit” and pro- motes a systematic rather than an episodic approach to ad- vancing equity. Health care experts and executives described two organizational prerequisites for integrating equity with QI: a strong QI infrastructure and an effective quality and safety team. Organizations with these resources have opportu- nities to identify disparities and inequities in the context of QI and patient safety. One interviewee advised that hospitals should stratify their QI and safety results by patient race, eth- nicity, geography, and socioeconomic factors to ensure that health disparities are not overlooked.

Ongoing Health Equity Training and Education Interviewees emphasized the role of training in developing the skills necessary not only to deliver culturally competent care but to engage in discussions about sensitive and some- times difficult topics related to health equity. Absent this ed- ucation, it is challenging for clinicians and health care staff to discuss, for example, the influence of implicit and explicit sys- temic issues and biases on health disparities. Interviewees ad- vised that staff members’ own experiences with institutional inequities, including systemic racism, have potential to un- dermine the credibility and effectiveness of efforts to foster the cultural and organizational components required for suc- cessful change if not acknowledged directly and thoughtfully. Executives described ongoing work in their organizations in- herent to cultivating the courage and willingness to engage in discussions about individual and organizational biases. The interviewees specified that efforts to create a culture of open- ness to discuss health disparities and to affect culture change must be iterative and continual, rather than episodic. Execu- tives noted that their respective organizations’ work has evolved and acknowledged that there is still much to learn. All concurred that integrating equity values into provider orga- nizations’ culture, strategies, and business and clinical practices is

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an endeavor that requires an extended time horizon and dedica- tion to ongoing training.

Several provider organization leaders described ongoing training and education initiatives to teach staff about exam- ining the patient care experience through an equity lens. Leaders explained educational opportunities as having dual goals: (a) to initiate an internal dialogue about how the orga- nization is working to advance equity for their patients and identify opportunities for improvement and (b) to better un- derstand how well the organization is serving the community.

Investing in Data Collection and Analysis All of the provider organization leaders we interviewed emphasized the importance of capturing granular, patient- reported demographic data at the point of care and the need for ongoing monitoring through data analysis. However, some interviewees tempered their emphasis on data collec- tion. They cautioned against the inclination to continually collect and analyze data at the expense of taking action and suggested that provider organizations take a more intentional approach to data analysis. Interviewees postulated that an- swering the questions “What is the organization trying to achieve?” and “What measures are the most meaningful?” should precede efforts to conduct analyses just because data are available. An interviewee offered the example of an organization that stratifies every quality measure and asked rhetorically whether this effort provided mean- ingful information.

Multiple leaders at provider organizations emphasized the value of investing in the ability to collect data on race, eth- nicity, and language (REAL) through an electronic health re- cord system. Most leaders also indicated that they still have a significant amount of work ahead to improve this type of data collection, noting that implementation of effective data col- lection mechanisms can take 5 years or more.

Recognizing the impact of social factors on patients’ ability to access and use health care services effectively, many of the experts and provider organization interviewees also described how provider organizations have begun to collect informa- tion about individual patients’ social needs (e.g., housing, transportation, access to food, and ability to pay for prescrip- tions). Provider organizations have developed different tools and approaches for collecting and responding to these data, and several interviewees noted challenges related to patient mistrust, leading to data collection difficulties. Patients often do not understand why an organization is asking for informa- tion about their social needs and may be reluctant to disclose it depending on how the inquiry is made. Moreover, although some hospitals collect REAL and social needs data through their electronic health record systems and make referrals to community organizations that aim to address specific social needs, fragmentation and duplication within and across pro- vider organizations persist. Several interviewees also pointed out that, once social needs are identified, “closing the loop” to determine if a patient’s social needs are successfully ad- dressed remains challenging. Data on the outcomes of social needs referrals can shed light on whether linkages are being

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made to organizations with the capacity to address the identi- fied needs.

In addition to understanding social needs at the individual patient level, all interviewees discussed the importance of provider organizations understanding the broader hardships experienced within their communities. This entails assessing how social determinants of health (SDOH), which include structural and economic factors, impact the organization’s ability to provide equitable care. Interviewees emphasized the value of obtaining local input on issues related to housing, transportation, and food security, as well as other social con- tributors that influence health disparities. Gathering data about the context and needs of the communities around the provider organization is especially important not only as part of a community health needs assessment but also for leverag- ing resources and relationships to address SDOH.

