Critical Theory, Culture Change, and Achieving Health Equity in Health Care Settings

Abstract

Achieving optimal health for all requires confronting the complex legacies of colonialism and white supremacy embedded in all institutions, including health care institutions. As a result, health care organizations committed to health equity must build the capacity of their staff to recognize the contemporary manifestations of these legacies within the organization and to act to eliminate them. In a culture of equity, all employees-individually and collectively-identify and reflect on the organizational dynamics that reproduce health inequities and engage in activities to transform them. The authors describe 5 interconnected change strategies that their medical center uses to build a culture of equity. First, the medical center deliberately grounds diversity, equity, and inclusion efforts (DEI) in critical theory, aiming to illuminate social structures through critical analysis of power relations. Second, its training goes beyond cultural competency and humility to include critical consciousness, which includes the ability to critically analyze conditions in the organizational and broader societal contexts that produce health inequities and act to transform them. Third, it works to strengthen relationships so they can be change vehicles. Fourth, it empowers an implementation team that models a culture of equity. Finally, it aligns equity-focused culture transformation with equity-focused operations transformation to support transformative praxis. These 5 strategies are not a panacea. However, emerging processes and outcomes at the medical center indicate that they may reduce the likelihood of ahistorical and power-blind approaches to equity initiatives and provide employees with some of the critical missing knowledge and skills they need to address the root causes of health inequity.

Figure 1

Diversity, equity, and inclusion (DEI) theory of change. Racism and other forms of oppression operate at the intrapersonal/interpersonal, organizational, and structural (i.e., the historical, economic, political, social, and cultural) levels. Changes at each level are critical to achieving health equity. The figure depicts 5 strategies that can help health care organizations build a culture of equity that can begin to undermine legacies of racism, colonialism, and other intersecting systems of oppression (structural level) embedded in the organization while creating conditions that support change among individual employees (intrapersonal/interpersonal level). In doing so, the organization builds a foundation for effective implementation of tools like the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care and the Roadmap to Advance Health Equity ^– that can contribute to the elimination of health care disparities and ultimately to health equity. Simultaneously, historically grounded intersecting systems of oppression hinder organizational and individual transformation, creating inherent tension in the system. Working within this tension can stimulate the innovation necessary for system transformation. Therefore, it is vital to view organizational DEI efforts as complex long-term initiatives requiring careful implementation and evaluation. Copyright © 2021 by the Department of Diversity, Equity, and Inclusion, University of Chicago Medicine. Reprinted with permission.

Figure 2

The Advancing Health Equity: Leading Care, Payment, and Systems Transformation’s Roadmap to Advance Health Equity. ^,– This roadmap informs the University of Chicago Medicine’s approach to creating a culture of equity. The model is composed of multiple components and stipulates that a culture of equity will support, inform, and sustain all equity-focused work of an organization and increase the chances of success. Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program of the Robert Wood Johnson Foundation based at the University of Chicago. Abbreviation: SWOT, strengths, weaknesses, opportunities, and threats. Copyright © 2021 by Advancing Health Equity: Leading Care, Payment, and Systems Transformation Program, University of Chicago, funded by the Robert Wood Johnson Foundation. Reprinted with permission.