Children - Key Activity 4

KEY ACTIVITY #4:

Use a Systematic Approach to Decrease Inequities


 

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance for a systematic evidence-based approach for identifying and then reducing inequities for children. It focuses on the first primary driver in PHMI’s equity approach: Reduce inequities for populations of focus.

 

FIGURE 8: PHMI EQUITY DRIVER DIAGRAM

Phmi Equitydriverdiagram

As with virtually any clinical outcomes, your practice is likely achieving better outcomes with certain populations or subpopulations and worse outcomes with others. Inequitable outcomes are generally most acute among persons of color, immigrants, persons speaking a primary language other than English, and other populations who have been marginalized. As we work over time to reduce and eliminate inequitable health outcomes, we need to understand both what contributes to these different outcomes as well as factors that do not contribute to them.

This includes recognizing that race is a social construct determined by society’s perception. While some conditions are more common among people of certain heritage, disparities in conditions such as cancer, diabetes and adverse maternal outcomes have no genetic basis. While genetics do not play a role in these inequitable outcomes, the extent to which inequities in the quality of care received by people of color contribute to inequitable health outcomes has been extensively documented.[1] These inequities are often a direct result of racism, particularly institutionalized racism – that is, the differential access to the goods, services and opportunities of a society by race.[2] Racial health inequities are evidence that the social categories of race and ethnicity have biological consequences due to the impact of racism and social inequality on people’s health.[3] It is also critical to recognize that we have policies, systems and procedures that unintentionally cause inequitable outcomes for racial, ethnic, language and other minorities, in spite of our genuine intentions to provide equitable care and produce equitable health outcomes.

Improving your practice’s key outcomes for children requires a systematic approach to identifying equity gaps (e.g., who your practice is not yet achieving equitable outcomes for) and then using quality improvement (QI), co-design, systems thinking and related methods to reduce these equity gaps. This effort will be more effective if it is guided by a theory of change that addresses the ways in which structural and institutional racism lead to inequities in care provision. For more discussion, read resources such as this one from the Center for American Progress on how structural and institutional racism contributes to declining childhood immunizations rates.

Identifying and meeting patients’ social health needs is a key driver of reducing inequitable health outcomes. We provide additional guidance in this key activity on how to both reduce inequities and meet patients’ social health needs.

Access to data required to identify and monitor inequities as outlined in the key actions outlined below is fundamental to this activity.

Relevant HIT capabilities to support this activity include care guidelines, registries, clinical decision support (modifications required to consider disparate groups), care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination (See Appendix D: Guidance on Technological Interventions).

EHRs have the ability to capture basic underlying socioeconomic, SOGI and social needs-related data but may in some cases lack granularity or nuances that may be important for subpopulations. Mismatches between how UDS captures REAL data versus how EHRs capture or MCPs report data can also create challenges. This may require using workarounds to capture these details. It is also important to assure that other applications in use, which may have separate patient registration processes, are aligned. Furthermore, tracking inequities in accessing services not provided by the health center may also require attention to data sources or applications outside the EHR.

In the pediatric population, some of the contributing data may pertain to the parent or caregiver. For example, children’s risk of experiencing chronic disease is associated with maternal health conditions including asthma, obesity and mental distress.[4] Where possible and relevant, comprehensive strategies might include ability to draw such data into analyses and reports.

Health centers should also be alert to the potential for technology as a contributor to inequities. For example, patient access to telehealth services from your practice may be limited by the inequitable distribution of broadband networks and patient financial resources (e.g., for phones, tablets, and cellular data plans). EHR-embedded algorithms used to stratify populations by risk may also contain inherent racial biases. The Techquity framework can be a useful way to structure an approach to assure that technology promotes rather than exacerbates disparity.

Language, literacy levels, technology access and technology literacy should also be considered and assessed against the populations served at the health center.

Finally, attention needs to be paid to the use of best practices in collecting the data, accurate categories in the technologies in which it is collected and stored, and adequate training and monitoring of staff responsible in order to assure reports and analysis have a valid basis.

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI and other demographic data.

Suggested team member(s) responsible: Data analyst.

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing disparities is to collect high-quality data that fosters a comprehensive understanding of each patient. This entails incorporating race, ethnicity and language (REAL) data, demographic data (age, gender) and social needs data. By leveraging this information, healthcare practices can gain valuable insights into disparities in access, continuity and health outcomes." Steps two to four below provide more information on this process.

Collecting REAL information allows for practices to identify and measure disparities in care, while also ensuring that practices are able to interact successfully with patients. This is done by understanding their unique culture and language preferences.[5] KHA Quality has a toolbox that assists with REAL data collection.

