Using Quality Improvement to Address Racial Equity

Healthy Black FamilyIn the U.S., the gap in health outcomes between non-Hispanic black and non-Hispanic white children continues to widen, with children of color more frequently suffering from chronic and preventable health conditions. Black children are 1.8 times as likely to have asthma, 1.32 times as likely to be obese and over twice as likely to die before reaching their first birthday. These racial gaps in health outcomes signify the significant role racism plays as a key determinant of health in the U.S.

To drive sustainable improvements in children’s health we must shift the way we promote and practice healthcare to incorporate both a health and racial equity lens. Using a health equity lens helps us consider the contexts in which children and families live and how these circumstances contribute to long-term health. Within this framework, we must be explicit in recognizing historical and current racism across policies and practices. A racial equity lens acknowledges how families of color are often systematically oppressed and have differential access to the opportunities and resources that allow families to thrive.

Without both a health and racial equity lens, organizations risk driving ineffective change by not first taking into consideration the structural factors influencing children’s health. While not comprehensive, the list below provides important considerations for implementing a racial equity approach in quality improvement work:

Tailor interventions with a centering approach
Using a centering approach to tailor a program means prioritizing the experiences of the underserved group by moving them to the center, making their lived experience the central expectation and focus. The popular adage, “nothing about me, without me”, serves as reminder that inclusion is mandatory for successful improvement interventions. When we focus on the experiences of those who have been historically underserved, we can better address the barriers and challenges they face.

Consider when a doctor’s office sends postcard appointment reminders. This system operates under the expectation that patients have a home address and stable housing, which may exclude populations outside of this expected norm. If the intervention was centered on the experiences of a historically underserved population, the office might switch their reminder system to use mobile application reminders, text messages or emails to create continuity in communication and develop a more inclusive system. When we place a historically underserved group at the center of system improvement interventions, our efforts become far more inclusive and thus effective.

Promote culturally representative and appropriate patient-provider interactions
When providers from the underserved population lead improvement projects, communities are more likely to trust and participate in the health program. This trust is essential among communities that have been historically maltreated by public health programs, such as in the experiences of black, indigenous and Latina women. To build this trust and provide optimized patient care, there should be increased diversity among physicians so they better represent the populations they serve. Incorporating increased representation across all levels of staffing ensures that the population primarily served is not represented by a handful of token providers. Increased representation also sets up a structure of mentorship where junior staff have colleagues that can provide advice through shared experiences, which makes the organization a more viable place of work for all members of the community.

Improve health literacy across the population
Health literacy is more than the patient receiving information; it means that the patient comprehends the health information fully enough that they can make an informed decision on their care. Interventions that include motivational interviewing or teach-back strategies can improve health literacy because they help providers pause and check for comprehension and understanding. For example, rather than simply provide a breastfeeding educational pamphlet, a physician practicing a teach-back strategy would pause after providing the education; he or she would then ask the mother to repeat two new strategies that might help her overcome obstacles to breastfeeding at home. This method of teaching provides more holistic care that respects and empowers the mother, or any individual receiving healthcare services. Physicians should also support health literacy by providing information that is both linguistically and culturally relevant, attending regular cultural competency trainings and helping underserved populations navigate barriers to attaining optimal health. Combined, these efforts can help raise the standard of care for historically underserved populations.

Increase stakeholder buy-in within the underserved community
Without stakeholder commitment, change can stall and remain unsustainable. Identifying community champions is a critical strategy, and should occur at the onset of an improvement project. Since community champions bring a wealth of expertise through their lived experience, they can best understand how the project will affect those it aims to serve. In response, they can identify crucial levers for improvement that may have been missed. Integrating the perspective of community members with those of public health professionals fosters a higher level of programmatic capacity to target the root cause of a health inequity.

This level of engagement is distinct from qualitative data collection, or gathering stories to bolster the existing paradigm and intervention. True champion engagement shifts the expertise to those with the lived experience by engaging community members in continuous dialogue that validates collective decision-making power. Frameworks such as community-based participatory research incorporate an equity lens by having community members directly participate in the design, implementation and evaluation of a program. These frameworks then lead to the most sustainable results. By elevating the lived experience of community champions, we can better drive changes that will close the gap in health disparities.

Ultimately, it is our collective responsibility to prioritize and support equitable healthcare for all children, ensuring optimal health across all populations. Discover more about elevating community champions in our Infant Mortality CoIIN Prevention Toolkit, where a North Carolina case study describes how strategies to improve access and education about long acting contraceptive were informed by female voices within the community.

Content contributed by Avery Desrosiers, a Project Specialist at NICHQ.