Create Cultures of Equity
What does it mean to create cultures of equity, and why is it important?
A culture of equity refers to the environment and culture of an organization that:
- identifies inequities; and
- takes responsibility for eliminating those inequities by applying an equity and anti-racist lens to make systemic policy and procedural changes that dismantle discrimination, biases, and disparities.
Creating a culture of equity means embedding equity into your organization’s core values and daily operations. It’s not just acknowledging health inequities, but actively identifying and addressing the structural and systemic factors that cause them. Creating a culture of equity requires everyone, from leadership to frontline staff, to recognize inequities as unacceptable and take action to eliminate them.
This work demands honest internal reflection. Your team must examine power dynamics, leadership representation, decision-making processes, and resource allocation through an equity lens—revealing barriers that limit effectiveness and inclusion. You are far more likely to reduce disparities rather than reinforce them when equity is embedded in your organization’s culture and all of its quality improvement activities. When equity is embedded in your organization’s culture, your quality improvement efforts are far more likely to reduce disparities rather than reinforce them.
Creating cultures of equity continues even after specific health equity initiatives end. It requires ongoing effort, not a one-time glance. A strong and healthy culture of equity will energize and help sustain nearly every other organizational goal and objective. Any initiative will have a higher chance of succeeding when team members feel included, valued, and have equal opportunities to exhibit their strengths and receive recognition and support. The Advancing Health Equity team has learned that health equity initiatives that take place within organizations with a strong culture of equity are more likely to succeed compared to equity initiatives launched in organizations without strong cultures of equity.
When should I create cultures of equity?
Activities to create a culture of equity should begin as soon as possible. Even though creating a culture of equity is in many ways its own initiative, it is a critical component of all work to advance health and healthcare equity.
The Time Estimate chart below provides a high-level overview of the steps as well as the approximate number of meetings for which to plan. The estimates will vary from team to team. Ideally, the work of creating cultures of equity will eventually involve gaining the buy-in (if needed) of organization leaders. Also, the work might move outside of your immediate health equity team because it will involve organization-level objective and goal setting, and strategic planning.
| Key Activities | Time Estimate: ~13+ Hours |
|---|---|
| Review and discuss Create Cultures of Equity: A Critical Approach To Understanding Systems of Oppression | 2 one-hour meetings |
| Review and discuss Create Cultures of Equity: Transforming Operations and Culture to Advance Health Equity | 2 one-hour mtgs |
| Review and discuss Best Practices for Institutionalizing Fair and Inclusive Health Care Practices and Measuring Progress. Note which of the activities for each of the five elements might be a good fit for your organization or team. | 2 one-hour mtgs |
| Reflect on the team policies and procedures of your organization(s). | 2-3 one-hour mtgs |
| Brainstorm ideas and make a tentative plan or proposal to begin creating or improving cultures of equity. | 5-6 one-hour mtgs |
| Share the tentative plan or proposal with key stakeholders, begin earning stakeholder buy-in, finalize the plan, and begin implementation. | Ongoing. |
How can you create cultures of equity?
As a team first review the Create Cultures of Equity: A Critical Approach To Understanding Systems of Oppression presentation as a team, below. Then, the team should review the Create Cultures of Equity: Transforming Operations and Culture to Advance Health Equity presentation. The team should be given plenty of time to discuss the concepts and ideas in both presentations.
Note: The presentations can bring-up conflicting world views amongst team members or within an organization that they might need to work through. It can be difficult to acknowledge and discuss these differences. An neutral facilitator from outside your organization(s) could help your team review and discuss the material.
Next, review Best Practices for Institutionalizing Fair and Inclusive Health Care Practices and Measuring Progress (from the Institute for Healthcare Improvement’s Advancing Health Equity: An Approach to Systematically Identify and Evaluate Health Disparities). This resource provides high-level guidance to create a multi-year strategic plan for advancing a culture of equity for healthcare sector organizations.
Resources to Create Cultures of Equity
Create Cultures of Equity: A Critical Approach To Understanding Systems of Oppression (Presentation)
A training presentation that grounds health equity work within critical theory. It covers definitions of health equity, equity vs. equality, and what an organizational “culture of equity” means. It introduces three theoretical frameworks (critical consciousness, intersectionality, relational-cultural theory) and examines systems of oppression — including racism, colonialism, and redlining — as root causes of health disparities.
