Lessons for Reducing Disparities in Regional Quality Improvement Efforts

Regional efforts to improve quality of care face particular challenges when addressing racial and ethnic disparities in health. Diverse populations have different needs and barriers, and the same quality improvement (QI) intervention can affect them variably. Thus, different approaches may be necessary to deliver high-quality healthcare to different populations.

Learning How to Improve Quality and Reduce Disparities

Inequalities in health and healthcare have been documented for decades, but concerted efforts to reduce or eliminate them are relatively recent. Since 2005, Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation (RWJF), has been discovering what works, and what does not, to reduce racial and ethnic disparities in healthcare.¹ Over the past 7 years, the program has synthesized intervention research in multiple high-impact disease areas and awarded 33 grantee organizations funds to evaluate different approaches to reducing disparities. In 2006, RWJF launched the Aligning Forces for Quality (AF4Q) initiative, a bold regional effort to improve quality of care and reduce inequality in health and healthcare.² The director of Finding Answers has been a member of the AF4Q initiative national advisory committee since 2008. Finding Answers began providing technical assistance in 2010 to help AF4Q regional alliances (multistakeholder partnerships in each AF4Q initiative community), and practices within them, to successfully incorporate equity into their ambulatory QI activities.

When Finding Answers and the AF4Q initiative started, relatively little was known about how to reduce inequality in healthcare. Some of the Finding Answers interventions have succeeded; others have failed or had mixed results. As a result, our knowledge of how best to incorporate equity into practice- and region-level QI efforts has grown substantially. Below, we share lessons from the past 7 years of Finding Answers, provide perspectives on the AF4Q initiative’s approach to equity, and offer recommendations for future regional efforts to reduce disparities.

Finding Answers’ Lessons Learned: The Roadmap to Reduce Disparities

Finding Answers grantees faced many challenges implementing interventions to reduce disparities. Their experiences highlighted the need for comprehensive yet flexible guidance to design and implement equity activities. And so, based on our grantees’ experiences and our systematic reviews of interventions to reduce disparities, Finding Answers developed the Roadmap to Reduce Disparities.³ The Roadmap is a guide for incorporating equity into QI efforts: it outlines the steps to plan, implement, and sustain equitable care. The Roadmap can be used by a single practice, multi-facility healthcare organizations, or regional multi-stakeholder collaboratives.

The Roadmap to Reduce Disparities is a 6-step process: (1) recognize disparities and take responsibility for reducing them (eg, by collecting and disseminating performance data stratified by patient race, ethnicity, and language); (2) implement a basic QI structure and process; (3) create a culture of equity that incorporates equity as an integral component of all QI efforts; (4) design specific interventions, using tools such as a root cause analysis to clearly address the underlying causes of documented disparities; (5) implement, evaluate, and adjust the intervention; and (6) sustain the intervention. The Roadmap is not necessarily a linear process; various components can be implemented simultaneously or maintained throughout. For example, planning for sustainability is ideally integrated throughout the entire process.

Additionally, the Roadmap does not recommend any specific interventions. Rather, organizations must tailor interventions to their particular setting and patient population. All organizations must partner directly with their patients to accurately assess the causes of the disparity and design interventions that are culturally tailored. Patient involvement is essential even for projects targeting providers, care teams, organizations, and the community. Furthermore, a disparities intervention must be cognizant of the organization’s mission, QI infrastructure, resources, leadership, and staff. Sometimes, the intervention includes changing organizational structures and attitudes.

Although no magic bullets or one-size-fits-all interventions exist, Finding Answers has identified promising practicesto reduce disparities. Promising disparities interventions are multifactorial, culturally tailored, and team-based; they often include nonphysicians such as nurses, patient navigators, and community health workers. They address multiple points along the pathway of care and closely coordinate and monitor care. They often involve family and the community, and emphasize interactive skills-based training rather than passive learning.^3,4

Why Is the Roadmap Necessary?

The Roadmap guides professionals along a standardized process to address issues that may vary within a region or practice. The causes of and solutions to any particular disparity can vary significantly within the same geographic region. When so many contributing factors are different, the Roadmap ensures that all organizations, whether regional or practice-based, will follow a comprehensive systematic process to discover the answers that work for them and, most importantly, their patients.

Perspectives on the AF4Q Initiative

Based on our grantee interventions, systematic reviews, and our experience delivering technical assistance to the AF4Q initiative, lessons relevant to regional QI efforts emerged. We did not know many of these lessons when the important work of the AF4Q initiative began; we hope that our perspective will be valuable to future efforts.

AF4Q Initiative’s Successes for Reducing Disparities

Key aspects of the AF4Q initiative provided a foundation for disparities reduction: Multi-stakeholder coalitions convened the key players. The inherent structure of the AF4Q initiative is a major strength of its approach to disparities reduction: multi-stakeholder coalitions of consumers, providers, and payers are vital to reducing regional health and healthcare disparities. They can establish the common message that disparities are unacceptable and must be prioritized, and serve as a vehicle for regionwide initiatives. They can provide technical assistance, establish practice-level patient and community advisory boards, and nurture partnerships between practices and community-based organizations. Regional multi-stakeholder coalitions can also encourage and motivate payers’ financial support of disparities-focused QI efforts at practices.

Healthcare organizations collected clinical performance data stratified by patient’s race, ethnicity, and language (REL). Disparities are ideally identified with REL-stratified performance data. The success of specific interventions can be measured by their impact on the same REL-stratified data. The AF4Q initiative provided intensive technical assistance to collect REL data in hospitals and practices. These efforts raised awareness of equity as an issue of quality and initiated analysis of disparities, especially in hospitals.

