Organizations that commit to being anti-racist, inclusive, equitable, and to improving outcomes for all patients, require a framework within which to accomplish those goals. The Institute for Healthcare Improvement offers one framework for healthcare organizations to achieve health equity:
- Make health equity a strategic priority.
- Develop structure and processes to support health equity work
- Deploy specific strategies to address multiple determinants of health on which health care organizations can have a direct impact.
- Decrease institutional racism within the organization.
- Develop partnerships with community organizations.
The Equity Impact Review (EIR) is an essential tool that can clarify opportunities congruent with this framework. While racism is deeply embedded within our systems, we also need to understand and address the other “isms” that limit the success of our workforce and negatively impact our ability to achieve the best outcomes for our patient.
The EIR uses quantitative and qualitative data to inform planning, decision-making and implementation of UW Medicine tailored healthcare delivery, consistent with the Healthcare Equity Blueprint. This tool provides a systematic examination of how different groups and stakeholders will likely be affected by a proposed action or decision.3 This tool should be incorporated into existing quality improvement work. It may be appropriate to determine a threshold above which decisions are reviewed by a centralized committee.
To ensure the equity impacts are systematically and rigorously considered in organizational decision making. This tool should become familiar to all decision makers; serving as an organizational check on policy making, financial investments, resource allocations, programmatic functionality, and other activities that significantly influence workplace values, norms, productivity, and culture.
How and when to use the EIR process:
It should be embedded within all decision-making processes involving allocation of resources, strategic planning, policy development and enactment, program development, operations, capital projects/programs, etc. Examples of decision points include:
- Planning – what to change and prioritize in programs/work plans in an appropriately contextualized manner?
- Budgeting – which items to prioritize, add or cut and the equity ramifications of either decision?
- Personnel – who to hire, retain, promote, or develop?
- Policy Development – what to propose or change? Why?
- Practices – routines/ protocols to continue, modify or eliminate?
- Impact – which marginalized populations may be affected and how?
- Clinical practices/policy – who is affected and what might be unintended consequences? Is the decision congruent with the mission of UW Medicine, the Healthcare Equity Blueprint and the commitment to be an anti-racist organization?
- QI and safety processes – whose voice is missing, what perspectives may be skewed?
Frameworks of Equity:
Distributional Equity – Fair and just distribution of benefits and burdens. In some instances, the historical inequitable distribution of burdens must be taken into consideration. A key concept of equitable distribution is that resources are assigned based on need – that those with the greatest need have greater priority. This sometimes leads to unequal but equitable distribution of resources.
Process Equity – Inclusive, open and fair access to decision processes.
Cross-generational Equity – Effects of current actions on the fair and just distribution of benefits and burdens to future generations of communities and employees. Examples may include income and wealth, health outcomes, white privilege, resource depletion, real estate redlining practices, etc.
Six Step Process
Step 1: Identity the decision to be made and its scope. Identify who will be affected – positively or negatively.
- Using available demographic information, pinpoint who will be burdened or advantaged. As comprehensively as possible, document the extent to which marginalized populations will be impacted. Populations include individuals and families experiencing financial, food, and/or housing insecurity; Black, indigenous and communities of color (BIPOC); limited-English speaking individuals; immigrants; LGBTQI+ individuals; individuals with physical and cognitive disabilities; religious groups; women; individuals with low health literacy, and others.
- Identify stakeholders and affected parties – including those who have historically been excluded and stripped of autonomous decision making. Clarify everyone’s applicable share of the decision making. Identify which interests are not represented in decision making.
- Name decision maker(s) for purposes of transparency, accountability and expeditious evolution of an informed course of action (e.g. policy development, review/enforcement of existing policies, or revisit resolution pathways).
Step 2: Assess equity and community context.
- Engage stakeholders or representatives. This should include community or health equity specific stakeholders. Learn about and understand priorities and concerns of stakeholders and affected parties.
- Recognize whose voice is missing and how can they be engaged.
- Understand how proposed course of action will affect known inequities. Is the action likely to reduce, exacerbate or have no impact on a related health disparity?
- Identify potential unintended equity-related consequences and their distribution on populations that we serve.
Step 3: Analyze data and begin decision process.
- Outline the effects of key alternatives on communities, and UW Medicine system wide priorities and concerns.
- How do key alternatives impact the goal of UW Medicine to be an anti-racist organization?
- Using available data, evaluate each alternative for populations disproportionately benefitted or burdened – now and in the future.
- Include upstream alternatives and costs that target root causes to eliminate disproportionate impact.
- Prioritize alternatives by equitable outcomes and reconcile with functional and fiscal drivers.
Step 4: Explain the purpose and adverse impacts.
- What does the proposal seek to accomplish? Will it reduce/amplify disparities or discrimination?
- Which adverse impacts or unintended consequences could result?
- Which populations could be disproportionately negatively affected?
- How could adverse impacts be prevented or minimized?
- Are there better ways to reduce disparities and advance equity?
Step 5: Advance anti-racist alternatives. Decision making and implementation.
- What positive impacts could result? Does the proposed change further anti-racist goals? Impede them?
- Clearly communicate with stakeholders, communities, employees including rationale behind decision and who is accountable.
- Engage with affected communities and employees to discuss decisions and ongoing assessment plans.
- Measure and evaluate intended outcomes in collaboration with those affected.
- Are there provisions to ensure ongoing data collection, public reporting, stakeholder participation and public accountability?
Step 6: Ongoing learning and engagement.
- What are success indicators and progress benchmarks? Do they align with the community’s needs and/or expectations?
- Evaluate whether action appropriately responds to stakeholder priorities and concerns.
- Learn with stakeholders to adjust actions as priorities and concerns shift.
- Regularly communicate progress to all stakeholders and affected communities.