Apr 24, 2023

In Health Care, There is No Quality without Equity

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In the pioneering publication, Crossing the Quality Chasm, the Institute of Medicine (IOM) defined six domains of health care quality. These domains are efficiency, effectiveness, safety, timeliness, patient-centered, and equitable. Health care organizations nationwide have shown significant commitment to the first five of these domains, emphasizing improving patient safety and quality. While continuing to strive toward improving the health care delivery system, much work remains within the equity pillar. With studies continuing to show significant disparities in health care quality and outcome metrics, one might ask — can we truly achieve quality of care without equity?

According to the 2016 National Healthcare Quality and Disparities Report, significant disparities in health care quality were reported. Racial and ethnic minorities, individuals with disabilities, individuals with low incomes, and individuals with other social risk factors are more likely to receive lower-quality care. Health equity, or the lack thereof, also increasingly affects the bottom line. Higher rates of chronic and costly conditions, combined with high rates of uninsured individuals among lower socioeconomic and minority populations, result in a greater reliance on emergency services, higher treatment costs, and, ultimately, a financial strain on providers and government programs.

While health care organizations alone do not have the power to improve the multiple determinants of health for all of society, they do have the power to address disparities directly at the point of care and to impact many of the determinants that create these disparities. The Institute for Healthcare Improvement (IHI) identifies five top barriers standing in the way of health equity programs, as identified by panel participants. These include:

  • Inconsistent collection of equity-related patient data (38%); capturing and stratifying data by race, ethnicity, ancestry, language, sexual orientation, and gender identity was selected by 23% of respondents as the most important thing that their organization needs to do to advance health equity.
  • Lack of resources other than funding, including staff qualified and knowledgeable in the stratification of data and other analysis that can drive health equity programming (38%).
  • Lack of funding directed specifically to help drive progress in health equity (28%).
  • Inability to demonstrate the impact of health equity efforts (26%). While survey respondents reported a number of actions already being taken to advance these priorities, only 1% could claim their activities as being “extremely effective.” Fourteen percent reported being unsure of the impact, with an additional 6% reporting these activities as ineffective.
  • Lack of guidance or know-how on what to do next (26%).

Health care organizations must recognize their role and their obligation to ensure that when they set standards for safety and quality, those standards apply to one hundred percent of all patients, not just those patients who may be more privileged for whatever reason, whether it’s race, ethnicity, socio-demographic status, or language. The question of health equity has also been important for value-based care. Organizations can only get the best clinical outcomes and fulfill their value-based care contracts when they ensure all patients have the same opportunity to obtain and maintain health.

Commitment to eliminating health disparities requires an “all in” approach. It starts with the collection of social risk factor data. Data are the bedrock of all measurement activities; however, data on social risk factors is currently limited. These limitations can impede efforts to find and reduce disparities. As such, stakeholders must invest in the necessary infrastructure to support data collection. There needs to be a standard collection of data related to social risks like housing instability, food insecurity, gender identity, sexual orientation, language, continuity of insurance coverage, etc.

To understand the factors that impact the patient’s health, hospitals must commit to using patient and family engagement strategies to achieve equity in quality and safety. Overcoming health disparities is a huge step. It requires a commitment to engaging patients and families from all backgrounds as equals and becoming active partners in healthcare improvement strategies. Developing a deeper understanding of the needs, perspectives, interests, values, and beliefs of all patients and families from diverse backgrounds will reflect what matters most to patients at each level of hospital care.  

Finally, prioritizing stratified health equity outcome measures must be understood. Stakeholders should first conduct a needs assessment to identify the extent to which they are meeting the goals outlined in the measurement roadmap. The domains should be considered as a whole rather than aiming to make progress in only one area. Stakeholders may find themselves at varying stages in achieving the goals outlined in the roadmap, but progress in all domains is necessary to achieve equity.

Dr. Sprouse is vice president of patient care services at Baylor St. Luke’s Medical Center. She is also an executive board member of the Philippine Nurses Association of America and president of the Philippine Nurses Association North Houston.