5 ways to use quality improvement tools to tackle health inequities

Andis Robeznieks , Senior News Writer

Hard-won lessons from the patient safety movement to reduce variability in care and eliminate preventable harm to patients also can be applied to the mission of building a more equitable health system, according to Karthik Sivashanker, MD, MPH, the AMA Center for Health Equity's vice president of equitable health systems and innovation.

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The goal is to design resilient and reliable health systems that capture and prevent errors before they reach the patient, regardless of whether the individual provider is tired, distracted, biased or having a bad day, said Dr. Sivashanker. The same is true of health inequities that are widespread, pervasive, preventable and unjust.

"Those inequities are not generally being driven by individual bad actors ... they are being driven by systems, by policies, by practices, by culture," he explained. "They are structural in nature, and so they require structural solutions."

Dr. Sivashanker, who is also Brigham Health's medical director for quality, safety and equity, spoke during a virtual meeting of the AMA Insight Network.

The network aims to help AMA Health System Program members gain early access to innovative ideas, get feedback from their peers, network, and learn about pilot opportunities. Learn more.

Past attempts to address health inequities fell short because they were understaffed, underfunded or failed to explicitly confront the roots of the problem by using euphemisms such as "race-based" or "sex-based" instead of clearly saying "racism" or "sexism."

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"If we can't name the problem, how can we possibly solve for it?" Dr. Sivashanker asked, adding that a new era is required where action is taken and supported by resources and infrastructure.

"The next era is where we're building this into ... the DNA of the work that we do every single day," he said. "The simple way to say it is that there's no such thing as high-quality inequitable care."



Driving out inequity

In his AMA Insight Network presentation, Dr. Sivashanker outlined these five key drivers of how an existing quality- and safety-improvement infrastructure can be used to promote equity.

Integrate equity into quality and safety work by examining if inequities contributing to risk.

Use equity-informed quality and safety education. Look for case studies that illustrate the impact of inequities and then support with data that shows the case study is not an isolated incident.

Use data to support equity improvement and root cause analyses by standardizing, centralizing and stratifying patients' data that had not been collected before such as race, ethnicity, age, gender, language, disability, insurance status, sexual orientation and gender identification.

Engage organization leadership and heighten their awareness with presentations to boards leveraging individual cases of patient harm supported by data.

Use findings to foster organizational accountability. This includes:

  • Examining access data to see whether your organization is providing its fair share of care for patients enrolled in Medicaid.
  • Studying care transitions. For example, Brigham Health found that it was referring Black patients with congestive heart failure to general medicine while white patients were more likely to be referred to a cardiologist.
  • Learning how clinical outcomes compare among different populations. 
  • Assessing whether your institution is a responsible community anchor organization. For example, does it use local vendors or minority-owned area businesses when possible?

Dr. Sivashanker said this model has been implemented by Brigham Health and is getting "national traction" and the goal is to test it at several more systems. He invited AMA health system partners to join the effort.

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"We've been trying to solve these types of problems for too long within our silos," he said. "We're not going to solve this as individual institutions, or even as an industry. We're going to have to solve this together across sectors."