Above Photo: From Practicalplaybook.org
Despite the position of the United States as the wealthiest nation in the history of the world, a staggering 43 million Americans and 1 in 6 children live in poverty—a level greater than that of its peers. Four in 10 Americans could not sustain living at the poverty level for just 3 months if their main source of income disappeared tomorrow. White family wealth remains seven times greater than African American family wealth and five times greater than Hispanic family wealth, as of 2016.1
These significant economic inequities, amplified by a long legacy of racial exclusion, create an impossible headwind in our nation to improving health and well-being if not addressed intentionally and systematically. Today, the difference in lifespan after age 50 years between the richest and the poorest has more than doubled—to 14 years—since the 1970s,1 and communities a few miles apart experience life expectancy differences of more than 20 years. According to Philip Alston, United Nations US Special Rapporteur to the United States, “Americans can expect to live shorter and sicker lives, compared to people living in any other rich democracy, and the ‘health gap’ between the United States and its peer countries continues to grow.”2
We must apply a health equity—as well as a racial equity—lens to our strategies, acknowledging both historical and systemic inequities as identifiable root causes of poor health that need to be explicitly named. Furthermore, and equally important, our communities and their leading institutions must therefore reevaluate the toolbox of solutions we bring to address these named systemic problems. Despite these staggering challenges, locked in our communities are unbelievable resources that we could align, leverage, and deploy in more thoughtful and creative ways to lay the foundation for a more equitable and healthy society.
These resources are anchor institutions, or nonprofit or public enterprises that are rooted locally because of their mission, physical investment, and/or the communities they serve and that have emerged as notable economic engines. Their ownership status creates greater accountability to the public and community and creates an opportunity for them to orient long-term in a way that benefits both their institution and their community’s most in-need residents. Among the largest employers and purchasers, anchor institutions represent “sticky capital” that can be more effectively channeled to strengthen the local economy and address economic inequities. Health systems and universities are the most common anchors, but this group may also include local government, public schools, place-based philanthropy, public utilities, and other community-owned institutions.
Health systems and universities alone have expenditures of more than $1 trillion annually, have nearly $1 trillion in investment assets, and have more than 9 million employees. Their scale is enormous, and the potential for impact on these systemic problems is equally great. If a thriving and healthy community requires a focus on equity, then the challenge becomes to discover how these institutions can more effectively align their business operations with their missions of health care and education to tackle these structural and economic drivers of poor health. That approach is an “anchor mission.” It requires going beyond traditional notions of corporate social responsibility and rethinking the very foundation of the institution’s role and how it deploys its economic and social assets in the community.
The Anchor Mission
An anchor mission is a commitment to intentionally apply an institution’s long-term, place-based economic power and human capital in partnership with its community to mutually benefit the long-term well-being of both.
Without embedding a core set of principles to guide its approach, an anchor institution is likely to perpetuate the same inequities we currently face. It is important to consider how the policies and practices implemented take into consideration the following factors with a systems-approach: (1) health, racial, and economic equity; (2) community connectivity; (3) individual agency; and (4) place-based impact.
The degree of current inequities previously outlined creates a sufficient moral imperative to act. Still, defining this imperative by community and context is often step one. It is critical to helping activate a new coalition needed to tackle these problems and lay the foundation for collaboration through new practices, such as reorienting everyday purchasing, hiring, and investment practices to disinvested zip codes and disconnected residents.
Although the urgency of this work is readily apparent, anchor strategies are ultimately insufficient tools if they are not grounded in rebuilding social bonds that have splintered as the resource gap has widened in our communities. Momentum for an anchor mission will be driven by the small wins that can come through changes in practices and policies, but also through the depth of empathy between institutional actors and community members. Relationship building, building trust, and cultivating power-sharing are all essential elements of this process. Achieving these elements cannot be rushed and may frustrate actors hoping to move more quickly, but avoiding this process will derail the impact of this approach. Naming and nurturing this process is an important early step.
As anchor institutions around the country have grown as notable local actors, they find themselves in close proximity to communities that have been pummeled by poverty and racism. Although not exclusively the same story everywhere, the result is that the social distance between senior leaders of these institutions and those living in these communities is immense. As institutions secure senior leadership buy-in and move toward implementation, staff biases—both implicit and intrinsic—and their beliefs regarding innate negative business consequences from a new approach focused on social impact can conspire to keep individual projects from being successful.
