From the frontlines of addressing inequity: ‘Health equity work is quality and safety work’

Leveraging data to improve equity is critical to creating a more resilient health system. And integrating equity into quality and safety efforts presents an opportunity to improve all three.

Tom Sullivan | May 5, 2021

Health care CEOs are increasingly motivated to address disparities and patient outcomes. Preliminary research by the Health Evolution Forum, in fact, found three-fifths of participating CEOs ranked health equity, diversity and affordability among their top 3 priorities for the next one to three years.

“The key question is how health care CEOs can best set up their organization to tackle these disparities by both increasing their responsiveness to disparities in clinical care and increasing the diversity of internal leadership in meaningful ways,” said Mark Smith, former Founding President & CEO, California Health Care Foundation.

While answering that question is a complicated matter, what has become clear is that building a higher quality, more resilient health care system based on prevention, affordability, access, equity, and outcomes must be led by data — and health care executives at the forefront are recognizing the opportunity and necessity to advance equity by including it in what has traditionally been quality and safety work. Whether the goal is improving primary care, digital health, community health workers, or adopting alternative payment models, it’s critical that equity work is at the center of it all.

“Equity work is quality work. The moment we start to separate them, it gets very challenging to understand why,” said Tosan Boyo, Senior Vice President of Hospital Operations, John Muir Health.

Framing equity within quality and safety helps leaders have a place to start. Now it’s about what leaders do with this data and how they actually intervene on the inequities.

Laurie Zephyrin, MD, The Commonwealth Fund

Discovering and addressing disparities  
Health care organizations are already collecting data on race and ethnicity, but few are effectively putting that information to use even though they possess it. That said, integrating equity into quality and safety does not require developing entirely new measures, Smith added, rather it is a matter of rethinking how to use and analyze existing measures.

Smith pointed as an example to analyzing data related to hospital readmissions or satisfaction with pain control as it relates to gender, race, primary language or proxies for those measures as needed. “The challenge is to stratify patient outcomes and experience data by the kinds of axes that we know are present for disparities and inequities in America,” he said.

University of California Health, for instance, built internal dashboards to measure the diversity of senior management, leadership across all its campuses, and analyze patient outcomes experience by race, ethnicity, language and sex, according to Carrie Byington, MD, Executive Vice President, University of California Health.

“We have been able to identify a number of disparities that have become areas of internal focus for improvement as we facilitate the recruitment and retention of a diverse workforce and leadership talent,” Byington said. “We’re looking for ways to embed interventions into the clinical workflows that will reduce disparities for patient outcomes and satisfaction.”

Before joining John Muir, Boyo served as COO of Zuckerberg San Francisco General. In one example of leveraging data to advance equity, the system had been sending patient reminders for imaging appointments to reduce no-show rates, a priority for that department. When sorting the data by race, ethnicity and language, the system determined that Asian Americans had the highest no-show rates. Further analysis revealed that the reminder calls, letters and text messages were universally in English, sometimes in Spanish but only minimally in Cantonese or Mandarin, Boyo explained.

“After discovering this disparity, we addressed that change and automatically we saw that the no-show rates among Asian Americans, specifically Chinese Americans, dropped dramatically,” Boyo said.

In another instance, San Francisco General was striving to reduce workplace violence by utilizing metrics relative to use of force by race and ethnicity and found that Black and Latino patients were responsible for 50 percent of all use of force even though they comprised 17 percent of the patient population. Drilling deeper showed that rather than engaging de-escalation tactics, the system was automatically calling security or law enforcement on such individuals.

“By understanding that data, we were able to create a behavioral emergency response team to ensure that whenever we had to call law enforcement or security, we always sent psychiatric nurses and social workers who knew how to deescalate a situation,” Boyo said. “We stratified the data and were able to get all of leadership around it to make sure that this was a powerful equity initiative and not just a project.”

The first challenge: Determining where to begin
Integrating equity work into the established data-rich practices and processes already in place and reasonably well understood relative to quality and safety presents an opportunity to advance each of the areas.

“Framing equity within quality and safety helps leaders have a place to start,” said Laurie Zephyrin, MD, Vice President, Health Care Delivery System Reform, Commonwealth Fund. “We know that organizations are collecting the data or collecting at least some of this data. Now it’s about what leaders do with this data and how they actually intervene on the inequities.”

Where to begin such intervening varies from one organization to the next but focusing initially on internal aspects will yield the greatest short-term impact. But when considering the premise that equity work is quality work, Smith said that CEOs should start by stratifying quality issues they already understand, whether those are hospital readmission rates, no show rates or others — because advancing equity is not altogether unlike the challenges in other issues of quality that span different care delivery systems and sites.

“Trying to solve really big problems that go beyond the hospital or beyond the clinic makes it very difficult to build momentum in the organization. Start with what’s within your control and your departments and your hospitals and your clinics and use metrics you can rally people around to begin making a difference,” Boyo said. “Then start thinking about the health assessment of the overall community.”  

Boyo, Byington, Smith and Zephyrin are Fellows of the Health Evolution Forum. The Forum convenes more than 200 CEOs, policy makers who participate in Roundtables that oversee Work Groups charged with identifying best practices working in parts of the industry and disseminate those more broadly to drive impactful change. The Forum’s Work Group on Leveraging Data to Improve Health Equity is currently exploring an industry pledge around collection and stratification of quality metrics by race, ethnicity, language and sex. 

About the Author

Tom Sullivan, EVP & Editor-in-Chief of Digital Content

Tom Sullivan brings more than two decades in editing and journalism experience to Health Evolution. Sullivan most recently served as Editor-in-Chief at HIMSS, leading Healthcare IT News, Health Finance, MobiHealthNews. Prior to HIMSS Media, Sullivan was News Editor of IDG’s InfoWorld, directing a dozen reporters’ coverage for the weekly print publication and daily website. Contact: or @SullyHIT on Twitter.