How does a health care clinic become a more inclusive organization that serves all people and populations equitably? Hill Country Health and Wellness Center (Hill Country), a federally qualified health center in northern rural California, set this goal for itself as the organization was expanding. It pursued this work under Advancing Integrated Models (AIM), a national initiative led by the Center for Health Care Strategies (CHCS) and made possible by the Robert Wood Johnson Foundation.
CHCS recently spoke with Brandy Isola, MPH, CHC, Chief Compliance Officer from Hill Country, along with Melissa Meza, MPH, Senior Program Manager and Rishi Manchanda, MD, MPH, CEO both from HealthBegins, to learn more about Hill Country’s experiences in becoming a more inclusive organization. HealthBegins, which provided technical assistance under the AIM initiative, reviewed Hill Country’s practices to identify opportunities for improving health equity and helped Hill Country develop strategies to support its ability to advance equity, diversity, and inclusivity among staff and patients.
Q: Can you describe why it was important for Hill Country to pursue this work?
We grew exponentially and when you start as a small family organization and grow big, there’s a culture shift that can’t really scale unless you put in some intentional steps.
Brandy: Hill Country has always been committed to health equity and inclusion, and meeting people where they are and working with people who need care the most. We had two things happen. We went through a period of rapid growth in what was a very small, very rural organization. We grew exponentially and when you start as a small family organization and grow big, there’s a culture shift that can’t really scale unless you put in some intentional steps. And we had an unfortunate incident of inappropriate behavior from one of our employees to another employee that was a wakeup call for us that instigated us to think through what we needed to do. We wanted someone to help us do an assessment of where we were at and what kind of training would be best.
Q: HealthBegins, can you describe the organizational assessment process that you undertook with Hill Country?
Melissa: First, we worked with Brandy and her colleagues to briefly review Hill Country’s policies and procedures and established baseline information, and then we provided them with an organizational self-assessment tool. We developed this organizational self-assessment based on the Toolkit to Advance Racial Health Equity in Primary Care — which HealthBegins developed and published in collaboration with the California Improvement Network in April 2022. The self-assessment tool emphasizes racial health equity, and not just health equity in general, which aligned with Hill Country’s goals. Hill Country selected five key leaders in the organization who completed the assessment. Then we analyzed the information and presented to the Hill Country team so they could have a candid conversation to identify their strengths as well as their main opportunities for improvement.
Q: Brandy, equity or racial equity are broad terms — in approaching this work, can you describe your goals?
We wanted to make sure we all have a basic level of understanding of health equity, and ultimately to see our own biases and be open to identifying and challenging them when we are interacting with our co-workers, our clients, and patients.
Brandy: To provide good care you have to have highly trained staff members who feel comfortable in their work environment. Within the broader goal of improving the quality of care for our patients is that underlying goal of an inclusive and diverse work environment. The focus of this effort is to keep our workforce engaged in that conversation and support an equity-focused workplace that benefits both our staff and patients. We wanted to make sure we all have a basic level of understanding of health equity, and ultimately to see our own biases and be open to identifying and challenging them when we are interacting with our co-workers, our clients, and patients.
Q: What were some key takeaways from the assessment process? Any aha moments or transformative examples that you can share?
Brandy: It was exponential in terms of the value. Just even doing the assessment with the key leaders was an educational opportunity for us. We have a leader with tremendous influence within the organization, and she said to me after doing the assessment, “I didn’t even know we were supposed to be doing or thinking about this stuff.” That awareness building to me was huge.
The real tangible benefit for us was understanding if we can’t measure health inequity in the outcomes of our patients, then we don’t know, and if we don’t know then we can’t change. We had this great conversation about the process that our front desk staff use and we explained why gathering race and ethnicity data is important because it wasn’t clear to everybody at first that if we don’t have that information in patient charts, there is no way we are ever going to be able to find where our blind spots are. I was also able to have a conversation with our staff for our Uniform Data System report (FQHC reporting) where we report the percent of our patients who are non-English speaking. We learned that there are flaws in that process and are now working to address them.
Q: In approaching this work, how has Hill Country envisioned what success would look like?
Brandy: Success would be to spark the same kind of commitment in staff that our executive leaders feel about health equity and sparking that in different places in our organization. Little things like when our human resources director looks through our policies and notes areas to add language to be more inclusive. Or when our staff start taking this work on themselves. It will look like our front desk staff saying, “I’m uncomfortable asking these questions, but I know it’s important, can we do this process improvement so that we can get better data from our patients?” Or “Here’s why we don’t get good information, and can we make this change?” That to me would be success — small measurable changes led by staff at all levels
Q: Rishi, you’ve worked with other organizations with similar goals — how do organizations need to rethink what they are doing to advance health equity?
If you don’t model a culture of love and equity and joy and growth, and you don’t have that space for leaders to find and exercise courage, then equity just becomes a check the box thing. And then it’s not only uninspiring — it’s ultimately ineffective.
Rishi: From my perspective, a lot of folks look at health equity in the same way they might look at clinical quality improvement (CQI) — as a strategic, operational or programmatic change. But those who really understand CQI and organizational change realize it’s not just about strategic, technical, and operational changes, it’s about culture change. But culture change gets short shrift time and time again. When CQI focuses on “equity” as just another set of measures to add to the list, it may overlook the need for organizational culture change. Words like “love,” “joy,” “inspiration,” “meaning,” as well as “discomfort,” “concern,” “frustration” and most fundamentally a word that we come back to a lot, “courage,” are concepts critical to our work and the culture change needed to address health equity — yet, these words are not typically measured in a spreadsheet or prioritized by regulators.
Right now, a lot of folks talking about health equity are skipping past the culture aspect of it, because understandably we have growing contractual requirements and regulatory and compliance issues. They’re saying, “Well we gotta check the box for health equity, now how do we do that?” That’s the exact opposite of what we need. For equity, a really important point we’ve learned is that courageous leaders need space to talk about emotions, history, values, and culture, and not just about the important programmatic or technical kind of changes to do this work well. If you don’t model a culture of love and equity and joy and growth, and you don’t have that space for leaders to find and exercise courage, then equity just becomes a check the box thing. And then it’s not only uninspiring — it’s ultimately ineffective.
Brandy: And what’s really cool about Hill Country is our leaders are courageous leaders. They also happen to be social workers and have the ability to be comfortable with emotions. I don’t think that’s entirely common in health care organizations, and a huge element of this is that leaders need to start being comfortable with having messy conversations with their staff.