Many of our senior leaders have participated in events in high-hardship anchor communities, allowing them to experience first-hand the neighborhood conditions that lead to poor health outcomes. Normalizing these community experiences for senior leaders along with employees from the same neighborhood allows leaders to connect strategy with personal day-to-day experiences.
Anchor institutions also have an economic imperative to act. The role of repairing local economic ecosystems so that well-being outcomes are more equitable, sustainable, and healthy can be an amorphous proposition. Why should we reorient our business practices and take on more responsibility for society’s ills, especially with shrinking margins?
Articulating this long-term value proposition is an essential foundational step in the process of achieving an anchor mission. We as a society and our communities cannot move forward and prosper while leaving more people behind. This fact is only reinforced by the gaps in life expectancy outlined earlier in the chapter as well as the fact that we as a nation spend more per capita on health care than any other country in the world. The long-term return on investment from these strategies on investment lies in a healthier population—living in equitable, civically engaged, diverse, safe, and economically strong communities.
In advancing an anchor mission, short-term actions must be nested within longer term strategies and within a new institutional culture that more effectively aligns organizational assets and connects with other community partners. This requires new roles and responsibilities internally and more formal structure to encourage collaboration and alignment across large institutions—especially among their business units (e.g., procurement, human resources, treasury, facilities and real estate, and government and community relations).
The following sections highlight examples of how two institutions—Rush University Medical Center in Chicago and RWJBarnabas Health, at various locations in New Jersey—are beginning to operationalize this approach, both within their institutions and in partnership with their communities. In addition, leading health systems nationally are coming together to embed this strategy within health care more broadly through the Healthcare Anchor Network, a national collaboration of more than 30 health systems seeking to improve health and well-being by building more inclusive and sustainable local economies.
Rush University Medical Center
Rush has been a health care fixture in Chicago for 181 years, tracing its incorporation as the area’s first medical school to 3 days before the city of Chicago itself was incorporated in 1837. Rush is a regional integrated academic health system with multiple sites across the Chicago region. The flagship medical center, Rush University Medical Center, sits on the Near West Side of the city. Quality of care is a hallmark of Rush, which is a four-time Magnet Nursing designated hospital, a multiple recipient of the Leapfrog A safety designation, consistently in the top 10 hospitals in the United States in the Vizient Quality and Accountability Study, and the only Centers for Medicare and Medicaid Services five-star hospital in Chicago.
The mission of Rush is to improve the health of the individuals and the communities it serves.
Yet neighborhoods just a mile away from the medical center have health outcomes and life expectancies similar to those of Iraq or Bangladesh, rather than those of a developed nation. It was the recognition of these large life-expectancy gaps that led Rush to reconsider its strategy and obligation to the residents in these neighborhoods. These nine West Side neighborhoods, largely segregated communities of concentrated poverty, high unemployment, and poor educational outcomes, are home to almost 500,000 residents (larger than Miami or Cleveland.) In July 2016, the Board of Trustees at Rush endorsed a broad-based health equity strategy that aimed to have Rush lever its size and success as the largest private employer on Chicago’s West Side to be a “catalyst for community health and economic vitality” there. Rush’s Community Health Needs Assessment named structural racism and economic deprivation as two root causes of the health gaps in these neighborhoods and also acknowledged that its many community-focused programs had not “moved the needle” quickly enough to narrow these gaps. There was also an acknowledgment among the senior leadership team that because the life expectancy gaps were driven by inequity, there was an urgency to act. A new senior vice president role was created on the senior leadership team to coordinate Rush’s health equity agenda.
In addition to identifying Chicago’s West Side as a geographic focus, Rush named its low-wage employees as its “first community.” Applying analytics and performing focus groups, Rush could begin to understand the financial and other struggles of its low-wage employees (many of whom lived in the neighborhoods surrounding Rush). The leadership was able to identify how well-meaning institutional policies and a lack of a career ladder program may have contributed to these difficulties. As a result of this analysis, Rush has developed programs to create opportunities for career growth and to promote financial literacy and reduce hardship among these low-wage employees. One unexpected consequence of this effort was the degree to which our employees were ambassadors for their neighborhoods within Rush. They transmitted their enthusiasm and pride for their communities, often depicted negatively in the media, to senior leaders, most of whom had never ventured into them.
