Where’s Your Health Equity Fulcrum? Part 2

Operationalizing and measuring health equity initiatives in your health equity strategy

In Part 1 of this article series, we discussed three of six “fulcrum points” that can enable positive momentum in a healthcare organization’s health equity journey. These points included pursuing health equality versus equity, conducting healthcare data analysis and research, and designing targeted interventions. 

In Part 2, we cover three additional health equity strategy fulcrums – operations, quality improvement, and performance measurements. These three health equity strategy fulcrums are pivotal for a program- or enterprise-level equity initiative building beyond a pilot, embedding health equity interventions as part of processes, and scaling success. We pick up where population analysis is complete, health equity objectives are established, and the team has designed and possibly tested interventions with patients or members.

Fulcrum 4: Health equity operations processes and systems

Preliminary research in 2021 found that 60% of healthcare CEOs surveyed “ranked health equity, diversity, and affordability among their top three priorities for the next one to three years.” With that kind of focus, operations and care delivery leaders will be vital to actualizing health equity efforts. 

Aligning health equity with quality and safety

Efforts to achieve more significant equity aren’t the sole responsibility of a chief equity officer or team. Healthcare organizations that take a leadership- and enterprise-energized approach make equity a part of every employee’s role. It’s the reason that organizations are beginning to align health equity with quality and safety. Dr. Laurie Zephyrin from The Commonwealth Fund shared, “Framing equity within quality and safety helps leaders have a place to start. Now it’s about what leaders do with this data and how they actually intervene in the inequities.” Dr. John Cowden, the Health Equity Integration Project Leader at Children's Mercy Kansas City, put it another way, “The deepest effect of integration is a shift in consciousness and culture within teams and among the larger staff.” 

Before integrating health equity interventions into specific workflows, it’s essential to establish the mindset that, just like with quality and safety, everyone should and can play a role in providing more equitable healthcare to the degree that their role supports.

Building capacity and optimizing workflow

Leadership at every level can look at process or workflow integration as a way to tackle disparities by increasing responsiveness and capacity. This would include recruitment and retention of diverse workforce talent, as well as how organizations design functional structures like committees, workgroups, and teams. 

Equally important is embedding interventions into the clinical, care management, and operational workflows that can have a direct influence on reducing healthcare disparities. Value chain mapping is a valuable tool that identifies various touchpoints between the healthcare organization and the patient-member. Capture relevant operational steps and processes as part of patient communication or direct care, highlighting where the team should integrate interventions. 

Ultimately, taking a process-driven view of operations with health equity changes the way leaders and teams view “business as usual.” For example, a west coast hospital wanted to reduce workplace violence. They analyzed their data by race and ethnicity and determined that, while making up 17% of the patient population, Black and Latino patients were the focus of half of the use of force. Research uncovered that the system called security or law enforcement as the go-to action rather than using de-escalation techniques. When viewed through a health equity analytics lens, the institution created a behavioral emergency response team that included psychiatric nurses and social workers who could intervene initially, which changed the dynamic of “care” for patients, families, and visitors facing high-stress situations.

Fulcrum 5: Quality improvement discipline

Taking a cue from quality improvement initiatives, health equity strategies can best achieve adoption within a data-based, science- and academic-focused environment through a systematic approach. Adopt a quality improvement mindset and engage with QI staff who leverage proven models like Plan-Do-Study-Act cycles (PDSA), Six Sigma, and Lean. A disciplined tact towards standardizing health equity demonstrates that the program can be embedded into operations and become sustainable. 

Model previous success

When teams and individuals own the work, they can incorporate discoveries, test theories, and engage the subject matter from everyday experiences. Look to previous change initiatives – clinical, cultural, or quality – and take lessons learned to inform health equity strategy.

Tap the existing DEI team as a COE

Diversity, equity, and inclusion (DEI) teams can act as a center of excellence (COE), providing training, guidance, and tools to staff leading health equity initiatives within individual clinical and operational departments.  

