Lack of Accountability

Too many senior leaders across the health system aren’t being held accountable for addressing racism and also lack the leadership competencies to carry out this work.

“I’ve always worried about leadership in healthcare—it is one of the reasons why we still have disparities identified over 50 years ago,” one health leader said. “It’s leadership that has not paid attention or has chosen not to respond to the need or the data. So, if I had my dream, I would totally revamp health system leadership, the competencies that you need to run a healthcare organization.”

In addition to more political will to address structural racism, many interviewees believe new leadership approaches are needed that deprioritize positional leadership, embrace collective action, and involve community members and other stakeholders in decision-making. 

“Leaders must have their communities as accountability partners,” a leader emphasized. “Anybody who has a leadership model that’s not a collaborative leadership model or doesn’t have some kind of accountability circle that’s not a board of directors, is not really serious in this work.”

New approaches require the development of deeper competencies for collective leadership, along with an ethos of deep justice, humility, and courage, many leaders said. 

“Healthcare organizations still promote self-centered misogynistic environments,” a leader said. “There needs to be a shift that honors and promotes community over individual, and empathy and compassion as qualities of leadership.” 

Another described it as, “Invested, authentic, kind, and committed leadership driving the efforts from board to executive leadership and down. And a willingness to have conversations.” 

Leaders called out the harmful impact of the hierarchical culture in healthcare, and the relationship of that culture to structural racism. “As a medical student, you weren’t even allowed to talk to the upper level attending physician. Hazing is normalized,” the leader said. “People [in different disciplines] don’t train together, so people don’t have respect for each others’ roles or competencies. This siloing mirrors the way we provide care.”

Many said health leaders need to be more aware of their own biases. One person shared, “There is a need for an organization to turn a lens on itself. For them to explore individual bias and prejudices, especially leaders. People acknowledging their biases and prejudices. There is a need for greater self-reflection and self-honesty to ensure lasting change.”

A sign of progress is when there is visible shared responsibility and accountability for equity. “It’s a win when a whole meeting passes and there’s lots of conversation about equity, and I haven’t had to say a word. [People from across the organization say] ‘I think there’s an equity consideration here,” one leader shared. “We need to move this from a siloed experience and responsibility of the few to the many, a state where everyone understands that equity is fundamental to the health of the enterprise.”

These are the views of health leaders who participated in an 8-month project to analyze structural racism across the U.S. health system and provide recommendations for the collective leadership required to dismantle it.