Create Cultures of Equity: Transforming Operations and Culture to Advance Health Equity (Presentation)
This action-oriented follow-up to the presentation above presents five implementation strategies:
- Ground diversity, equity, and inclusion efforts in critical theory
- Train staff beyond cultural competency to include critical consciousness
- Strengthen relationships as vehicles for change
- Empower an implementation team that models equity
- Align culture transformation with operational transformation.
This presentation includes real-world examples from multi-organization collaborative teams in Washington, Delaware, and Illinois.
Best Practices for Institutionalizing Fair and Inclusive Health Care Practices and Measuring Progress from the Institute for Healthcare Improvement’s Advancing Health Equity: An Approach to Systematically Identify and Evaluate Health Disparities; Appendix B).
This resource guides organizations in developing a strategy to maximize the chances of successfully identifying, reducing, and eliminating health and health care inequities. Implementing the strategy and tracking progress will provide key data to organization leadership regarding the status of the organization’s equity efforts.
In addition to addressing the advancement of equity for patients and health plan participants, this practical guidance also addresses equity, inclusion, and belonging for the organization’s employees.
Assessing and Improving Activities to Create Cultures of Equity
| Assessing Team and Organization Key Stakeholder Alignment | Next Steps |
|---|---|
| Are initiative participants and key stakeholders (e.g., team members, organization leadership) operating from the same definitions of health equity, disparities, inequity, and equitable care? | Discuss the following questions and use the team’s responses to identify next steps: *What resources, if any, were used to create the definitions? *Were patients and/or representatives of community based organization partners consulted and involved in deciding which definitions and concepts to use? *Have all team members and/or key stakeholders been meaningfully involved in selecting and learning the definitions of key concepts? |
| Diverse transdisciplinary teams grounded in critical theoretical paradigms that explicitly center on power analysis will experience fewer challenges in negotiating worldview differences than transdisciplinary teams that do not share that perspective. Are initiative participants and key stakeholders (e.g., team members, organization leadership) grounded in, and operating from the same critical theoretical paradigms? Do participants agree on the need to focus the work of creating a culture of equity on explicit power analyses? | Discuss the following questions and use what is uncovered to identify next steps: *What resources and processes, if any, were used to learn about critical theories and power analysis? *Are team members and key stakeholders able to individually describe the critical theories utilized for creating cultures of equity and how to apply a power analysis to the work? *Do participants agree on utilizing those theories and approaches? |
| Have initiative participants and key stakeholders (e.g., team members, organization leadership) discussed the following questions: Is the team/organization: * Replacing a focus on cultural competence with a focus on critical consciousness? * Hiring and supporting implementation teams that model a culture of equity? * Emphasizing relationships as a vehicle for change? * Ensuring equity-focused implementation and operations? | Utilize the discussion to identify areas for improvement. Create specific, measurable, realistic, and time-bound goals to address improvement needs. |
| Have initiative participants and key stakeholders (e.g., team members, organization leadership) discuss if the organization’s activities to create a culture of equity have: * adequate funding and personnel support. * long-term evaluation periods. * support for experimentation, including failure. | Utilize the discussion to identify areas for improvement. Create specific, measurable, realistic, and time-bound goals to address improvement needs. |
| Assessing Common Root Causes of Problematic Relationships with Surrounding Communities and Patients Living with Inequities | Next Steps |
|---|---|
| How is the initiative actively working to recover historical memory to understand the etiology of oppression and understand the lived experiences of those experiencing oppression? Note: Recovering historical memory requires partnering with the patients, families and members of excluded communities living with and impacted by health inequities. It involves learning more about their perspectives and experiences regarding the multi-sector healthcare system, its organizations (especially your own), and the roles that they play creating health and healthcare inequities. | 1. Conduct a self-assessment of your organization’s history of positive and negative impacts on the patients and families of excluded communities living with and impacted by health inequities. Include: * Your organization’s positive and negative impacts on community based organizations * Research on the entire organization’s whole history, not just the recent past and not just certain parts of the organization 2. Respectfully partner directly with community-based organizations and the patients and family members of excluded communities living with and impacted by health inequities. Ask them about their memories and perceptions of how your organization has impacted them and the community in which they live and work. * Seek guidance from those experienced in doing such work. You may do more harm than good by seeking guidance without adequate preparation. * Remember to fairly and adequately reimburse participants for their expertise and time. * Ideally, approach them with an offer of tangible resources or an inquiry of how you can be helpful to them. |
