In 2013, Health & Human Services promulgated the enhanced National Standards for Culturally and Linguistically Appropriate Services in Health Care. These updated standards now include an emphasis on the critical role of health care leaders in advancing quality care and health equity for diverse populations. These standards are intended to guide health care leaders in implementing a strategic approach to improving care for diverse populations. In addition, the standards promote health equity as integral to the operational environment and strategic planning process of a health care organization.

Pursuing Equity — A Context, Not a Program

Our aim in this article is to point out that pursuing quality care and health equity for diverse populations is an organizational value or context — not simply a separate program or project — for today's accountable health care leaders. In serving today's diverse communities, health care leaders focus on: (1) effective community engagement, (2) expanding the diversity of the organization's governance body and leadership team, (3) strengthening a diverse workforce, and (4) delivering culturally and linguistically competent services.

Creating an Organizational Value System

All health care leaders manage organizations guided by integrated core values that permeate their organization's decision-making and day-to-day operations (see Organizational Ethics in Healthcare — AMA). Serving diverse communities and promoting equity requires leaders who understand that they are operating in an area where they are no longer experts. There is some risk in becoming "learners" who are asked to give up control so they can collaborate on ideas for building accountability with minority and under-resourced communities (see Joint Center for Political and Economic Studies, "The Economic Burden of Health Inequalities in the United States").

In 2011 the HHS Advisory Committee on Minority Health took on the charge of developing a core values statement to guide the work of this congressionally established committee in the context of the Affordable Care Act. The committee's work resulted in highlighting key organizational values that are critical to a strategic approach to quality care and equity for diverse communities. Three of the values articulated by the ACMH are particularly relevant to leaders intending to direct their organizations toward equity:

Promoting health for the common good. Achieving the status of a healthy nation requires a national strategy for ensuring that costs and benefits are shared as a public good, with everyone contributing according to their means and receiving services based on their needs.
 
Respecting the diversity of our nation's communities. It is critical to understand and place value on diversity in managing and directing the health care system, including, among other factors: race, ethnicity, culture, language, sexual orientation and age.

Effectively engaging diverse communities. Develop and maintain open dialogue with communities through interactions with members and trusted leaders to identify critical issues and effective strategies for improving the public's health (ACMH, Core Values Statement).

Acting through the Lens of Leadership

The ACA provides an opportunity for health care leaders to collaborate on achieving genuine health reform with an emphasis on quality care and improved health status for all U.S. communities. The American Hospital Association's participation in the Equity of Care/National Call to Action follows on the work of the Institute of Medicine's "Crossing the Quality Chasm," which outlined six quality aims: health care should be safe, effective, timely, patient-centered, efficient and equitable. It also embraces the research and recommendations of the IOM's subsequent report, "Unequal Treatment,"which provided the first detailed, systematic examination of racial and ethnic disparities in health care and a blueprint for addressing them.

Achieving health care equity is both a challenge and an opportunity for any organization. Barriers clearly exist in the form of constrained budgets, insufficient staffing, technology gaps and the absence of patient data needed to address disparities. However, there is now a significant compendium of research, promising practices, model strategies and training resources related to equity that is available to accountable leaders who are informed about and committed to serving their communities. (Examples of strategic approaches include America's Essential Hospitals and Essential Hospitals Institute’s "Assuring Healthcare Equity: A Healthcare Equity Blueprint" and The Disparities Solutions Center at Massachusetts General Hospital, "Improving Quality and Achieving Equity: "A Guide for Hospital Leaders" (see also reference list below).

Over the years, the critical role of executive leaders in achieving health equity has been analyzed in a number of studies and projects. The consensus derived from this work calls for leaders to take a strategic approach for achieving equity that focuses on four specific dimensions or domains of health care management:

Engaging effectively with all segments of the community. Responsive leaders engage in open dialogue and interactions that ensure community influence in developing policies that affect the whole community. This community influence is critically important for informing executives about the origin, nature and effects of health disparities on all populations.