Interviewees described several challenges associated with data use in counterpoint to significant efforts to spur organi- zational transformation aimed at advancing health equity. Difficulties with data collection and limited or no systems in- teroperability across entities within provider organizations were among the most prevalent obstacles mentioned. Spe- cifically, consistency, accuracy, and completeness of data elements collected by individual hospitals and providers remain an elusive goal for provider organizations. Inter- viewees described a lack of interoperability of information systems within larger provider organizations as an ongoing challenge. Several interviewees also noted that the lack of common data collection standards across states and the lack of requirements in hospital accreditation systems to ensure an equity lens is incorporated into quality and safety plans limit the incentives for provider organizations to address data barriers. Interviewees also remarked that implementing pop- ulation health interventions and aggregating data at the pop- ulation level without first considering the needs of certain subpopulations can be problematic. Interventions that are not appropriately tailored can exacerbate rather than narrow the disparities gap for segments of the population, despite yielding improvements for majority populations.

Stakeholder Communication, Engagement, and Collaboration Stakeholder engagement was described by interviewees as a principal component of any provider organization’s approach to advancing health equity. All those we interviewed empha- sized the importance of engaging employees throughout the organization, as well as patients and community partners to holistically identify and address disparities.

Capturing patient perspectives, experiences, and knowl- edge was viewed as essential to informing an organization’s decisions about how resources are allocated. Experts and ex- ecutives described patients as active agents of change for orga- nizations via patient advisory councils and community boards and asserted that patients should not be viewed simply as the targets of enhanced health services and care delivery models.

All of the provider organization leaders we interviewed articulated the importance of fostering partnerships with organizations in their respective communities. Interviewees

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emphasized the concept of “looking at the provider organiza- tion through a community lens” rather than vice versa; some leaders use this principle to prioritize organizational resources internally and leverage community investments. External partnerships described by interviewees included local govern- ment agencies, coalitions, and community-based organizations. As one executive maintained, an organization’s population health strategy must be aligned with the community’s concerns in order to positively change public health outcomes.

Discussion and Practice Implications In order to determine ways to intervene on disparities and promote equity, provider organizations must first commit to better understanding the differences in the care provided to their patient population and subpopulations, and their health outcomes. However, provider organizations are at different stages in the process of recognizing, understanding, and ad- dressing health disparities and promoting health equity. Some provider organizations, such as those discussed in this article, are at more mature phases in the change process and have learned valuable lessons and developed strategies that organizations at earlier stages can adapt and adopt. Although there is no “one-size-fits-all” approach to this work, insights from the interviews we conducted offer actionable strategies that shed light on where provider organizations could invest their energies and resources to begin to more systematically implement changes that advance health equity. Health care leaders emphasized that there are different pathways organiza- tions can take to systematically advance health equity; the optimal pathway depends on the specific needs and resources of the organization and the community it serves. All of the pathways, however, require a provider organization to take a broad view of their community and SDOH, understand and leverage their role as an economic engine of the commu- nity, and empower staff to use QI processes. Improving collec- tion and analysis of self-reported (REAL and social needs) data, as well as information on neighborhood needs and re- sources, is a starting point.

In addition, oversight organizations play a key role in monitoring how provider organizations progress toward meet- ing expectations that are required by regulators. By working with policymakers, these entities could support policies re- quiring enhanced and more consistent data collection and stratified quality reporting so that provider organizations be- come aware of and address disparities in care delivery and out- comes. Policies could also be designed to encourage provider organizations to more effectively leverage community benefit dollars, for example, by coordinating the provider organization’s efforts with broader neighborhood, community, and regional improvement planning. Developing consistent expectations and standards across oversight organizations, coupled with federal and state policies, would facilitate the work of creating the lasting change necessary to address health disparities and achieve health equity.

Although the team identified a diverse group of provider organizations, leaders, and experts focusing on advancing health equity and organizational change, the study results are limited by the small number of interviews. The identification

Organizational Change to Advance Health Equity

of potential respondents was limited by the availability of public data. It is plausible that qualified organizations and inter- viewees were not considered because of an absence of pub- licly available information about their efforts and that another cohort of provider organizations with different cul- tural and organizational characteristics could yield some- what different themes. The results of this study reflect these, and the other inherent limitations associated with a limited set of qualitative interviews.

Although our findings are based on a limited sample, they nonetheless offer important insights. We ensured representa- tion of individuals with different professional backgrounds whose institutions serve different geographies and represent a range of organizational structures. Future research with a larger sample may illuminate additional key components re- quired to support organizational change and explore the value proposition for provider organizations to conduct and sustain work in advancing health equity.

Although systematic, coordinated approaches to reducing health disparities remain nascent in many provider organiza- tions, the national dialogue around social justice issues and the further disparities highlighted by the COVID-19 global pandemic serve to magnify the need for provider organizations to adopt a systematic approach as they work to achieve the promise of high-value, equitable, and safe health care for all.

Acknowledgments The authors thank Jordan Luke, MA, Centers for Medi- care & Medicaid Services Office of Minority Health, and Tenly Biggs, MSW, LCSW, Substance Abuse and Mental Health Services, for their technical direction. The authors extend their gratitude to the health equity experts and ex- ecutives from the health systems and hospitals featured in this article; the team is appreciative of the interviewees’ contributions.

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