President of the Commonwealth Fund
Joseph Betancourt, President of the Commonwealth Fund, explores how health leaders can drive positive health equity outcomes by anticipating challenges, being strategic and transparent, and establishing measurable goals.
What are the critical leadership traits for C-level leaders and boards to impact health equity in their patient populations?
In my 20 years of work in this area, I’ve found that there are several keys to being successful. First, it’s important to have clarity on the leadership role that is accountable for this work. In the past, we had roles that aimed to address health equity, diversity and inclusion, community health and more. We need to be clear about what we mean today by equity, whether it's all-encompassing or specific pieces of the agenda, because the skills needed may differ. For example, the Chief Diversity Officer was previously within HR and now it’s evolved. Additionally, some roles are merging.
Second, you need the historic perspective and understand that equity has long been seen as a marginal, not mainstream area of work. Often it was bolted on, but not built in. By this I mean it was managed differently than other key areas in health care, such as quality or patient safety. We spent years making the case that equity is a key part of health care, including quality and safety, among other areas. We explored different angles on how to build it in.
Third, you need to identify points of current pushback. Today, we are facing more outward resistance than ever before on equity. The key factor in my approach is to be a good student of all of health care. To bring equity to any discussion, you need to be respectful of what is on that leader’s plate and make it easy for them to see how equity can fit in.
Building on those traits, what actions are needed for equity leaders to be highly effective?
Equity leaders need to be strategic, knowing that change and perspective shifts happen at different times in different places. They may need to reframe the core principles of what they want to accomplish for different audiences. For example, the work may be framed differently in blue versus red states, community settings versus C-suite, hospitals versus health plan, for example. Equity is a principle, and many variables shape the message. You need to make the link to how equity can help leaders advance their work.
Some general leadership principles apply, including being a genuine, authentic leader, having strong communications skills and high emotional intelligence, and being transparent and values driven. Building teams and building trust in teams is important for all leaders but even more important in this space. Effective communication is central because people have stereotypes about equity and that can color what they think the role is.
Can you share some examples of how being strategic plays out in equity?
You need to understand the currency with whom you are trying to effect change. For example, leading solely with social justice in a red state may not be persuasive enough. I often tap into the patient experience, cost, and value—terms everyone has to care about—and work to show how equity impacts each of those areas.
Can you share an example of how you’ve used change management in your career to effect larger equity transformations?
The biggest example is my time at Massachusetts General Hospital. It began with a hospital President who understood the value of equity in health care and charged me and several other leaders to advance our work in the space back in 2003. My responsibility was to craft the right set of conversations with various leaders. I met with the quality and safety team to talk about how we monitor our care and what dashboards we have for tracking, and I also leveraged the Institute of Medicine report that came out at the time showing that minority Americans had poorer health outcomes compared to white Americans in preventable and treatable conditions. Equity is a key component of quality, and I asked if we could create a disparities dashboard. In that moment, I had to anticipate or examine people’s reactions and tailor my conversation appropriately. To be successful, you also need to create a culture that is about improvement, not blame—we want to be part of the solution. Our hard work on equity culminated in receiving the nation’s first Equity of Care Award in 2014 from the American Hospital Association for our work in measurement, education, patient access, and experience.
How do you embed that culture of improvement across the leaders of your health organization?
You have to do the work of helping them see how equity fits in. My predilection is the cost/quality/value/safety case. You appeal to the mission and vision, values that are about high-quality care—and how our inability to do this for everyone is something we need to be addressing. People get uncomfortable with the blame game, but this is about building better systems. It’s more aspirational than punitive.
Of course, this takes time and often multiple campaigns. You have to make it visible to patients, staff, and leaders. It’s a large, deliberate process to create this type of culture and you also need to build in accountability.
Tell us more about how you build equity into the core of an organization not bolt it on.
It’s all about execution. For years, we were heavy on aspiration, and lite on execution. Now we need to be very explicit about what we mean by equity. So, for example, equity in quality of care. Are you measuring it and are you addressing disparities when you see them? It’s also about setting goals, timelines, milestones; apportioning the right resources, building a transparency plan, and holding leaders accountable. You have to be deliberate about “we are going to achieve x this year and measure it.” You have to get down to basic execution like in all other areas of health care.
What about when you face resistance?
There is always resistance—people resist change generally. The first impulse is the sense that one is being blamed for disparities. As leaders, we have to think about the currency for change and leverage it in a targeted way in specific environments. You have to ask yourself, “How can I smoke out the resistance, and then what is the strategy to get past it?” Sometimes it’s through conversations and sometimes you create a culture where leaders have to fall in line because there is accountability across the organization. Essentially, you have to identify the resistance, dissect it, and then develop a strategy to overcome it.
An example of this is when I was back at Mass General meeting with the quality and safety team. When I talked about measuring equity, there was concern about how people would respond if we showed our results. I explained that we wouldn’t be pointing fingers and that we needed to be transparent about where we were starting from. Then they were worried about the time it would take. I said we’d bring in the resources to help. Then there was pushback about the lack of clarity on the final product, which I said we would work on and iterate on. This was a new area for the team, and they were also worried that doctors might get upset and that it could be a reputational risk to show these disparities. I needed to provide answers to the concerns, and we got through a lot of resistance together. It wasn’t resistance of bad intent, but the fear of the unknown.
My style is to engage at a deep level. People appreciate decisions when they feel like they were heard. We try to make the solutions very participatory.
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