Why It Matters
“The beautiful, well-intended [improvement efforts] we implement can sometimes cause disparities.”
Not long after they started trying to ingrain equity into performance improvement in 2020, teams at New York City Health + Hospitals (NYC H+H) carried out hundreds of improvement initiatives across the system. When they first looked at the results, recalled Komal Bajaj, MD, MS-HPEd, they were thrilled. “People, rightfully so, were high-fiving each other about the tremendous gains that were experienced,” said Bajaj, who serves as Chief Quality Officer for two Bronx-based acute-care facilities within the system.
But then they looked deeper, stratifying the data based on identified structural barriers such as language preference and BMI. They found that approximately 18 percent had an intervention-generated disparity. In other words, said Bajaj, “in one in five projects there were groups that did not experience those same gains.” She described the moment of astonishment as the realization sunk in that “the beautiful, well-intended [improvement efforts] we implement can sometimes cause disparities.”
Although this insight could have been dispiriting, it turned out to be galvanizing. It motivated the team to “take that next step to make sure that we are advancing health equity by closing the gap,” Bajaj recalled.
Ingraining Equity into Quality
At NYC H + H, ingraining equity into quality and safety is the goal. That includes thinking about how improvement activities can advance health equity at each step. It means that when the leaders and staff think about improvement, said Bajaj, “you have to think about improvement for who?” They are committed to centering under-resourced communities and ensuring they have adequate data on the populations they serve.
It also means looking beyond the health system and into the community. “The health of our patients is impacted tremendously by what happens outside of our care,” noted Bajaj, “so we consider how to partner with those addressing key social determinants of health to advance care for all,” said Bajaj.
Why is it so important to ingrain equity into quality from the start? As teams work hard on improvement, “the worst thing we can do is exacerbate inequities that exist within our communities,” Bajaj explained. Intentionally ingraining equity into performance improvement helps to avoid unintended consequences and ensure that all people experience the benefits of this work.
Embed Equity Into Safety | IHI Patient Safety Congress
When Bajaj and her colleagues first started trying to ingrain equity into performance improvement, they asked staff to apply an equity lens by identifying structural barriers to whatever clinical or operational process they were trying to improve. For several months, they heard little from their colleagues. “People were learning and thinking and trying to figure out how to apply the concepts to their own work,” she remembered.
It took time, but teams began to collect data and have conversations. “We started to see folks not only doing improvement work but stratifying their outcome measures based on whatever structural barrier they had identified,” Bajaj explained. Once teams identified disparities, staff members began to think, in partnership with patients, about solutions that could help eliminate them.
Recommendations
For health systems interested in ingraining equity into quality, Bajaj recommends taking time to understand the inequities in the populations your health system serves as an important first step. Next is determining the data you need, including the social determinants of health. “At each step I think it’s about engaging individuals, both patients and staff, in improvement work,” she said.
Bajaj emphasized both that change is hard and that it can be disturbing to see data that documents inequities. She expressed a desire to “normalize the guilt” that comes with realizing that sometimes improvement projects can have disparate impacts and instead ensure a culture that promotes action to close the gaps.
Ingraining equity into improvement hinges on data, and often that data is not perfect. But Bajaj cautions against delaying too long before getting underway. “Do not wait until the data’s perfect because it never will be,” she advised. It is important to understand, she emphasized, that whatever data you have may be flawed, but it is likely good enough to get started.
Getting Results and Global Enthusiasm
One of the organization’s first key initiatives to ingrain equity into each step of design focused on decreasing falls. Not only did the effort decrease falls — an impressive accomplishment — but when they stratified the data, they found that all groups experienced similar improvements. Seeing the success of this effort had an especially profound effect on one member of the team who had been working on decreasing falls for many years. “We are not only advancing health equity,” Bajaj observed, “we’re going back to our humanity. Health care workers are here to do the right thing.”
The enthusiasm for ingraining equity into improvement is not limited to NYC Health + Hospitals. Bajaj noted that she has seen excitement and energy for “not just doing great work but improving on that great work and making it more equitable for everyone” from improvers and patient advocates from around the globe.
Bajaj expressed confidence that successful work to advance health equity will have a positive impact on the trust patients have in the health system. “We have a long way to go but I’m firmly convinced that we will begin to see dividends beyond these charts and graphs in the feelings that people have when they interact with our health care system,” she said.
Editor's note: Hear more from Komal Bajaj, MD, MS-HPEd and her colleagues at the IHI Patient Safety Congress session A02 called “Success Cause Analysis” as a Strategy to Promote Learning and Staff Engagement on Wednesday, May 15.
Throgs Neck Bridge, The Bronx, NY, USA | Photo by Andre Frueh | Unsplash
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