| Does your organization or initiative view marginalized individuals and communities through a strengths-based perspective that values their resilience, knowledge, and lived experiences as critical for reducing health and healthcare inequities? | Discuss the following questions and use what is uncovered to identify next steps. Employing a strengths-based perspective requires: * Recognizing the imperative to partner with patients, family members, and community organizations to identify and eliminate the root causes of health and healthcare inequities. – Does your organization actively partner with patients, family members, and community organizations to conduct root causes of health and healthcare inequities? > Why or why not? – How can your organization improve? * Valuing the lived experience and expertise of patients and communities living with health inequities at least as much, if not more than, those working within healthcare organizations and academic settings. – Does your organization give equal weight to the expertise of patients and community based organizations when designing care delivery transformation activities to reduce and eliminate health and healthcare inequities? > Provide examples to support your answer. – How can your organization improve? * Ceding decisional authority and power to those with lived experience. – Does your organization share or cede decisional authority to patients and community based organizations when designing care delivery transformation activities to reduce and eliminate health and healthcare inequities (e.g., having substantial patient and community-based organization representatives on governance boards with decision-making authority versus only on advisory boards)? > Provide examples to support your answer. – How can your organization improve? * Providing equitable and adequate compensation for those who shared their lived experience and expertise. > Does your organization provide financial compensation for patients and community based organizations when they share their insights and expertise with you? – If no, why not? – If yes, what is the level of compensation (e.g., hourly rate of pay) for their expert insight and recommendations compared to what your organization typically pays other external consultants? Is it different? Why? – Does your organization pay less than the equivalent of the local minimum wage for the expertise and recommendations of patients and community based organizations? If yes, why? – Provide examples to support your answers. > How can your organization improve? |
| Assessing Core Assumptions Underlying Your Team’s or Organization’s Work to Advance Health Equity | Next Steps |
|---|---|
| Has your team or organization reoriented its perspective and work from focusing on the “individual level” to the “structural level” of health and healthcare inequities? For example, instead of asking questions such as: “Why are African American and Black pediatric patients with asthma hospitalized more than our other patients?” your team and organization would ask: “Why is our health system less successful helping African American and Black pediatric patients with asthma stay out of the hospital?” | Use self- and group-reflection to consider the ways that individual, professional, and organizational socialization might reinforce racism, white supremacy, and other forms of oppression. Review and discuss the following resources and use the team’s responses to identify next steps. *Create Cultures of Equity: A Critical Approach To Understanding Systems of Oppression Ask how your health system or organization might be impacted by, and also reinforce, existing systems of oppression. *Conducting a Root Cause Analysis with an Equity Lens: Key Considerations Gain practice orienting your world view utilizing a structural perspective. Identify one or more health or healthcare disparities in your patient population. Then, identify or hypothesize potential root causes of each inequity for each of the following levels: policy, community, organization, microsystem, and care team members. |
| What actions is your team or organization taking to create and advance cultures of equity? | Discuss the following questions and use what is uncovered to identify next steps. *What steps is the team or organization taking to de-naturalize structural-level discrimination and oppression in the following contexts? Inside the organization as experienced by employees. For patients, families, and community based organizations that serve them. *What has the team or organization done to analyze and deconstruct the various circumstances that produce and exacerbate poor health? *How is the team or organization utilizing theories of critical consciousness to transform unjust conditions and power dynamics? *Who is held responsible and accountable at your organization for reducing inequities amongst employees? – How is accountability assessed or measured? – What are the accountability mechanisms? *Who is held responsible and accountable at your organization for reducing health and healthcare inequities within the patient population? – How is accountability assessed or measured? – What are the accountability mechanisms? |
About the Roadmap Goal and Objective Setting Tool
Use the Roadmap Goal and Objective Setting tool to facilitate and document the development, implementation, and evaluation phases of your health equity initiative. It will help your team realize your vision to reduce and eliminate health and healthcare inequities by providing a centralized resource to:
- establish process goals that align with each Roadmap component;
- document task status, identify project champions, and maintain detailed notes;
- monitor progress across multiple Roadmap components simultaneously; and
- promote consistent team communication, accountability, and progress.