The spotlight on health care disparities in the United States is far from new. Over a decade ago, the Institute of Medicine (IOM) landmark report Unequal Treatment summarized findings of significant variations in treatment by race and ethnicity in the United States.1 While the focus of that IOM report was on racial and ethnic disparities, disparities between populations may be viewed through the lens of many other personal characteristics, including gender identity, sexual orientation, disability status, primary language, or having a mental health condition. Equitable care, defined as “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status,”2 has existed as one of the six IOM domains of high-quality patient care for close to two decades. Yet, jointly addressing health equity alongside quality of care remains foreign to many health care systems, their quality leaders, and medical educators. However, providing equitable care is only one facet of health equity, which extends beyond the care provided by health care professionals and health systems to the many factors within society that influence the health of populations.
In this article, when we reference health equity, we are referring to equitable care. Our primary focus is equitable care given the recent call to address health care disparities that has come from the Accreditation Council for Graduate Medical Education’s (ACGME’s) Clinical Learning Environment Review (CLER) program.3 The intent of this program, introduced in 2013, is to foster improvement and innovation in six areas within the clinical learning environment for graduate medical education (GME) trainees. The CLER program specifically identifies health care disparities as a key focus area and aspires that faculty and residents will identify disparities among the patient populations they serve and engage in quality improvement (QI) activities designed to address them.
Meeting this ACGME requirement would improve patient care within the clinical learning environment, yet it may appear to be a daunting task for medical educators and GME programs within academic institutions. Here, we present a framework we created for resident training and faculty development that integrates QI and health equity efforts to meet these ACGME expectations. Our framework consists of four key steps that educators and learners can use to initiate dialogue and action to address health care disparities found among the populations they serve and to consider equity when designing any QI project. We first present the concepts behind our framework, which require educators to think critically about their understanding of QI and equity and to ask themselves what it means to apply an equity focus to quality efforts and vice versa. Then, we detail the four key steps to integrating QI and equity endeavors.
Quality and Equity: How Do These Concepts Relate?
Rethinking quality with an equity focus
While it is now common in academic institutions to hear of QI projects focused on such quality domains as safety (e.g., reducing health-care-associated infections) or effectiveness (e.g., increasing the use of appropriate perioperative antibiotics), it is much less common to hear of QI work with a health equity focus. Applying an equity focus provides an opportunity to ensure that every QI intervention results in equal benefits to all populations or, in other words, results in outcomes that are equitable. For example, after New York State’s Medicaid program stratified the quality outcomes of its asthma program by demographic characteristics such as race/ethnicity and discovered inequities, it formed a QI collaborative to reduce the racial/ethnic disparities in asthma quality of care measures identified within New York City communities.4 Informed by baseline data, the QI collaborative identified individuals within the populations experiencing the greatest disparities and surveyed them to understand how best to tailor QI interventions to meet their needs and reduce the inequities in the asthma program. This large effort was supported by the New York State Department of Health, but local QI efforts can integrate equity using similar approaches.
Crucial to integrating health equity into QI is to recognize that most if not all QI interventions that result in overall improvements have one of three equity outcomes: QI interventions may reduce or eliminate existing disparities, sustain existing disparities, or exacerbate existing disparities.5 For example, early public health smoking cessation interventions that focused on educational campaigns served to worsen the socioeconomic disparity in tobacco control.6 It is therefore important to evaluate any planned QI intervention for equity outcomes. Applying this concept, as part of a QI project at our institution, a cohort of 10 internal medicine residents identified that blood pressure control for patients cared for in the resident clinic was significantly worse than for patients cared for by faculty in the same practice. After the problem was defined, the data for both groups were stratified by patient characteristics, and the QI team discovered a racial/ethnic disparity in hypertension control. Identifying this baseline disparity afforded the QI project’s faculty facilitators an opportunity to engage the residents in a discussion about what factors may contribute to these disparities and how to design QI interventions to simultaneously reduce these disparities and improve the overall quality of hypertension control in their patient population.