The Uniform Data System (UDS) Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and sexual orientation and gender identity (SOGI). Note: While UDS does not currently require that practices report on the specific primary language of each patient, practices should make an effort to identify and record each patient’s primary language, as UDS reporting still requires for languages other than English to be reported.

Accurate collection of data requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including promotion of patient self-report.

In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable supporting its collection. Example language can be found at The MGH Disparities Solution Center. High rates of “undetermined” or “declined” in these fields may be indicative of the need to attend to these staff training needs.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender. There are certain risks and condition indicators that are gender-specific, which impact how care teams provide care to a patient. By understanding the needs of patients more fully, care teams can make more informed decisions for the best treatment of their patients. The World Professional Association for Transgender Health (WPATH) has provided further guidance regarding standards of care related to gender diversity.

 

2. Use the practice’s EHR and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: Data analyst.

This includes reviewing your care gap report or care registry and being able to stratify all of the following:

  • Core measures for the population of focus.
  • Supplemental measures for the population of focus.
  • Process measures for the population of focus.

Stratify this data by:

  • Race, ethnicity and language (REAL).
  • Sexual orientation and gender identity (SOGI), when possible.
  • Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, etc.).

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step three below.

Consider reviewing data on disparities at the state and health plan level for greater context.

You might not have enough sample size in some REAL categories to identify whether a trend is significant or not. If you’re seeing something in your patient population, you can examine other known data sources, such as a recent state health disparities report, for context.

 

3. Screen patients for social needs.

Suggested team member(s) responsible: Care team.

Key Activity 7B: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACESs) that Informs Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. This is not a one-time event, but rather a continuous process and should be done in tandem with step two above.

 

4. Analyze the stratified data from steps two and three to identify patterns of inequitable outcomes.

Suggested team member(s) responsible: Data analyst, QI leads, care team.

Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes.

This includes:

  • Utilizing tools to examine, visualize and understand disparities across different populations or subpopulations.
  • Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

Update your practice’s measurement strategy so your practice’s improvement efforts remain centered around advancing equitable outcomes. Some examples include creating specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals and updating your process and outcome measures so you can understand differences by REAL or SOGI indicators. See Appendix C: Developing a Robust Measurement Strategy for more.

This is not a one-time event but rather a continuous process (see step 13 below). Periodic review of stratified data allows for recognition of gap closures and emergence of new disparities.

 

5. Use a root cause analysis to identify improvement approaches for subpopulations with lagging health outcomes.

Suggested team member(s) responsible: Implementation team.

Select root cause analysis approaches that work best for the equity gap you are closing:

  • Engage and gather information from patients affected by the health outcome in your root cause analysis (see step six).
  • Brainstorming.
  • Systems thinking (understanding how interconnected social, economic, cultural and healthcare access factors may be impacting the health outcome).
  • Tools that rank root causes by their impact and the feasibility of addressing them (e.g., prioritization matrix and/or an impact effort matrix).
  • Visual mapping of root causes and effects (e.g., fishbone diagram).
  • Perform focused investigations into selected root causes, gathering qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders to validate the identified root causes and gain additional insights. Incorporate their feedback and refine the analysis, as needed.

 

6. Partner with patients to build successful strategies addressing inequitable outcomes.

Suggested team member(s) responsible: Care team and people with lived experience (patients representative of the population(s) of focus).

Using one or more human-centered design methods, such as focus groups, Journey Mapping, etc. (see links to these methods below), and engage patients to better understand perspectives that may influence the health outcome of interest. This may include collecting information on:

  • Their assets, needs and preferences.
  • Cultural beliefs, including traditional healing practices.
  • Level of trust in healthcare generally and in the topic of focus specifically (e.g., immunizations, behavioral health, etc.).
  • Barriers to accessing care.
  • Barriers to remaining engaged in care.
  • Trusted sources of information or communication mechanisms for this population.
  • Their ideas for improving health outcomes.

The patients you partner with for this and other steps in this key activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work. Fairly compensating patients for participating in improvement activities is a best practice.

Selected resources on human-centered design and co-design:

 

7. Develop strategies that address or partially address the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experience.

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities this guide could address or partially address the equity gap.

Most of the activities in this guide either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of activities that can be adapted to reduce identified equity gaps include but are not limited to:

If one or more of your root causes cannot be addressed fully through key activities in the relevant implementation guide, use one or more human-centered design methods to develop ideas to improve health outcomes and reduce inequities among this population.

Developing these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice's care team. During this brainstorm, you are developing ideas without immediate judgment of the ideas in an effort to generate dozens of potentially viable strategies.

 

8. Determine which strategies to test first.

Suggested team member(s) responsible: Care team and people with lived experience.

