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Improving Quality and Achieving Equity:
A Guide for Hospital Leaders

Chapter 5: What Can You Do? (pdf)

“As it relates to disparities, we need to get beyond just diagnosing the problem—we need to start treating it.”
Peter Slavin, MD, CEO, Massachusetts General Hospital

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Getting Started

Creating the Foundation

Moving to Action

Evaluate, Disseminate, Reengineer
Several recommendations emerged from our research, leadership interviews and case studies in regards to how to begin the process of developing an action portfolio to improve quality, address disparities, and achieve equity. This guidance is built on real-world experience. The recommendations are meant to provide an overall outline for how to move forward on this issue, and are in no way exhaustive. Included here are the basic themes, in step-wise fashion, along with resources to assist in the process. All these resources listed below can be found in Chapter 6 Resources Section.

“[It’s] Important to engage leaders on the issue…challenges are the attention span is short, time is limited; the content needs to be powerful, and it needs to be almost indisputable.” - William Fulkerson, MD, Chief Executive Officer, Duke University Hospital

Getting Started

Create a Disparities Committee or Task Force
Creating a committee or task force to both conduct an assessment of where the hospital is in terms of identifying and addressing disparities can be an important first step. This group can also develop an initial plan of action using guidance from the Creating a Foundation section below.

Resource: The MGH Disparities Committee website has highlights of how this was done, as well as meeting minutes and organizational information that can be helpful.

“In addition to physician and clinical leadership, you need support from the heads of IT, medical records, and other areas you may not typically work with in clinical improvement efforts." - Rohit Bhalla, MD, MPH, Chief Quality Officer, Montefiore Medical Center

“You need to do a fairly good assessment of where you’re at.” - William Walker, MD, Director and Health Officer, Contra Costa Health Services

Committee should be composed of leaders in a variety of disciplines, including patient registration, quality and safety, nursing, patient advocacy, human resources, social services, as well as the leadership of clinical services, among others.

Committee should be composed of leaders in a variety of disciplines, including patient registration, quality and safety, nursing, patient advocacy, human resources, social services, as well as the leadership of clinical services, among others

The committee should be tasked to:

  • Create a rapid self-assessment of what is being done in area of disparities, quality, equity, including whether the following are being done:
    1. Data collection of patient race/ethnicity
    2. Stratifying of the following measures by race/ethnicity
      • National Hospital Quality Measures
      • HEDIS Outpatient Measures
      • Patient Satisfaction
        • Assess if done in multiple languages and if questions include issues related to race, ethnicity, culture, language
      • Patient safety/medical errors
    3. Education and awareness of faculty, staff and patients
      • Cross-cultural communication for doctors, nurses, staff
      • Overall awareness of disparities among all staff, patients
      • Training of registrars in data collection
    4. Efforts to address language barriers
      • Use of and training of interpreters
    5. Efforts in development of medical homes/access
    6. Interventions targeted at disparities
      • Community-based programs
      • Hospital-based programs
  • Develop an initial strategic plan of action to develop, solidify, or improve on and/or expand any of the aforementioned efforts.

“We have to build a shared vocabulary among the people who do this work.  And I think that’s really key… everyone has different ideas and definitions about…. this terminology,.. it’s critical for people to have a shared vocabulary about the meaning of all these different words.” - William Walker, MD, Director and Health Officer, Contra Costa Health Services

Educate leadership team on disparities, quality, equity via local champion or local or national expert

Either before or during the process of convening a committee as described above, it is helpful to begin to educate the leadership team about the issue of disparities, quality, and equity. This can be accomplished via internal or external means.  

Resource: The Institute of Medicine’s Report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care has an Executive Summary that is very helpful in this regard. We have provided a PowerPoint presentation as well that can help achieve this goal if the decision is made to do this internally.

Creating the Foundation

Begin to build foundation to address disparities
There are several key efforts that are essential to identifying and monitoring for racial and ethnic disparities in health care. These include:

  • Race/Ethnicity Data Collection

Resource: The Health Resource and Education Trust Race and Ethnicity Data Collection Toolkit is the standard in the field. There are several web seminars that can be helpful in developing these efforts (DSC Webinars: Getting Started: Building a Foundation to Address Disparities through Data Collection andGetting it Right: Navigating the Complexities of Collecting Race/Ethnicity Data)

  • Disparities and Equity Measurement and Monitoring Tools

Resource: The premier tool in the field is Creating Equity Reports: A Guide for Hospitals, with two accompanying web seminars Collecting Race and Ethnicity Data is Not Enough: Measuring and Reporting Disparities and Creating Equity Reports: A Guide for Hospitals.

