There has been a heightened awareness in recent years about the need to ensure equity in health care delivery. While some professional organizations are working toward generating robust guidance to identify and manage inequities in health care, there currently is no widely accepted road map for health care organizations to utilize in their journey to achieve health equity. This means many health care systems are figuring out the best approach as they go along, according to Nadia Huancahuari, MD, emergency department physician and medical director of quality, safety, and equity for Brigham and Women’s Hospital. 

Yet many health care leaders may feel challenged to understand how—and where—to start their efforts to address health equity within their own systems, says Esteban Gershanik, MD, MPH, MSc, an internal medicine physician and medical director of quality, safety, and equity for Brigham and Women’s Hospital. 

Both Huancahuari and Gershanik also serve on the faculty of Harvard Medical School’s (HMS) Master of Science in Healthcare Quality and Safety program, where they share their own experiences addressing health inequities within the Brigham Health System.

“Today there is wide variability in how organizations, as well as clinical spaces within organizations, are addressing inequities in care,” Huancahuari explains. They both agree that this lack of consistency highlights the need for more organizations to begin implementing a coordinated effort to address inequities in care on a systemwide scale.

Understanding the Difference Between Equitable and Equal

In order for organizations to effectively address equity in health care, Huancahuari points out that it’s important to truly understand the difference between equal and equitable care. “When it comes to inequities in care, many well-intentioned health care workers may believe that treating everyone ‘equally’ is the best way to eliminate inequities in care. But we want to be equitable and not equal,” she says. 

She offers this example: Imagine that a physician sees three patients—one is an English-speaking older patient with great hearing, one is an English-speaking senior citizen with impaired hearing and the third is a young, non–English-speaking patient. If the physician communicates with each of these patients in English and in the same tone of voice and volume—in other words, communicates the care in the same way—only the English-speaking patient with great hearing will fully benefit from the care received. The patient with hearing impairment may need sound-amplifying headphones or written instructions, whereas the non–English-speaking patient may need an interpreter. 

“This illustrates, then, how equity can require a different allocation of resources to ensure that each patient has a chance at getting the best care possible,” she says. “Once you explain it in this way, people start understanding what you mean. There’s a cultural change once people get it. It’s amazing to go to a meeting and see the buy-in [once it starts to click].”

Including Patients and Families in Your Processes

How a health system handles a possible inequity and addresses patient and family concerns is also critical to successfully creating health equity on a wider scale, Huancahuari says. For instance, once you identify a possible inequity and start a review process scanning for details, patients and families who have been impacted by the situation deserve to hear your findings. They should also be briefed about the implementation of improvements that are based on your findings.

“This is such a difficult topic, but it’s also so rewarding on the other end,” Gershanik indicates. “We have had cases where we have brought in family members who have felt an inequity occurred. They may have held on to this feeling for years and may not have been planning to discuss it, but now we include a way for them to share their concerns as part of our process and we also share how they are assisting us in making changes in our system. This allows them to finally feel understood and it can provide them with some closure,” he says. 

This is important—both for providing validation for how the patient or family felt and also from the broader perspective of changing the current system to create a more effective environment moving forward.

Enhancing the Quality and Safety Framework with an Equity Lens

Huancahuari and Gershanik agree that one important way health care systems can streamline equity efforts is by connecting them to the broader quality and safety structures that are already in place, enabling equity to become an integral part of how health systems assess risk. 

“At Brigham and Women’s Hospital, we review concerns for inequities in care and in patient experience through our quality and safety framework,” Huancahuari says. This means that when an adverse event occurs, part of the quality and safety exploration will include identifying the inequities that exist and that may have contributed to the event. She mentions that this approach systematically teaches people to scan for inequities every time they review a near miss or an adverse event. “In fact, a successful analysis of an adverse event requires applying an equity lens to the clinical review, rather than separating the case into clinical events and inequitable events,” she says. This is essential since equity should never be separate from quality and safety, she stresses.

Exploring the Connection Between Equity and Human and System Performing Factors 

“To look at equity from a quality and safety perspective requires identifying system and human performance and behavior factors and evaluating how structural, institutional and interpersonal factors can contribute to the potential inequity,” Gershanik states. “How do we get the buy-in [from all of the key players] on things we need to change and how can we normalize these changes?” he asks.  

He suggests that, when looking at health equity, organizations go back to the six pillars of quality introduced in the Institute of Medicine Committee on Quality of Health Care in America’s Crossing the Quality Chasm: A New Health System for the 21st Century, which includes providing care that is safe, timely, efficient, effective, patient-focused and—last but not least, though often forgotten—equitable. Furthermore, he notices that in the current health care landscape, equity has been among the priorities of new federal initiatives from the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and US News & World Report rankings and also has been included in a variety of efforts orchestrated by local communities and organizations. 

“Building upon this [recognition of equity] requires the education, practice, and learning that help people identify the uniqueness of each obstacle that may have come into play to impact each potential situation,” he says. Taking such a comprehensive approach to addressing the problem means that once the skills are integrated into practice, everyone gets engaged and it becomes part of the culture and practice of an organization.  

Sharing the Model More Broadly

The approach of including equity within quality and safety improvement efforts and making them a more accepted part of doing business has proven to be very effective for Brigham and Women’s Hospital. Now, they are sharing parts of their model with other hospitals within the Mass General Brigham system, as well as with other health care systems through the American Medical Association Peer Network. Huancahuari and Gershanik point out that what’s been extremely rewarding is seeing how this model works—not only at their own institution but also at other institutions within the U.S., as well as at hospitals located in other countries around the world.