Rush partnered with the Civic Consulting Alliance, a pro bono arm of the Commercial Club of the City of Chicago, to build an anchor mission strategy, to hire locally, to develop wealth-creating career pathways, to purchase locally and stimulate new business development on Chicago’s West Side, to invest locally, and to volunteer locally. These efforts were documented in The Anchor Mission Playbook, which was co-edited by The Democracy Collaborative.3 Rush also convened 100 community-based organizations and six other anchor health care institutions into a health-equity focused collaborative called West Side United to develop a place-based, multisector, private–public partnership to address health and economic well-being on the West Side. The ultimate aim is to reduce the life expectancy gap between Chicago’s Gold Coast and the West Side neighborhoods by 50% by 2030 by addressing population and community health, educational outcomes, economic development, and the built environment. Nine health care anchor institutions have joined the West Side Anchor Committee under the West Side United umbrella. Collectively, these institutions have almost 45,000 employees and 6,000 new hires yearly, and they have enormous purchasing power. These institutions have committed to directing a portion of their economic and job engines to the economic vitality of Chicago’s West Side.
The Rush health equity strategy is an inside-out, outside-in strategy. While West Side United is building high-value external partnerships to address the structural root causes of poor health outcomes on Chicago’s West Side, inside Rush, a reorganization of the quality infrastructure was initiated to address health care inequities. Partnered with the Institute for Health Care Improvement, Pursuing Equity project, Rush began a project to screen and refer patients who experience negative social determinants of health (e.g., transportation, food and housing insecurity). Rush has also assembled its health care quality data to better understand by race, gender, age, insurance status, language, gender and sexual identity, and geography who among its patients were not thriving. The quality plan for Rush now includes specific goals related to health care equity with an infrastructure to lead equity projects. The work to improve the lives of our low-wage employees, while reorganizing Rush business units to the anchor mission, also reflects the impact of the new equity strategy. Finally, a new 5-year Diversity and Inclusion plan for Rush includes community health equity as a pillar, as well as a goal to achieve demographic parity to better reflect the voice of the community in all leadership roles across the organization.
All of this work is organized under a senior vice president for community health equity and a department of community engagement and health equity. An anchor mission manager was hired to manage the business unit activities. Staff were added to Human Resources and Quality to manage new programs. The health equity mission needed specific ongoing investments to succeed. The Civic Consulting Alliance in 2017 provided almost $4 million in pro bono consulting services in addition to the in-kind time of business unit leaders across Rush. The work is painstaking and requires a high degree of organizational focus. Yet the Rush leadership is convinced that, in addition to the moral imperative to repair historical injustices, there will be a longer term return on investment when the population of the surrounding neighborhoods experiences improved health and economic vitality.
RWJBarnabas Health
RWJBarnabas Health (RWJBH), the state’s largest integrated health care delivery system, treats and serves more than 5 million patients each year. This system reaches from northern New Jersey to the state’s ocean shores and serves diverse populations, cities and townships, and urban, suburban, and rural areas. System leaders are committed to providing the highest quality of patient care and health education to the community and the region.
Beyond addressing health care through the provision of patient care within the walls of its hospitals, clinics, and home-care facilities, RWJBH leaders are driven to make a unique impact in local communities throughout the state. The ultimate aim is to make communities healthier. RWJBarnabas Health’s leadership believes that the system has a responsibility to meaningfully serve its communities; to be an anchor institution that fosters health and well-being by playing its part in addressing the social determinants of health. In order to realize that belief, RWJBH has established its social impact and community investment practice, a system-wide professional operation aimed at helping to advance the organization’s vision of improving the health, quality of life, and vitality of New Jersey communities.
The RWJBH social impact and community investment practice leverages the system’s range of assets to advance a culture of health and lift the quality of life in New Jersey communities. With a programmatic emphasis on ensuring health equity, the practice spearheads innovative social-impact and external affairs initiatives that address the social, economic, and environmental conditions that have a significant impact on health outcomes. The policy arm leads the practice as it seeks to change systems, structures, and policies through the equity lens to create a more equitable future for all New Jerseyans.
Despite the aspirational desired outcome of a more equitable future for all, large-scale organizations struggle with the naturally occurring strategic tensions that present themselves during an organization’s attempt to alter missions and cultures. At RWJBH, the constant in the battle is not of good versus evil, but of traditional bottom-line focus versus community health and wealth-building focus. One such tension presents itself in the departure from traditional community benefit project planning, which often occurred behind institutional ivory walls by hospital executives and then resulted in new projects erected in communities in a “if-you-build-it-they will come” manner. Rather, RWJBH’s adoption of an anchor mission required both the formalization of a corporate office-led Anchor Roundtable and an enhanced understanding that while community health needs, county health rankings, and state department of health data utilization have their place, a community solution needs to be led by the community.
