If health care hopes to achieve equitable care for all patients, providers have to understand that quality improvement can actually worsen health disparities.
When quality improves for one racial group (often the group that’s already doing better) at a faster rate than for others (often the groups already doing worse), quality for the whole population improves, but the gap between subpopulations widens. Focusing on the whole population rate obscures the fact that the disparities for some subpopulations are actually worse than before.
But quality improvement methods are also an important tool to reduce disparities. To tailor QI interventions to reduce, rather than exacerbate, disparities, IHI recommends six key activities. You can read more in the IHI white paper, Achieving Health Equity: A Guide for Health Care Organizations.
- Collect and analyze data by patient race, ethnicity, and language.
To improve health equity, organizations first need to understand where disparities exist. They can start by developing reliable systems to accurately collect collection of race, ethnicity, and language (REAL) data, along with the resources to analyze it.
Organizations are still struggling to effectively collect and analyze these data, sometimes lacking effective processes for collecting the information from patients, or having information systems that do not incorporate the information across all computer interfaces. Quality improvement work can help develop consistent processes to collect the data.
Once health systems collect REAL data, they need to analyze it to identify disparities in care and, more importantly, health outcomes.
- Center at the margins: begin improvement work by considering the needs of the disadvantaged.
Typically, organizations start improvement work by focusing first on making improvements for patients with less complex needs.
Once they’re successful, teams then turn their attention to implementing the improvements for patients with more complex needs. Too often, they find that the initial improvement design is inadequate to be effective for this latter population.
Improvement strategies that are effective for more advantaged populations aren’t necessarily effective for less advantaged populations. Improvement work needs to be designed from the start to meet the needs of marginalized populations — known as “centering at the margins” — rather than taking a generic, “one size fits all” approach.
In some cases, a tailored approach may even result in better care for the population as a whole. HealthPartners, an integrated system in Minnesota, used improvement science to reduce racial disparities in breast cancer screening rates — while also improving screening rates for all patients.
- Test change ideas that address patients’ social conditions and cultural influences.
For example, reducing hypertension in a population of uninsured or underinsured persons requires a care design that provides access to affordable medications, transportation, healthy food, and safe places to exercise.
Improvement work must also account for cultural considerations that can be barriers or facilitators to the success of the intervention. For example, individuals from different cultures may have various preferences when discussing important medical decisions, such as who is in the room for those discussions.
- Establish trust between providers and patients.
As health systems work to promote equity, they have to confront a difficult reality: that the health care system has betrayed the trust of some patients of color in the past. Two well-known examples include the 1932 Tuskegee Institute “Study of Syphilis in the Untreated Male” and genetic research among the Havasupai Tribe in Arizona. The experience of Henrietta Lacks, a black woman whose tissue sample was used to develop the first cell line for research without the permission of her family, has also led some patients of color to wonder if white patients are receiving higher-quality care.
While today’s health care providers aren’t to blame for these events, their memory keeps some patients from seeking out care. This mistrust is compounded when patients have their own negative experiences with health care providers. They may feel that providers are incompetent, biased against people like them, motivated by profit, or interested in experimenting on people of color.
Building trust is an integral part of reducing disparities. Systems can do this by conducting focus groups with patients to understand their preferences and attitudes about care, and designing comfortable, safe experiences for them, where providers take pains to treat them with dignity and respect.
- Provide accessible primary care tailored to the needs of marginalized people.
Primary care providers can play a role in identifying children who are at risk for social, developmental, and physical needs early in life and connecting them with support and services.
Primary care services can also be distributed into the community, working with community members and organizations to engage individuals in managing their health. For example, the Centers for Disease Control and Prevention National Diabetes Prevention Program trained barbers in black neighborhoods to screen for hypertension and provided cancer screening education in churches.
Safety net providers and clinics are already playing a critical role in providing access to affordable primary care to underserved communities and should be included in any effort to expand primary care services.
- Use the required Community Health Needs Assessment as an opportunity.
Under the US Affordable Care Act, the IRS requires not-for-profit hospitals to conduct a Community Health Needs Assessment at least once every three years. Hospitals then develop and execute an implementation strategy along with a set of performance metrics to meet the needs identified in the CHNA.
The CHNA reports must describe the community served, identify existing health care resources, and prioritize community health needs. At the same time, the Public Health Accreditation Board requires that health departments complete a Community Health Assessment with community collaboration that results in a Community Health Improvement Plan.
Instead of treating these requirements as a box to be checked, health systems can use them as an opportunity to combine efforts with public health departments and community-based organizations, and improve the health of disadvantaged populations.
Learn more about how health systems can promote health equity in their communities in the IHI white paper, Achieving Health Equity: A Guide for Health Care Organizations.
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