  • Interpreter Services

Resource: The Hablamos Juntos/We Speak Together projects have detailed state-of-the-art information on the creation of interpreter services, as well as highlight cutting edge technology in the field. The International Medical Interpreters Association is also an excellent resource for ideas and consultation and we reference these in our resource section.

  • Medical Homes

Resource: Medical homes have been deemed a key initiative to address disparities and facilitate equity. The Commonwealth Fund has created an issue brief which can be helpful (

Develop medical policies to support all new work.
As new efforts develop, it is important to go through a formal process of formalizing them through the development of medical policy. This may include policies on the collection of patient race/ethnicity data, the stratification of quality measures by race/ethnicity, etc.

Finalize a strategic plan of action with 1, 3 and 5 year goals.
A formal strategic plan can be essential in charting a course of action. This can take on either a targeted set of issues (e.g. quality of care) or a broader set of issues (e.g. diversity training for staff, etc.)

Resource: The National Association of Public Hospitals, the Office of Minority Health, the Institute for Healthcare Improvement and the MGH Disparities Solutions Center recently released Assuring Healthcare Equity: A Healthcare Equity Blueprint which covers a range of activities that can serve as a template for developing a strategic plan.

Assign an organizational leader/report who can liaison with Disparities Committee; align with other hospital champions.
The leadership of the Disparities Committee should have a direct report from the hospital leadership (e.g. Vice-President of Quality and Safety, Vice-President of Clinical Affairs, etc.), as well as be aligned or supported by other champions within the hospital.

Engage in efforts to raise awareness of the issue and secure support among the Board, faculty and staff, Board, Senior Leadership, Medical Staff Leadership, and faculty, and provide broad education on the issue.

Engaging the Board of Trustees early to garner their support, as well as disseminating the plan of action to Senior Leadership, Medical Staff Leadership, and faculty, is essential along the path of mainstreaming these efforts, creating cultural transformation, and assuring success.

Develop any community-based relationships that are necessary.
Efforts to monitor or address disparities can be evaluated and supported by community advisory boards or community leaders so it is essential that these relationships be solidified in anticipation of efforts in this area.

Moving to Action

Routine monitoring for disparities.
Once an initial plan and template to identify disparities and measure equity has been developed, a portfolio of measures can be stratified and presented to leadership routinely, including the National Hospital Core Measures (congestive heart failure, acute myocardial infarction, community acquired pneumonia, surgical infection prophylaxis) as well as other high-impact measures of interest, such as diabetes and breast, cervical, and colon cancer screening.

“It's tempting to sit in a conference room and draw out a battle plan and say 'this is what we're going to do, because other organizations have been successful.' But, I think it is important to sit down with staff and share with them what you're THINKING of doing, and the broad direction that you want to go in, and try to engage them in the process. Because ultimately then, when you get to the point of implementation, you're more effective because you've listened to the staff, are are moving forward together." - Rohit Bhalla, MD, MPH, Chief Quality Officer, Montefiore Medical Center

Develop pilot interventions to address disparities when found.
When disparities are identified, there are various models that can be used to address them. They can incorporate the standard tools of quality improvement and disease management with specific components targeted at addressing the root causes of disparities (language barriers, cultural barriers, literacy issues, etc.).

    • Programs developed with this goal in mind included the use of health coaches, navigators, community outreach workers to address diabetes, cancer screening, congestive heart failure and other conditions.

Resource:A web seminar describes these interventions in detail (DSC Webinar: Using Multi-Disciplinary Teams to Address Disparities: Navigators, Health Coaches and Community Health Workers)

Expand measurement capabilities.
Stratifying existing quality measures by race/ethnicity is perhaps the easiest first step in monitoring for disparities. Once this is done, additional measurement capacities can be developed to further assure equity. These can include:

The development of disparities-specific measures that link to research, such as pain management in the emergency room, referral to cardiac procedures, etc.

Additional ways to get at patient experience besides stratification of patient satisfaction. This may include targeted surveys of minority patients regarding their experience with care, for instance.

The incorporation of questions about disparities into Quality Rounds in addition to standard questions about quality and safety.

Surveying the staff about disparities-related issues as this may be helpful in identifying additional issues of importance.

Evaluate, Disseminate, Reengineer

Evaluate pilot interventions to address disparities.
Once pilot interventions are developed, they should be formally evaluated and modified if necessary to achieve their stated goals.

Disseminate points of action and success.
As successful strategies are developed, it can be helpful to disseminate these internally and externally to further garner support. This should include routine presentations to the Board and to the leadership team regarding progress in this area.

Reengineer efforts as necessary.
Mid-course adjustments should be expected and occur routinely.

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