There are many ways to prioritize ideas. The Institute for Healthcare Improvement (IHI) often recommends a prioritization matrix and/or an impact effort matrix and offers a video on making them.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one or two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. It is critical to determine the bandwidth for the team(s) who will be doing the testing so that you can determine how many ideas to test first.

 

9. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Nearly all the key activities and all of your new ideas will require some degree of adaptation for use within your practice and to be culturally relevant and appropriate to your patient population.

Use plan-do-study-act (PDSA) cycles, generally starting as small as feasible. Think “ones” (e.g., one clinician, one hour, one patient, etc.) and become larger as your degree of confidence in the intervention grows.

Whenever testing a key activity or new idea, we recommend that the practice:

  • Use plan-do-study-act (PDSA) cycles to test your ideas and bring them to scale. See more information on PDSAs below in the tips and resources section.
  • Generally, start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use the chart titled “How Big Should My Test Be?” below in the tips and resources section to help you decide what size test is most appropriate.

Develop or refine your learning and measurement system for the ideas you are testing. A simple yet robust learning and measurement system will help you understand improvements, unintended secondary effects, and how implementation is going.

By working out the inevitable challenges in the idea you are testing using a smaller scale PDSA cycle, the improvement activity will ultimately work better for patients and be less frustrating to the care team. Testing and refining also can eliminate inefficient workarounds that occur when a new process or approach is imposed onto an existing system or workflow.

Select resources on quality improvement (QI):

 

10. Implement – bring to full scale and sustain – those practices that have proven effective.

Suggested team member(s) responsible: Care team.

Once an idea has been well tested and shown to be effective, it is time for your practice to hardwire the idea, approach or practice into your daily work. Consider using the MOCHA Implementation Planning Worksheet to think through:

  • Measurement.
  • Ownership.
  • Communication (including training).
  • Hardwiring the practice.
  • Assessment of workload.

Sometimes implementation may require that you update your protocol and/or policies and procedures for the populations of focus.

 

11. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

This might include going back to the ideas developed previously but not prioritized and/or going back through the testing steps above to develop and prioritize new ideas and potentially for additional populations of focus.

 

12. Put in place formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: Care team.

Establishing formal and informal feedback loops regarding new processes will ensure that your practice’s ideas are meeting the needs of patients and are reducing identified equity gaps. These feedback loops also ensure the changes are feasible and sustainable for your practice.

For patients, feedback loops could be created using many of the human-centered design tools used to design your improvement activity (e.g., surveys, interviews, focus groups). Feedback loops should also involve the patient satisfaction survey and grievance processes. Consider establishing a standing funded patient advisory board that is available to design, implement and evaluate all of your practice’s improvement activities.

For the care team, feedback loops might include:

  • Existing or new staff satisfaction and feedback mechanisms.
  • Regularly scheduled meetings and calls to obtain staff feedback on processes, methods and tools. Leverage existing meetings to mitigate staff burnout.

 

13. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: Care team.

This includes regular (at least monthly) review of the key stratified measures from your measurement strategy. Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

Implementation tips

  • When testing a change idea (either a key activity or new idea) for your practice to address a known equity gap, the size of your test scope or group is critical.
  • We recommend starting with a very small test (e.g., with one patient or with one clinician) or a small test (e.g., with all patients seen during a three-hour period by this clinician) unless you are certain the change idea, key activity or test will lead to improvement with little or no adaptation for your practice, the cost of a failed test is extremely low, and staff are excited to test the change idea.
  • As you learn from each test what is and isn’t working, you can conduct larger scale tests and tests under a variety of conditions. While at first glance this would appear to slow down the implementation effort, starting small and working out the kinks as you progressively work to full scale actually saves time and resources and is much less frustrating for your patients and care team. The visualization below provides guidance on how big your test should be.

FIGURE 9: HOW BIG SHOULD MY TEST BE?

How Big should my test be

Endnotes

  1. Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/10260  
  2. Improving Health Equity: Build Infrastructure to Support Health Equity. Guidance for Health Care Organizations. Boston, Massachusetts: Institute for Healthcare Improvement; 2019. (Available at www.ihi.org)  
  3. Chadha N, Lim B, Kane M, Rowland B. Institute for Healing and Justice in Medicine; 2020. https://belonging.berkeley.edu/race-medicine 
  4. Ahmad K, Kabir E, Keramat SA, Khanam R (2021) Maternal health and health-related behaviours and their associations with child health: Evidence from an Australian birth cohort. PLOS ONE 16(9): e0257188. https://doi.org/10.1371/journal.pone.0257188 
  5. REaL Data Collection Toolbox [Internet]. KHA; 2022 [cited 2023 Dec 18]. Available from: http://www.khaquality.com/Portals/[4]/Resources/HQIC_REaL%20Data_Collection_Toolbox.pdf