Acquiring and analyzing quality data by personal characteristics does not routinely occur in QI work or GME, yet it offers a rich and untapped opportunity to inform health system leaders and QI teams of the equity gaps in their institutions and patient populations. Considering equity as an aspect of quality should become routine for residents and faculty and lead to informed discussions that serve to address quality gaps and attempt to reduce equity gaps, rather than sustaining or widening them.
Rethinking equity with a quality focus
QI activities naturally fall within two of the six ACGME core competencies: systems-based practice (SBP) and practice-based learning and improvement (PBLI). Both of these core competencies can incorporate activities that focus on health equity. In SBP, competency in QI involves looking outward at the “village” of the health care system and demonstrating the ability to understand and participate in activities designed to improve health care delivery systems.7 In PBLI, competency in QI involves turning a “mirror” on one’s own patients or patient populations and evaluating the quality outcomes.7,8 These two core competencies dovetail with the two reasons cited in Unequal Treatment for why disparities in treatment occur between populations with equal access to care, after controlling for clinical need and patient preferences.1 The first reason relates to the operation of health care systems and the legal and regulatory climate in which they function, which by design serves to benefit a majority culture. To address this reason and improve equity, we must engage in the practice of looking outward at the “village,” or the system-level factors that perpetuate unequal care for minority populations. This process may include reaching out to case managers, social workers, or family members to receive their perspectives in order to fully understand system-level barriers to providing equitable care. The second reason relates to provider stereotyping, uncertainty, and/or implicit biases. To address this reason, we must look inward, or in a “mirror,” to thoughtfully examine our role in health care disparities.
Applying QI methods to address equity challenges
As we strive to improve equitable care in the U.S. health care delivery system, we can approach health equity problems in a structured manner using QI methods and tools. QI is grounded in the science of structured problem solving and emphasizes the importance of defining, measuring, and analyzing a quality problem before developing and planning improvement strategies. For example, if a QI team identifies that Hispanic women have the lowest breast cancer screening rates among their primary care clinic’s patients, the team’s residents could speak with a small subset of Hispanic women in the waiting room to understand their knowledge, experiences, perceptions, and barriers related to mammography screening. This approach, referred to as “voice of the customer”9 in QI work, allows for the patient’s voice, preferences, and expectations to be heard. The residents could incorporate these patient perspectives into an Ishikawa diagram (also known as a fishbone or cause-and-effect diagram), a QI tool that allows for visualization of the many potential causes of a specific problem. Selecting an intervention that targets one or more of the root causes of the problem would allow the QI team to begin a plan–do–study–act (PDSA) cycle in which they test their change by planning it, doing it, studying its effect, and acting on what they learn. Incorporating QI tools such as these into health-equity-related quality problems can provide concrete activities for learners and cement the connection between equity and quality for faculty, residents, and other members of interprofessional health care QI teams.9
Four-Step Framework: Faculty Development Workshop
Based on the concepts detailed above, we provide a four-step framework for medical educators for embedding equity into their existing educational efforts in quality and vice versa: (1) define terms and concepts, (2) understand and disseminate the current knowledge of health care disparities in a field, (3) identify health care disparities locally and apply QI methods to address them, and (4) evaluate every QI effort for the potential equity angle. To illustrate our framework, we describe the 90-minute interactive workshop in which we have presented this framework to educators at our institution.
Step 1: Define terms and concepts
A key step to addressing health equity is understanding what it means, as the terms related to health equity are often conflated in the literature.10,11 We begin our workshop with a review of the basic terms and concepts related to health equity. We draw the distinction between health care disparities, or differences in quality of treatment after accounting for access to care, clinical need, and patient preferences; and health disparities, or differences in disease burden and related outcomes.12 Health disparities result from social determinants of health, or the social and physical conditions in which people are born, grow, work, and age.13 For residents/fellows to design interventions that tackle social determinants of health would prove challenging without significant institutional investment and community partnerships. Therefore, we emphasize that while health care disparities may contribute to health disparities, they are distinct entities, and we recommend an initial focus on reducing health care disparities alongside QI efforts. We then review the two reasons cited by Unequal Treatment as to why disparities in treatment occur between populations with equal access to care1 and, as above, describe the parallels to the core competencies of SBP (the “village”) and PBLI (the “mirror”).
