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"Not all improvement efforts automatically lead to equitable improvement. In fact, without centering equity, we risk improving for some but not all or even expanding equity gaps."
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Tips for Centering Equity in Improvement Coaching

By Dorian Burks | Friday, March 31, 2023
Tips for Centering Equity in Improvement Coaching Photo by Mahbod Akhzami | Unsplash

When I am improvement coaching, I love helping team leads look at their projects and approaches in new ways. Often teams are already doing great work, but they feel a little stuck. Maybe their progress has plateaued. Bringing in a fresh perspective and using different methods to get creative can help a team uncover new ways to approach a problem and reach the outcomes they are hoping to see.

One important way for teams to look at their work in a new light is to consider how to center equity in their improvement work. In improvement, we cannot assume “a rising tide lifts all boats.” Not all improvement efforts automatically lead to equitable improvement. In fact, without centering equity, we risk improving for some but not all or even expanding equity gaps. To avoid this, we must uncover how some groups may be disproportionately affected by a system and involve those most affected by system redesign — especially those who have been historically marginalized — in our improvement work.

Inequitable outcomes are not only the result of explicit discrimination, but of failures of our systems to truly care for all equitably. If we do not intentionally uncover which populations have worse outcomes and focus our work there, we are likely to leave them behind in the improvement process. They may realize some positive effects from our efforts, but without designing with equity in mind, we are leaving equitable improvement to chance. Here are a few ways you can help teams center equity in improvement work:

  • Bring the right people to the table — For example, let’s imagine a team is focused on reducing complications of diabetes by working with patients’ family members. The team has decided to get input from the patient and family advisory council (PFAC). In this example, the PFAC members are a mostly White and economically homogenous group. As a coach, I may prompt the team to ask if the PFAC is representative of our patient population. How might we understand who makes up our patient population with diabetes? Have we segmented data by race/ethnicity, and/or economic status? If we find our PFAC is not representative, we have to design ways to get input from those we may not hear from otherwise. How might we make it easier for their family members to participate? If coming to the hospital during the day is challenging, how can we bring participation opportunities to them? How do we avoid designing for and, instead, design with the communities and populations we need to hear from?
  • Pay attention to team dynamics — When a new team is forming, it may be the first time this group of people is working together. They may be from across the organization and represent multiple disciplines and departments. If we have community members as part of a team or meeting, how can we create a space where their voices are prioritized and valued? Before a team starts tackling a problem, one way the members can center equity is to talk openly about their cultural, ethnic, racial, and other identities, and work to understand how power dynamics — across gender, race, roles in the organization, socio-economic status, etc. — might show up in the room. Having an open conversation about these dynamics could influence whether a nurse working at the frontline feels as confident about bringing their ideas forward as a senior leader. Every member of the team has something valuable to contribute and ddressing these dynamics helps ensure that everyone on the team has a voice.
  • Learn and acknowledge your local history — As you are trying to close equity gaps, it is vital to understand the root causes of the inequities that exist in your organization’s community. The actions of many health care organizations have had both intentional and unintentional consequences in their environment. If your health system, for example, was at one time racially segregated or if it closed a facility a decade ago and left already medically underserved people worse off, consider the long-lasting impact on the people in your neighborhood. Acknowledge this history as you then co-design solutions with those who experienced that harm and understand that it may take time and intentional effort to build or rebuild trust with the community.
  • Consider adapting traditional improvement tools and methods for equity – Organizations such as Montefiore Medical Center have adapted fishbone diagrams (also known as Ishikawa or cause and effect diagrams) and driver diagrams across their system to center equity from the start of their improvement efforts. Even if you are coaching a team that is already well on its way to a defined project, how might the team add a secondary aim to focus on a specific sub-population experiencing worse outcomes? How might the team stratify measures to ensure both outcomes and processes are being improved equitably?
  • Make space to process hard truths — As teams dive into equity issues, they will likely uncover things that are hard to face. They may learn about injustices in the organization’s past or recognize inequitable patterns of care happening now. This is painful for people who have dedicated their lives to caring for others. It is important to create space and time for the team to reflect together, acknowledge harm, name racism and oppression that may be occurring systemically (unintentionally or intentionally), grieve, and eventually think about how to do something new.

As an improvement coach, you are not the one with all the answers. Your role is to help teams discover their own solutions. This is also true for centering equity in improvement. What a coach can do is help the team view their work through an equity lens, support them through that process, guide them to the right tools and measurement strategies, and help them capitalize on the successes they have already had.

Dorian Burks, MPH, is an Institute for Healthcare Improvement (IHI) improvement advisor and Equity and Culture Team lead.

You may also be interested in:

The Rise to Health Coalition: A Different Kind of Health Equity Initiative

Better Meetings and Deeper Listening: The Underrated Keys to Improvement

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