Health equity is a massive topic for hospitals to address, with hundreds of avenues that can be taken in confronting the issue. It's no wonder many leaders are often overwhelmed and unsure where to begin.
"Dismantling all of the systems that contribute to inequities in health in this country will take a massive societal effort involving education, housing, food supply and employment," Lynne Richardson, MD, New York City-based Mount Sinai Health Center's endowed professor of emergency medicine and health equity science and founding co-director of the Institute for Health Equity Research, told Becker's. "But healthcare inequities belong to us as healthcare professionals, and it's a problem we can solve together, even as society works on the larger issues."
Equity touches every part of healthcare and "should be the guiding principle for everything we do, from clinical delivery to population health." Srinivas Merugu, MD, president of Cleveland-based MetroHealth's Institute for HOPE, told Becker's.
How to begin
Health equity issues span across every disease, care model and community. With so many places to start, it can be difficult to narrow down into only one place to begin.
"I regularly ask hospital leaders, 'Are you delivering equitable care to everyone?' and 'Have you measured it?'" Dr. Richardson said. "That's where to start. We measure everything else, so let's measure this accurately. It may take some effort to improve the completeness of patient-level data in some hospitals, but with proper staff training, it's achievable. It doesn't cost more — it just requires attention and the belief that it can be done."
Starting with data is a simple, no-extra-cost way for systems to begin tackling health equity within their walls. Harnessing this "massive apparatus for performance improvement" can show systems their inequities exist by race, Dr. Richardson said. But this starts by collecting accurate and complete information on race and ethnicity, and language preference.
"Properly trained, hospitals can gather this data without offending patients, explaining that it helps ensure equal quality of care," she said. "When asked this way, over 95% of patients are willing to provide their self-reported race and ethnicity."
Once the information is accurate, leaders can stratify the data by patient groups across different process measures. If there's a difference by subgroup, that can indicate a disparity that needs to be addressed.
"Every hospital leader knows how to tackle quality improvement projects, so now it's about using those tools in service of equity," Dr. Richardson said. "Embedding equity measurement into quality measurement across every service in the institution is the way to start. Don't just go through the motions — use the data to take meaningful action."
Some hospitals begin by addressing inequities inside their system, but others start with the community. Healthcare systems are an economic force in their community, and that can be harnessed to improve the community beyond care.
"In hiring practices, purchasing, and authentic engagement with the community — all of these things are crucial," Dr. Merugu said. "That's where I suggest healthcare organizations start. At MetroHealth, we've done this by clearly aligning equity with our mission."
Community initiatives
Maternal mortality has significant healthcare disparities across the country, and in Cleveland, where MetroHealth is based, infant and maternal mortality was identified as a crisis.
"We see high rates of low birth weight, premature deaths and postpartum complications, with racial disparities a major factor," Dr. Merugu said. "In response, we reviewed our data at Metro. When addressing a known public health concern, organizations should look at their own performance to see if it mirrors the larger community trends. In our case, we found disparities in the rates of prenatal and postpartum visits, especially among African American patients. Lower rates of these visits point to a disparity, so we built processes to address it."
The approach included community engagement to understand the root cause of fewer visits. From that, the system learned that transportation and child care for mothers with multiple children was a barrier. So they began a transportation program that would help these women bring children to their appointments.
The system also brought in doulas, certified midwives and partnered with community-based organizations to help offer culturally sensitive care.
"We worked with payers to incorporate these initiatives into our value-based care contracts," he said. "By adjusting our model, bringing in new providers, raising awareness of these inequities and fostering partnerships, we're better responding to this crisis. While we haven't eliminated these disparities, we're making measurable progress."
Revisiting clinical algorithms
Systems can also improve equitable care by re-evaluating the clinical algorithms they use.
Recently, clinical algorithms made the news when a kidney disease algorithm was found to use flawed, race-based adjustments. This estimated glomerular filtration rate metric falsely made Black patient's kidney function appear better than it was, delaying treatment and referrals. However, most hospitals and physicians weren't aware the algorithm used that formula.
"Most hospitals have now removed this correction, and the national transplant organization has mandated a race-neutral approach," Dr. Richardson said. "If your hospital still uses such race-based formulas, it's time to change them."
How to prioritize action
There are potentially hundreds of disparities that need to be addressed in healthcare — so where do systems begin?
"I'd say go back to the principles of quality assurance," Dr. Richardson said. "It's reasonable to say you can't address everything at once, but you should address something and use common sense in prioritizing. This is something I learned in healthcare management years ago: focus on high-volume, high-risk and problem-prone areas. Once you've successfully addressed one area, keep monitoring to ensure that the solutions are sustained."
Tackling each disparity means taking a new approach.
"We have to hold ourselves accountable for achieving those equitable outcomes — not just applying the same approach for everyone, which may not work equally well for different groups," she said. "We need to be accountable for the health outcomes we achieve, not just the actions we take."
Dr. Merugu argues though, that the most important priority systems should make is to provide more opportunities.
"We're all so focused on this end goal of outcomes, wanting to show that we reduced a disparity or somehow eliminated the gap between African Americans and another group," he said. "But guess what? It's going to feel like playing whack-a-mole if that's the only focus. That's why I believe we need to move away from an emphasis solely on outcomes. Opportunities are where our focus needs to be. I actually believe this approach lowers our sense of distress somewhat without diminishing our purpose."
The community itself can tell systems where the opportunities are lacking and which they prioritize most. This can provide hospitals with the framework for where to begin.
The future of health equity
Equity work is never truly finished, Dr. Merugu said. It's an ongoing project that will evolve as hospitals make changes.
But for Dr. Richardson, the future of health equity is based on patient experience and satisfaction.
"The focus should be on improving patient experience by actually taking better care of patients," she said. "It's not just about customer service training; it's about delivering quality care. That's how you build a successful hospital."
Better patient experience will lead to greater satisfaction for staff, which can improve recruitment and retention, and benefit hospitals financially.
"With the right tools, we can continuously improve and work toward providing genuinely equitable, high-quality care for all," she said.