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Quality Update - Health care quality issues for Minnesota's health care leaders

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Minnesota Health Systems Making Health Equity Actionable

Group of diverse people smiling and pumping fists in the air

As Minnesota's communities become more diverse, health care organizations recognize they must catch up to meet the needs of their changing populations. For some, that means addressing disparities in health outcomes.

"There seems to be a movement in Minnesota and awareness around addressing disparities that I haven't seen in any other state," said Aswita Tan-McGrory, deputy director, The Disparities Solutions Center at Massachusetts General Hospital, which offers a disparities executive education program. Since 2007, 11 Minnesota health care organizations have participated in the program.

Minnesota organizations are trying varied approaches to embed health equity into their processes and cultures.

Disparities data builds awareness

Health care organizations are helping their staff understand that inequities can infiltrate their work. And how, despite best intentions to put patient needs first, they may not be providing optimal care. Disparities data is a starting place to make the case to focus on equity.

Mayo Clinic's electronic health record (EHR) system implementation earlier this year enhanced its quality data team's ability to stratify priority metric data by race, ethnicity, language, (REL) and gender to uncover disparities. "Today, we're really trying to understand how our data can be used to reveal and identify disparities that we know exist within our practice," shared John Knudsen, medical director, Mayo Clinic, Office of Health Equity and Inclusion.

Allina Health started getting traction on addressing health equity when it built REL and other demographic filters into its clinical quality dashboards. "Quantitative data showing disparities in clinical quality outcomes helps engage leaders and clinicians," said Mollie O'Brien, Allina's director of health equity. "This data comes to life when we pair it with stories from our patients. They help provide insights on what is causing the disparities and how we can work together to create solutions."

"We started including health equity goals within our system-wide Measures of Caring scorecard for quality. That was a game changer," added O'Brien. "If something's on the scorecard, we're saying this matters across our system."

To support benchmarking and transparency from an equity perspective, HealthPartners ranks all of its clinical sites quarterly by achievement of key clinical quality measures for patients of color and patients insured through government programs.

Root cause in the context of culture

As with any quality improvement issue, understanding root causes for health disparities is essential. Staff need the knowledge and skills to navigate across culture, class, race, and language. They need to understand implicit bias and have the cultural competence or intercultural agility to develop interventions addressing underlying health equity issues. Minnesota health care organizations are applying this knowledge to address equity in care.

Allina uncovered statistically significant shorter hospice lengths of stay for some populations. Further investigation showed a lack of minorities in hospice in the first place, leading to the questions of whether referrals were made and whether hospice was rejected. Understanding cultural communities is critical to understanding why gaps exist. Allina is exploring potential causes such as differences in values and beliefs at end of life related to family caretaking, distrust of the medical system, and implicit bias in clinical decision making.

Mayo took its three key hospital inpatient metrics, stratified them and found statistically significant variations in one or more of those metrics when looked at by REL and gender. Rochester had disparities in readmission rates for its non-English speaking patients. When the issue was deeply explored, Mayo uncovered that patients were often released into the community without connection to a primary care network. Care coordinators now make sure non-English speaking patients have their needs met so they can manage their care after leaving the hospital. Although a disparity remains, readmission rates are trending downward for this population.

"We need our staff to ask, 'Where do culture and care intersect with each other? And, how can we get it right?'" Knudsen said.

Culture change for equity

Five Essential Domains to Successfully Adress Disparities and Improve Quality of Care

While data collection, performance measurement, and multifaceted interventions are foundational tools to eliminate disparities, organizations are discovering that culture change is needed to truly address equity. A study by the Disparities Leadership Program looked at the experiences of 115 organizations that had been through its program. After individual projects were completed, participants often felt there was still some resistance to organizational buy-in about the importance of addressing disparities. The program identified shaping organizational culture as one of five essential domains to successfully address disparities and improve quality of care.

"We realized that health equity work feels so difficult because it's about transforming how the organization works," said Tan-McGrory.

Even Federally Qualified Health Centers, which focus on serving diverse populations, find they have disparities in care. West Side Community Health Services wanted to work on its gaps in care. The clinic realized it first needed to take a step back and work on organizational change management.

Health equity has to align with the culture of the organization. Organizational change management strategies are needed to do that. “We need to weave equity throughout the organization to keep it from being siloed,” said Tan- McGrory.

HealthPartners does just that. Advancing equity is embedded across its strategic plan, with goals for a diverse workplace and decreasing gaps in care. Specific equity measures are built into its executive incentive program.

"We want to have a coordinated organization-wide approach that reinforces that equity is part of everyone's work," said Brian Lloyd, strategic initiatives consultant at HealthPartners.

The Diversity & Inclusion workgroup, focused on workforce, and the Health Equity workgroup, focused on clinical care, work together closely to drive culture change. HealthPartners has leveraged its twice-annual "team talks" to reach all 26,000 employees. Senior leaders have facilitated education and conversations about topics such as equity, diversity, inclusion, and racism. Tools and resources were made available to support subsequent learning and action.

HealthPartners also has 170 self-identified Equitable Care Champions across the organization who serve as point people at their site or on their team to carry forward the message of equity.

Integrating equity into organizational structure

Allina Health prototyped "Health Equity Action and Learning (HEAL)," which began as a four-month program, where cohorts from the different service areas learned as a team about data, cultural competency, implicit bias, understanding root causes using literature and community and patient engagement, and action plans.

To sustain the work, Allina is integrating elements of the HEAL program into its quality improvement framework and infrastructure by launching a HEAL committee. This group of people from across the organization prioritizes opportunities and engages system stakeholders to take on the work.

Allina's HEAL committee looks at all of the measures on the system's Measure of Caring scorecard to determine which are "disparity sensitive" and assesses them for disparity gaps. The committee established prioritization criteria for determining which disparity gaps to take action on. Higher priority is given to opportunities that have meaningful impact, strategic alignment, operational feasibility, and engaged and passionate people willing to take on the work.

Mayo is building health equity education into its Quality Academy curriculum. As a natural outflow of increased knowledge through that training, Knudsen expects staff will begin to automatically ask how equity plays a role in quality shortfalls.

"Our goal is that in 12 to 18 months we see a significant increase in the number of quality projects that include equity as one of the pillars that are being addressed," noted Knudsen.

Equity an emerging discipline

We've known about disparities in care for some time. O'Brien likened the integration of an equity focus into an organization to that of the integration of quality. "Fifteen years ago, quality improvement was new, now it's just part of what we do," said O'Brien. "While health systems have viewed health equity as a moral imperative for over a decade, figuring out how to activate health equity as a business imperative is new."

Health equity is an emerging discipline across the country. Looking at quality improvement through a health equity lens requires different approaches. If we want to advance equity, health care organizations need to get out of their care settings and work on community-based interventions. They need to explore social determinants of health and push on their spheres of influence. Health care organizations across Minnesota are at various stages of the journey, and promising changes are underway.