Equity was emphasized as an important goal in program messaging. The programmatic materials and models of the AF4Q initiative used to inform alliance-level activities routinely stress the importance of equity in healthcare. Although many practice leaders were initially unwilling to prioritize equity over competing demands, this messaging provided a foundation for eventually promoting disparities reduction activities.

Hospital collaboratives addressed equity concerns. Four different hospital collaboratives have included disparities-related data collection as an activity for participants: the Equity Quality Improvement Collaborative, Language Quality Improvement Collaborative, Hospital Quality Network, and Transforming Care at the Bedside. The majority of hospital teams participating in these collaboratives collected REL data, and some have stratified QI measures by REL (personal communication: Marcia Wilson, PhD, MBA, and Christina Rowland, MPH, April 10, 2012). The Equity Quality Improvement Collaborative and the Language Quality Improvement Collaborative also began actively incorporating equity into their QI activities by identifying and testing strategies for disparities reduction in selected measures.^5,6

AF4Q Initiative’s Challenges for Reducing Disparities

Several challenges to reduce disparities emerged from the AF4Q initiative, which in hindsight related to late and limited ambulatory disparities reduction efforts: Comprehensive ambulatory QI efforts were developed several years into the initiative. The AF4Q initiative prioritized alliance public reporting of performance data from the beginning. If a vigorous effort to build QI infrastructure had occurred concurrently, quality of care might have improved more rapidly. During the early years of the AF4Q initiative, Finding Answers and others were still learning that incorporating equity efforts into a preexisting ambulatory QI infrastructure increases the potential for success.³ However, this principle was not widely known and the AF4Q initiative did not establish specific ambulatory QI goals for the alliances until 2009—3 years into the program. These initial goals focused on the patient experience of care and success in collecting patient-level REL data. The AF4Q initiative added more comprehensive ambulatory QI goals in 2011.

Ambulatory equity efforts were limited to REL data collection. Although the AF4Q initiative did not require reducing a disparity in the early years of the project, it did emphasize REL data collection from the start. But after the AF4Q initiative began, Finding Answers learned that using REL data collection to identify disparities is helpful but not sufficient to improve outcomes.⁷ REL data collection is only 1 activity in the complex process of incorporating equity into QI. Organizations need to know how to reduce disparities once they recognize them.

Demonstrated reduction in disparities was not required until late in the program. Although the AF4Q initiative had strong messaging around equity, concrete requirements to measurably reduce disparities are not required in ambulatory settings until 2014. The late start to establishing equity goals was partly because the AF4Q initiative leadership recognized that many alliances and practices had limited QI infrastructure and were not willing to prioritize disparities. Many alliance leaders perceived equity as a low priority given their healthcare organization markets (eg, many small private practices) or demographics (eg, low number of diverse populations). Early efforts by the AF4Q initiative leadership to prioritize and require progress on equity would have been impeded by this low readiness to change.

Recommendations

Use the Roadmap to reduce disparities from the beginning to the end of any regional effort. The Finding Answers Roadmap emphasizes that integrating equity into ambulatory QI requires multiple steps, which go beyond the usual emphasis on REL data collection and intervention selection. For example, the Roadmap stresses the importance of creating a culture in which providers, healthcare organizations, and regional stakeholders view disparities as important and take responsibility for reducing them. It also provides guidance or tailoring interventions to specific practices and patient populations. Additionally, the Roadmap can serve as a template for standardized technical assistance at the level of the practice and the region. For example, practice coach networks or QI collaboratives can use the process described by the Roadmap to create technical assistance activities that are flexible for a variety of clinics. Regional alliances can apply the Roadmap’s basic principles to different healthcare markets and stakeholders.

Utilize a QI model that establishes equity as a cross-cutting dimension of every component of quality. Six years after the AF4Q initiative began, the Institute of Medicine updated its model of quality so that equity was elevated from 1 of 6 separate components to a cross-cutting dimension that impacts each component of quality.⁸ This model discourages equating equity efforts with any singular activity (eg, the collection and analysis of patient-level REL data) or goal. It supports the incorporation of disparities work into current QI efforts. For example, organizations involved in a regional effort to increase the number of certified patient-centered medical homes, or to create an accountable care organization, can incorporate equity activities into these larger goals. All measures of quality of care, whether rates of hemoglobin A1C testing for patients with diabetes or hospital-acquired infections, must be examined not only for overall average performance, but also stratified by race and ethnicity to ensure that no subgroups experience significantly worse outcomes than the majority.

Do not get stuck on 1 step: move forward with your equity agenda in several ways. Finding Answers found that organizations without REL-stratified quality data can move forward with creating a culture of equity, establishing community and patient advisory boards, and collaborating with communitybased organizations. Potential activities include continuing education for providers on disparities; organizational assessments of cultural competency followed by technical assistance to improve it; identifying and nurturing champions of disparities reduction; and communication campaigns While alliances establish regional REL-stratified clinical performance databases and identify specific disparities goals, they can implement pilot equity activities with practices and hospitals that have particularly strong interest and capacity for addressing differences in care.

Provide a menu of best practices and model interventions for reducing disparities. It is critical that individual providers and healthcare organizations design interventions tailored to their setting and patients. However, they can learn from the growing number of researchers and practices that have implemented interventions to reduce inequality in care. Examples of websites that assemble disparities reduction models and lessons include those of Finding Answers (www.solvingdisparities.org) and the Agency for Healthcare Research and Quality Healthcare Innovations Exchange (www.innovations.ahrq.gov/).