Tying Health Equity to Quality

Breaking down barriers to health equity programs

By Megan Headley

More healthcare leaders than ever are setting health equity as a strategic priority for their organization, according to the Institute for Healthcare Improvement (IHI), but not all see a clear path forward. There is still a tremendous lack of data, both on inequity and on the impact of initiatives to make improvements, and healthcare organizations are certainly burdened with their fair share of challenges. However, the biggest barrier to stronger progress on health equity may be that few healthcare organizations see it as directly connected to quality.

“I think there’s some hesitation from quality and safety leaders about whether or not this is in scope, and whether or not equity work is part of the work around quality,” says Dr. Kedar Mate, president and CEO of the IHI. However, as Mate, the IHI, and the Institute of Medicine (as it defined 20 years ago in its report Crossing the Quality Chasm: A New Health System for the 21st Century) might argue, there is no quality without equity.

This connection between the two may be critical in addressing the barriers keeping more healthcare organizations from prioritizing progress in health equity.

Barriers to health equity

IHI conducted an industry poll in July 2021 to develop a baseline around current attitudes and perceptions surrounding health equity work in the United States and to identify roadblocks preventing healthcare delivery organizations from advancing health equity goals. The survey of more than 500 healthcare professionals found a sizable increase from 2019 to 2021 in the number of healthcare leaders who identify health equity as one of their organization’s top three priorities: from 25% in 2019 to 58% in 2021. It’s significant progress, but a number of challenges seem to remain in terms of broader advancement.

In its report Health Equity: Prioritization, Perception, and Progress, IHI identifies five top barriers standing in the way of health equity programs, as identified by panel participants. These include:

1. 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.
2. 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%).
3. Lack of funding directed specifically to help drive progress in health equity (28%).
4. Inability to demonstrate 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 being ineffective.
5. Lack of guidance or know-how on what to do next (26%).

However, Mate challenges that if organizations recognize health inequity as a problem and commit to making it a strategic priority, they will find they can address many of these barriers through the growing body of available resources, from IHI as well as health systems that have made progress.

“I think that what’s missing is the will and motivation to make a difference here,” he says.

A quality-based path forward

As many of these healthcare organizations are finding, setting health equity as a strategic priority holds leadership accountable for results and is a critical first step in driving resources toward these programs, including support frameworks and training for staff.

“If an organization makes equity a strategic priority, then almost by definition resources ought to flow towards those strategies,” Mate says. “Otherwise, why on Earth is it a strategic priority? It doesn’t make operating sense.”

The next step, Mate says, is to mobilize quality teams to create a framework for program progress. “One observation we’ve made in IHI’s Pursuing Equity initiative is that the teams that had the most success around remediating inequities and closing gaps in care were the teams that had the quality infrastructure to work on inequity,” he says.

“The diversity inclusion and equity parts of HR operations within health systems is not enough to move the needle on this work,” he adds. “You have to couple that interest and knowledge with quality expertise, because that’s what actually leads to meaningful clinical improvement around disparity.”

Pushback can drive progress

While health equity initiatives are having a big moment, the poll results themselves make clear that not all healthcare organizations are making it a priority. Of those 42% of IHI survey respondents who report not setting health equity as a priority, 34% indicated that their organization either does not experience deep or persistent disparities related to race/ethnicity, language, sexual orientation, or geographic location, or does not believe prioritizing health equity is necessary based on its context. An additional 18% noted they do not have the right leadership to drive this work.

Mate notes that some pushback should be anticipated, especially in the quality arena, but pushback itself presents an opportunity. “Resistance should be anticipated. Pushback should be anticipated. That is not always bad,” he says. “We can roll with it and actually convert often people that are resistors into activated agents of change with data and story.”

Mate makes the case for this approach with his own data and stories. As he points out, the history of establishing safety and quality metrics in medicine made significant progress through an approach that combined data on harm with patients’ stories of being harmed. “That was extremely powerful motivation for those that didn’t see safety as a priority, and I believe the same will be true around equity,” he says.

He encourages equity advocates to share information about the disparities in the system with storytelling from patients who have been harmed by racism or other examples of structured injustice.

Tying health equity to quality

The IHI has emphasized for some time that there can be no healthcare quality without health equity. “You can’t have high-quality care when you systematically exclude some of the population from the benefits of the service that you’re producing, so there is no quality without equity,” Mate elaborates. A majority of respondents to IHI’s healthcare poll (82%) agreed. However, the inverse—that there’s no health equity without quality—may be true as well, he argues.

This conclusion stems from an observation around how healthcare systems in the U.S. are legislated to produce high-quality care. Regulations ensure that healthcare delivery systems achieve quality and safety goals, and they might also be necessary to drive clear improvements in health equity.

“The idea of tying equity to quality is really important because it gives equity a regulatory basis, a powerful basis for actually being realized,” Mate says. “If the executive leadership teams at health systems are accountable for quality, and they have a fiduciary responsibility for it to their communities, we must indeed tie equity to quality because it will then have that same standing within leadership and governance systems going forward.”

While real progress is likely to take time, there are already clear steps that organizations can take today to begin undoing structured injustices and building a path to health equity. The first step is acknowledging the need to address health equity as a strategic priority and a clear part of the quality team’s scope.

Megan Headley is a freelance writer and owner of ClearStory Publications. She can be reached at megan@clearstorypublications.com.