To transform an organization into a true community change agent requires an entity to adopt the humble position of active listener. The challenge remains ripe as we further embed the social impact practice throughout the system and adopt a position of co-learning and co-leading with community-based organizations and residents in order to fulfill the mandate of assisting our communities to build community wealth. This work moves only at the speed of humility. As such, since adopting this understanding, we have witnessed a welcome into community-based organizations that have existed for years but that have never opened themselves up to the hospital that has been in their neighborhood for 119 years. They now do so after witnessing the appreciation of the community members’ daily living experience and expertise.
To embed this practice into the institution’s operations side, we created a Corporate Anchor Roundtable (CAR). The CAR is co-chaired by the system CEO and the Executive Vice President who are charged with driving this work across the system. The composition of the CAR includes the system’s asset leaders, including supply-chain, Human Resources, construction, and facilities management; information technology and services; and treasury. The CAR members convene quarterly to update the system CEO on the progress of the use of local diverse suppliers, the hiring rate of local residents, and investment into community building. Moreover, the Social Impact and Community Investment practice adaptation into system operations is the sixth pillar of the system’s strategic plan. As such, it is measured and tracked just as every other strategic initiative is within the business’ strategic plan. More, a one and half (FTE) (.75 to be exact) is required to drive this work across the system as staffers need to work with each facility to coordinate and align the identification of local purchasing and local hiring target goals.
An important element of our local hiring initiative is our Hire Newark program, conducted in partnership with our local municipality, the City of Newark, as well as with the Hire Newark program and the Mayor’s local hire program, Newark2020. Hire Newark trains and places participants in businesses in Newark to help close the gap between Newark’s unemployment rate and that of the state of New Jersey.
Case Example
One of our participants actually had a dream to work for herself as a commercial wedding cake baker but had enrolled in our program out of necessity. The married mother of five showed such promise that she was placed in a job with the hospital’s dining vendor in order to secure the 300 hours of baking in a commercial kitchen needed to satisfy her small business certificate. She continues to thrive on her own as a bona fide minority- and woman-owned diverse local supplier of professional baked goods. As a result of this opportunity, she recently announced the purchase of her first home. The work is equity-focused with the constant of creating opportunity in order to help build community wealth and to push back the tide of generational poverty.
Scaling for Impact: A National Collaboration Is Formed
The challenges facing our communities are systemic. Our solutions for addressing them and meaningfully achieving health equity must be equally bold. We need this approach to take root in each of our communities. All of our institutions must rise to the occasion.
An example of this is the Healthcare Anchor Network. Formed in early 2017, it is a growing collaboration of more than 35 leading health systems, representing more than 600 hospitals, that are committed to deepening their understanding and implementation of strategies that leverage their business operations (e.g., hiring, purchasing, and investment) to benefit the communities they serve and to address economic and health disparities. The purpose of the Healthcare Anchor Network is to help institutions more effectively advance an anchor mission in their institutions, in partnership with their communities and across the health care sector.
Any health system committed to these goals can join the Healthcare Anchor Network. Together, we can help collectively to forge a new narrative in health care related to practical—but perhaps not initially intuitive—strategies that health systems and partner anchor institutions can take to meaningfully address the systemic inequities that have contributed to the current disparities we continue to confront in the United States.
Anchor institutions represent significant economic resources. If reoriented with an equity lens toward broader impact and leveraged along with other local resources in our communities, we could finally bring to the equation the resources needed to ensure that all in our country can live healthy lives with dignity.
References
- Tavernise S. Disparity in life spans of the rich and the poor is growing. New York Times, February 12, 2016. https://www.nytimes.com/2016/02/13/health/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html. Accessed 1/18/19.
- Philip, A. Statement on Visit to the USA, by Professor Philip Alston, United Nations Special Rapporteur on extreme poverty and human rights. United Nations, Human Rights. Office of the High Commissioner. December, 15, 2017. http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=22533. Accessed 1/18/2019.
- Rush University Medical Center. The Anchor Mission Playbook. Chicago, IL: The Democracy Collaborative; 2017.