Look at existing data-rich processes for health equity opportunities

A QI approach to health equity may begin with a health equity analysis that reveals health disparities. Existing processes can also be a starting place for discovering health equity opportunities. Taking on the premise that “equity work is quality work” could include stratifying quality issues and seeing how health equity challenges may be causing or exacerbating readmissions, no-shows, and poor survey results.

Fulcrum 6: Performance measurement and reporting 

According to the Lown Institute, “relatively few top healthcare organizations rank high for health equity and social responsibility.” Only 75 out of 3,000 assessed hospitals received an “A” ranking for health equity. Their Lown Hospitals Index of Social Responsibility ranks institutions based on equity, value, and outcomes. Larger and for-profit hospitals tended to score lower, possibly due to conflicting demands between economic health and furthering equity. What’s key is that performance measures like these provide evidence for real-world impact and progress. 

Assessing existing health equity measurement approaches

One helpful report in determining which health equity measures an organization or initiative should track and report on comes from RAND’s work for the Office of the Assistant Secretary for Planning and Evaluation. 

RAND identified 10 existing approaches to health equity measurement and convened a technical expert panel (TEP). “Of the 10 health equity measurement approaches evaluated by the TEP, the CMS Office of Minority Health’s (OMH) Health Equity Summary Score (HESS) received the highest ratings overall.” 

The HESS summarizes performance across two types of data: 

1. Patient experience, as measured by CAHPS: doctor communication, ease of getting needed care, getting care quickly, ease of getting needed prescription drugs, customer service, care coordination, and flu immunization
2. Clinical care, as measured by HEDIS: breast cancer screening, colorectal cancer screening, diabetes care, and adult body mass index assessment. 

RAND defined health equity measurement as “an approach to illustrating or summarizing the extent to which the quality of health care provided by an organization contributes to reducing disparities in health and health care at the population level for those patients with greater social risk factor burden by improving the care and health of those patients.” 

Using enterprise-level, historical data as a baseline

Dr. Lane Donnelly’s opinion piece in the Journal of the American College of Radiology sheds light on the approach Stanford Children’s Health took to incorporating health equity analytics into their QI activities and their assessment of quality, safety, and service. Their KPIs included rates for serious safety events, central line–associated bloodstream infections, hospital-acquired pressure injuries, influenza vaccination, cardiovascular arrests outside the intensive care unit, as well as case-mix index and service indicators like top box scores for “likelihood to recommend” on patient experience surveys and filing of complaints or grievances by patients and families. Their example highlights how each service area can use enterprise measures and historical data to provide a baseline for health equity engagement.

Embedding new health equity measures into an existing framework

An example of evaluating existing care models from a health equity measurement includes the Age-Friendly Health Systems initiative at the Institute for Healthcare Improvement (IHI). The framework focuses on “four evidence-based contributors to high-quality, cost-effective care” known as the “4Ms.” The measures include medication, mentation, mobility, and what matters to the patient. 

In 2020, the group embarked on making racially and ethnically equitable care an explicit and core element of the 4Ms framework. The health equity-focused measures included 30-day readmission rates, length of stay, emergency department utilization, ratings of the hospital experience survey and the CAHPS Clinician and Group Survey (CG-CAHPS), dementia rates, as well as older patients’ access to age-friendly 4Ms care within a health system. 

Over 1,000 clinical sites currently use the framework. And, because these sites have established the framework, collecting and reporting on the new health equity measures are reinforced by the “regular processes that are part of its operation.” This helps hold “care systems accountable for taking action in response to racial and ethnic inequities that come to light.” 

Operationalizing health equity initiatives

Our team provides expertise across the health equity continuum, from healthcare data and research strategies to health equity analytics tools and services to programmatic design and quality improvement. We take a tailored approach built on best practices but are as unique as your business needs and the patients and members you serve. 

Learn more about RTI Health Advance, where we’re illuminating the way toward equitable health.