Step 2: Understand and disseminate the current knowledge of health care disparities in a field
After reviewing key terms and concepts, we outline a tiered set of strategies that medical educators can use to engage residents/fellows in clinical site initiatives to address health care disparities. These strategies are presented in a visual two-by-two, effort–impact matrix, which displays the strategies according to two domains: effort (low and high) and impact (low and high). First, we assert that the most basic step is for faculty to raise awareness about the health care or health disparities relevant to their clinical specialty. Because faculty attending the workshop may not be familiar with this information, we engage them in a brief literature search activity to identify one or more health care disparities published in their field.
We then ask faculty to develop a plan to disseminate this information to colleagues and trainees within their specialty. Methods for dissemination could include an e-mail brief that outlines key take-home points with links to relevant articles or a dedicated journal club. Initiating discussions among residents/fellows and faculty about relevant health care disparities is a low-effort–high-impact activity that sets the stage for subsequent inquiry and ongoing dialogue.
Step 3: Identify health care disparities locally and apply QI methods to address them
The logical question that emerges from faculty discussing literature in their fields pertaining to health care disparities is whether and to what extent the published disparities in a field occur locally within the patient population a faculty member serves. For example, the literature shows that among patients with end-stage renal disease who desire a renal transplant, black patients are significantly less likely than white patients to be referred to a transplant center and placed on a transplant waiting list, even after adjusting for patient preference and several potential confounders.14,15 We ask, does that same health care disparity occur at your institution? We thereafter review the potential sources and methods for obtaining and analyzing local data to determine where and why an equity gap may exist in an institution.
We then review strategies for and share examples of applying classic QI methods to address identified disparities. For example, at our institution, we asked residents familiar with QI methods to apply the Ishikawa diagram to identify the root causes of racial/ethnic disparities in renal transplant referrals. In that exercise, one of the root causes residents identified was physician implicit bias, or unconscious assumptions or stereotypes. Implicit bias as a root cause for differences in care quality may prove challenging to address. Educators could encourage learners to take the Implicit Association Test,16 to assist them in self-reflection regarding implicit biases that may influence the care they provide, and promote a forum for discussion using illustrative cases.17,18
Step 4: Evaluate every QI effort for the potential equity angle
This final step addresses how every QI effort provides an opportunity to consider health equity and is not dependent on the other three steps. In our workshop, to make embedding equity into existing QI efforts seem less daunting, we elicit examples from workshop attendees of their current or past QI projects and demonstrate ways to integrate an equity focus. For example, if a QI team led by residents identifies that incidental lung nodules found on radiographs are not consistently communicated with patients or followed up in a timely fashion, the residents could analyze their data on the basis of patients’ personal characteristics to determine whether certain patient populations are more or less likely to experience this outcome and to influence their system-level interventions. Similarly, QI educators may add an equity lens to PBLI activities. Asking residents to reflect on their referral rates for eye or foot exams for their patients with diabetes, considering patients’ personal characteristics such as race/ethnicity, gender, or socioeconomic status, could afford both teacher and learners an opportunity to identify disparities as well as the causes and potential solutions. As with any other QI project, time constraints, appropriate mentorship, and the process for continuation of the project as the resident population changes need to be carefully considered by the individual GME program.
QI With a Health Equity Focus: What Will It Take to Get There?
