Eli MacLaren

Written by Eli MacLaren @elithechef eli@bif.is

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In 2015, BIF was working in Dallas, TX – a racially segregated city – with Children’s Health System of Texas. As part of that work, we were building Children’s design thinking capability – and nothing was getting designed without customer feedback.

At the end of a particularly grueling design sprint, we brought in a group of teenagers – for whom the staff had been designing and asked them to critique the concepts. We could see the staff sweating – getting critiqued by customers is hard; getting critiqued by teenagers is harder. And, not for nothing, race was on our minds:

How open and honest a conversation would we have, with a primarily black teenager customer group and a primarily white staff group?

Privilege and power were the two elephants in the room.

But something amazing happened. After a fabulous critique, the teenagers were invited to ask questions of the staff. One of the teenage boys turned to the staff and said:

“Was that hard for you? Because it was incredibly uncomfortable for us.”

That question began a courageous conversation that openly and honestly explored and addressed our two elephants.

It is a well-established that racial inequity in the United States generates poor health outcomes. Countless studies, programs, and initiatives have been launched to attempt to close this racial gap in health outcomes, yet disparities persist. Why?

Part of it has to do with implicit (and sometimes explicit) biases. White doctors will often dominate the conversation when seeing a black patient and spend less time listening to the personal experiences of the patient. They will often discredit their patient’s abilities to comply with medical instruction and undervalue perceptions of pain. Often, all done without conscious intent.

These biases affect how healthcare is delivered and also how it is received. When a patient feels belittled by their physician or if their experiences and feelings are discredited, trust in the medical community erodes. As it is, distrust exists writ large, stemming from deep historical roots of unethical and racially motivated practices, from slavery and sterilization to Tuskegee and syphilis in the 1970’s.

This distrust that is not easily abdicated by a well-intentioned institution. Trust is even harder to establish when diversity, equity, and inclusion is treated as a bolt-on, which it so often is. For example, while designing a community health center in a primarily Latino community, we heard first hand how families often screened for Spanish speaking physicians only to discover that Spanish speaking meant the ability to say, and only say: “Hola, como estas?”

The institution is trying of course, but the result is often insulting.

The challenge is that bolt-on’s like this is what we know how to do.

Begging the question:

How might we design healthcare business models that generate better outcomes by recognizing the importance of diversity, equity, and inclusion?

First, we must understand the job that people want done. We hear often from patients that this is as simple as being treated as a human being. This requires that we practice inquiry – instead of creating a story about someone based on the color of their skin or the language they speak, we invite them to tell their stories. In this sense, storytelling is a critical organizational capability  – and the reason why BIF has worked with innovating organizations, such as Mass General Hospital and the Robert Wood Johnson Foundation, to build storytelling muscle within the medical industry.

Second, we must begin to recognize what white privilege means and the implications of that from a customer’s point of view. Our privilege means that we can buy band-aids in “flesh” color and they will likely match the color of our skin. Our privilege means that we recognize and know how to use the food that is sold in our supermarkets. Our privilege means that we can comfortably avoid, ignore, and minimize the impact that racism has on our lives.

This just isn’t true for Americans of color, and it’s incumbent on the healthcare industry to acknowledge that the lived experiences of inequity play a pivotal role in the health and well-being of marginalized communities.  Gaps in income, housing, and education are all significant factors when addressing the underlying disparities in both physical and mental health outcomes. To the extent that upwards of 70 percent of health outcomes are from social determinants, not medical determines. And while we know this, our approaches have been insufficient bolt-ons. We have created and funded collective impact efforts around housing or asthma; we have created care management programs. But rarely have we considered if we needed to fundamentally reimagine the business that we’re in. This is why the business model BIF designed for Children’s Health System of Texas moved it out of the business of delivering health programming and into the business of brokering relationships with social service agencies. This is why we authored the blueprint for creating sustainable new business models for moving Health Care Upstream.

Thirdly, we have to recognize that some aspects and assumptions of white culture in healthcare make it unattractive and irrelevant to many. Our white culture assumes a future orientation with delayed gratification. When we invert this, we’re able to recognize that people just want to feel well now, and that inspired a model for family well-being. Our white culture emphasizes creating divides between the personal and professional, which prevents the empathy, trust, and context that is essential between patient and caregiver.  Our white culture emphasizes rugged individualism which is not aligned with how many people live and thrive. This is why, when addressing preterm births in Cincinnati, we considered “what if we changed our care delivery model and approached medical appointments more like community gatherings” where patients share experiences that affect their overall health and well-being with a community of people who live and look like them?

When care becomes personalized, instead of medicalized, health outcomes improve.

As part of BIF’s early design work in Dallas, we created a small prototype called Your Best You to determine if improving well-being was actually possible. Our hypothesis was that if we activated kids’ sense of personal power, we could improve their sense of well-being. Your Best You was a 2-week curriculum that married aspects of Hip-Hop culture with design thinking, heightening kids’ sense of agency, creativity, and personal impact. One of our participants, an 11-year-old girl, spoke specifically about how awesome and important it was to be in an environment that let her be herself versus asking her to conform to a different set of norms. As it turns out, the ability to be yourself does wonders for your well-being and health.

Our healthcare system, however, still prioritizes quantity over quality. It also remains true that our healthcare workforce is not taught to address societal inequities or community norms. Addressing the social differences of patients would require a different set of skills that is not currently imparted in our medical education. Which leads us to address the question: how might we begin to re-imagine medical education so that group facilitation, bias recognition, and empathetic listening are core skills taught in line with clinical practice?

This is hard work and it all requires new capabilities, like storytelling. This is why efforts to address diversity, equity, and inclusion have been treated as bolt-ons. And herein lies the opportunity:

When healthcare business models are created with equity at their core, they have the ability to move beyond the bolt-ons that have sustained the structural norms of bias and discrimination, both known and unknown and seize the opportunity to fight against insidious structural racism, the implicit biases of practitioners and patients, and even overt external discrimination.

They also have the ability to finally include and pull people into a system which otherwise feels intimidating and hostile.

At the Business Innovation Factory, we know that when our social systems treat diversity, equity, and inclusion as mere bolt-ons to the current models, our systems become fragile and unsustainable. As new business models emerge, we believe that those that put and maintain DEI at their core are best positioned to transform and improve the experiences and lives of their consumers.

Join the conversation and explore how putting DEI at the core of your business model could identify opportunities for transformation.

Part 1: The Diversity, Equity, Inclusion Imperative

Part 2: Finding Our Equity Why

Why DEI? Join The Conversation