Expanding the diversity of the organization's leadership team and governance body. These groups should represent and be responsive to the diverse populations they serve. Genuine diversity and inclusion in the C-suites and governing bodies of health care organizations is about more than simply numbers; it also involves expanding perspectives and responding to the needs of all populations. Representative and responsive leadership ensures that providing quality health care and pursuing equity become part of the organization's environment, policies and practices, and that effective operational and administrative infrastructures provide support (see American College of Healthcare Executives, "A Race/Ethnic Comparison of Career Attainments in Healthcare Management" and IFD/HRET, "Diversity and Disparities: A Benchmark Study of U.S. Hospitals").

Strengthening a diverse workforce through planning and administering a human resources program that recruits, orients and trains staff to provide culturally and linguistically appropriate care. Leaders promote human resource strategies that move the organization's patient care programs beyond cultural sensitivity ("I mean well") toward cultural competency ("I am doing well for the patient") and the elimination of health care disparities (see IOM, "In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce" and WK Kellogg Foundation, "Missing Persons: Minorities in the Health Professions" — Report of the Sullivan Commission).

Delivering culturally and linguistically competent services using evidence-based measures of care. Clinical and administrative leaders understand that quality care for diverse populations requires that cultural and linguistic competence be an essential element in the design, administration and delivery of services. The organization should communicate with patients and families in their own languages and be responsive to patients' individualized and cultural needs. Standardized data collection and measures of care should be established and maintained to understand and eliminate disparities in health care (see HRET Disparities Toolkit and The Commonwealth Fund, "Who, When, and How: The Current State of Race, Ethnicity, and Primary Language Data Collection in Hospitals").

As we work through this current transition in health care, it is critical for leaders to collaborate in transforming a health care system that is characterized by equity, responsiveness and genuine inclusion of all U.S. communities.

Disclaimer: The ideas and opinions expressed in this article are those of the authors and do not necessarily reflect the policies or positions of the organizations with which they are employed or affiliated.

Edward L. Martinez, M.S., is a health care consultant and the 2013 chair of the board of directors of the AHA Institute for Diversity in Health Management; he was a member of the U.S. DHHS Advisory Committee on Minority Health and the CEO of LAC+USC Medical Center in Los Angeles. Frederick D. Hobby, C.D.M., M.A., is the president and CEO of the AHA Institute for Diversity in Health Management. Robert C. Like, M.D., M.S., is a family physician with a background in medical anthropology; he is a professor and the director of the Center for Healthy Families and Cultural Diversity at the Department of Family Medicine and Community Health, part of Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.

Selected Resources for Leaders Pursuing Equity

America's Essential Hospitals (formerly National Association of Public Hospitals and Health Systems), Research Brief, "Public Hospitals Focus on Reducing Health Care Disparities."
http://essentialhospitals.org/wp-content/uploads/2013/12/08DisparitiesBrief.pdf

DiversityBusiness.com, "When Minorities Become the Majority — The Vision for 2050," Leonard Greenhalgh, Ph.D.
http://www.diversitybusiness.com/news/diversity.magazine/99200801.asp

DiversityRx, hundreds of resources on cross-cultural health care and a directory of organizations that work in this field.
http://diversityrx.org

HHS, "HHS Action Plan to Reduce Racial and Ethnic Health Disparities."
http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285

National Quality Forum, "Healthcare Disparities and Cultural Competency Consensus Standards."
http://www.qualityforum.org/projects/Healthcare_Disparities_and_Cultural_Competency.aspx#t=2&s=&p=3

Institute for Diversity in Health Management/Health Research & Educational Trust,"Building a Culturally Competent Organization: The Quest for Equity in Health Care"
http://www.hret.org/quality/projects/cultural-competency.shtml

The Joint Commission, "One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations"
http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf

The Joint Commission, "Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide"
http://www.jointcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf

The Disparities Solutions Center at Massachusetts General Hospital, publications highlighting practical solutions to identify and address disparities within hospitals and other health care organizations, including guides for health care executives and leaders.
http://www2.massgeneral.org/disparitiessolutions/resources.html