It is important to integrate health equity with QI initiatives, but implementing experiential curricula in this area requires several critical ingredients. First, institutional leadership should ensure that quality data are reported by patient race/ethnicity, gender identity, sexual orientation, and primary language, within currently available data systems.12 If these data are not available, institutions should build capacity and training to improve data collection of personal characteristics. Second, institutions must build infrastructure to support routine reporting of quality metrics by demographic variables. Third, health system leaders should provide resources to disseminate lessons learned from equity-focused QI work within the organization and promote a learning health system.14 Fourth, institutions must support faculty development in QI and key health equity concepts to mentor trainees through improvement work that will invariably involve multiple stakeholders, competing organizational priorities, and change management. Lastly, GME program directors should prioritize time in the curriculum for learners to participate in equity improvement activities.
We recognize that curricular additions may be met with resistance due to time constraints of both learners and teachers. Therefore, we suggest reframing this conversation as “two for the price of one” from a curricular and QI perspective to assist educators in discussions with key stakeholders about introducing such a curriculum. We also realize that this education cannot occur in a vacuum without system-level changes that support effective measurement and reporting of health care disparities. In this article, we have provided a framework and outlined a faculty development workshop aimed at addressing these challenges by using available resources and institutional support to apply strategies and tools that embed health equity into existing educational efforts in QI. Integrating QI and equity curricula, as outlined above, offers exciting opportunities to capitalize on and leverage these efforts in GME to improve patient care.
The authors wish to thank Dr. P.J. Brennan, Dr. Jeffrey Berns, and Dr. Eve Higginbotham at the University of Pennsylvania for their support of this work; Dr. Rachel Kelz, who contributed to the content of the faculty development workshop on health care disparities and quality improvement; and Dr. Amber-Nicole Bird, who led the resident quality improvement project on hypertension.
1. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care [full printed version]. 2003.Washington, DC: National Academies Press.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.Washington, DC: National Academies Press.
3. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370:991993.
4. Anarella JP, Wagner VL, McCauley SG, Mane JB, Waniewski PA. Eliminating disparities in asthma care: Identifying broad challenges in quality improvement [published online ahead of print December 1, 2016]. Am J Med Qual. doi: 10.1177/1062860616682587.
5. Chin MH. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):9921000.
6. White M, Adams J, Heywood P. Babones SJ. How and why do interventions that increase health overall widen inequalities within populations? In: Social Inequality and Public Health. 2009:Bristol, UK: Policy Press; 6582.
7. Ziegelstein RC, Fiebach NH. “The mirror” and “the village”: A new method for teaching practice-based learning and improvement and systems-based practice. Acad Med. 2004;79:8388.
8. National Academies of Sciences, Engineering, and Medicine. Communities in Action: Pathways to Health Equity. 2017.Washington, DC: National Academies Press.
9. George ML, Rowlands D, Price M, Maxey J. The Lean Six Sigma Pocket Toolbook: A Quick Reference Guide to Nearly 100 Tools for Improving Process Quality, Speed, and Complexity. 2005.New York, NY: McGraw-Hill.
10. Braveman P. What are health disparities and health equity? We need to be clear. Public Health Rep. 2014;129(suppl 2):58.
11. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O 2nd. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293302.
12. Betancourt JR. Eliminating racial and ethnic disparities in health care: What is the role of academic medicine? Acad Med. 2006;81:788792.
13. World Health Organization Commission on Social Determinants of Health. Clos ing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. 2008.Geneva, Switzerland: World Health Organization.
14. Epstein AM, Ayanian JZ, Keogh JH, et al. Racial disparities in access to renal transplantation—Clinically appropriate or due to underuse or overuse? N Engl J Med. 2000;343:15371544.
15. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med. 1999;341:16611669.
16. Project Implicit. Take a test: Preliminary information. https://implicit.harvard.edu/implicit/takeatest.html
. Accessed October 10, 2017.
17. van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A Medical Student CHANGES Study report. J Gen Intern Med. 2015;30:17481756.
18. Viswanathan V, Seigerman M, Manning E, Aysola J. Examining provider bias in health care through implicit bias rounds. Health Affairs Blog. http://healthaffairs.org/blog/2017/07/17/examining-provider-bias-in-health-care-through-implicit-bias-rounds/
. Published July 17, 2017. Accessed September 21, 2017.