Public health students and experts alike will agree that there are staggering disparities between the different races and ethnicities in America. Even students could explain that racial and ethnic minorities suffer disproportionally from poorer outcomes such as diabetes, asthma, maternal mortality, and even premature death from chronic diseases.

When discussing health disparities, much attention is focused on disparities in health outcomes. However, these are the final culminations of systems stacked against minority groups and, although important, lack the whole story of what causes disparities in the first place. Recent research has focused on social determinants of health, including physical environments, which play real roles in shaping a person’s health. In turn, health care organizations have been faced with the puzzling question of how to address these determinants.

However, in addition to focusing outward, organizations must begin to address disparities by looking inside the walls of their facilities and examining the discriminatory practices that, irrespective of individual behaviors and physical environments, contribute to racial disparities in health. Patient outcomes are an important aspect of assessing the quality of health care, but missing from the discussion are measurements of hospital structure and processes that inevitably lead to outcomes downstream. Structure and process can best be understood by the Donabedian model, which define structure as the administrative and related processes, including facilities, budget, and programs, and process as the delivery of medical care.

Examples of structural measurements could be the extent to which disparities are a priority of a hospital’s mission, the presence or absence of an equity task force, salaries of employees by profession and race, communities in which capital projects are placed, and whether patient demographics represent the community in which the hospital is located. Process measurements may include wait times, times spent with patients, and resources utilized by patients. These measures may be reported internally, but there may not be a standardized method to publicly release information.

Having these measures does not have to be a burden on organizations. Even the simple act of ensuring already-existing quality metrics are disaggregated by race and ethnicity can draw attention to inequities in facility processes.

In addition to all this, patient outcomes are the results of health care organizations that have long and entrenched histories of segregation. Facilities segregated by race, color, religion, and national origin have been long prohibited due to the Civil Rights Act. However, segregation still occurs in a more discrete way. Take health insurance for example: certain facilities and clinics, even within the same hospital network or building, may redirect patients to different facilities depending on their insurance status. Given that Medicaid reimburses less for care compared to other forms of health insurance, the clinics that accept Medicaid may become under-resourced. A health measurement including utilization of separate facilities based on insurance would be helpful to understanding an institution’s role in disparities and may inspire policy makers to act.

To my knowledge, there is no systematic way to measure health equity and no agreed-upon suite of measurements that would be most useful to identifying and reducing disparities within and between organizations. Aside from ad hoc reporting requirements, hospitals might not even examine health disparities in patient outcomes by race and ethnicity. Without mandates or accreditation requirements, there are little to no incentives for health systems and hospitals to release data or information, leading to less accountability and transparency. Certain aspects of data can be extracted from large federal and state datasets but that offers a limited understanding of the full extent of disparities. This presents an opportunity to develop standardized measurements that best capture a holistic perspective of an organization’s contributions to disparities.

Health care organizations shouldn’t contribute to, or even merely react to, disparities; rather, they should be proactive in providing equitable care to prevent disparities in outcomes before they manifest. Health systems and hospitals can do their part by practicing self-reflection and examining their upstream contributions to widening health disparities. Greater research focus needs to be placed on structural and process measures of health to allow for comparisons within and between institutions.

Through the development of a health equity measurement, health systems can be held accountable and begin to make real changes, improving the health of patients and communities.

Author’s Note:

The author thanks Dr. Neil Calman and the Institute for Family Health.