Roadmap Step 1: Linking Quality and Equity
Adler, N. (2006). Overview of Health Disparities (Appendix D), in Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business. Committee on the Review and Assessment of the NIH’s Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, Board on Health Sciences Policy.
This paper examines conceptual approaches and data on health disparities in the United States and highlights the fact that evaluating health disparities requires some discussion before looking at the data. Health disparities are more than simply differences in health. It highlights several different ways to conceptualize and measure health disparities and notes that often there is very little consensus on the definition of health disparities or how to measure them.
PDF and web-based versions of the full report, including Appendix D, can be accessed for free here.
Agency for Healthcare Research and Quality (AHRQ) 2010 National Healthcare Quality & Disparities Reports
AHRQ produces the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) annually. These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The reports present, in chart form, the latest available findings on quality of and access to health care. The National Healthcare Quality Report tracks the health care system through quality measures, such as the percentage of heart attack patients who received recommended care when they reached the hospital or the percentage of children who received recommended vaccinations. The National Healthcare Disparities Report summarizes health care quality and access among various racial, ethnic, and income groups and other priority populations, such as residents of rural areas and people with disabilities. These reports provide broad, data-based arguments for the importance of addressing disparities in health and healthcare.
PDF of the National Healthcare Quality Report can be found here.
PDF of the National Healthcare Disparities Report can be found here.
Institute of Medicine. 2003. Unequal treatment: Confronting racial and ethnic disparities in healthcare. Edited by B. D. Smedley, A. Y. Stith and A. R. Nelson. Washington, DC: The National Academies Press.
This report is considered one of the seminal works on racial and ethnic healthcare disparities. It examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients’ and providers’ attitudes, expectations, and behavior are analyzed. Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas.
PDF and web-based versions of the report can be accessed for free here.
Jones, C. P. (2000). Levels of Racism: A Theoretic Framework and a Gardener’s Tale. American Journal of Public Health. 90(8), pp. 1212–1215.
This article can serve as a primer for understanding the basic concepts of disparities. The author presents a theoretic framework for understanding racism on three levels: institutionalized, personally mediated, and internalized. This framework is useful for raising new hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences. She then presents an allegory about a gardener with 2 flower boxes, rich and poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide thinking about how to intervene to mitigate the impacts of racism on health.
PDF of the article can be accessed for free here.
LaVeist TA, Gaskin DJ, Richard P. The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. Sept 2009.
This article quantifies the economic consequences of racial and ethnic health inequalities for the nation as a whole. In that study, Joint Center’s researchers found that over the 4-year period of the study, between 2003 and 2006, the nation spent nearly $230 billion dollars to address direct medical costs associated with the excess burden of disease and disability in communities of color. When indirect costs are considered (such as lost wages, productivity, and tax revenue when people are too sick to work or die prematurely), the total cost to the nation was $1.24 trillion. This research continues to offer pivotal evidence for policymakers developing legislation and fact sheets that address health care reform legislation. In addition, HPI and the National Health Policy Training Alliance for Communities of Color, released a new report, Patient Protection and Affordable Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations. The report takes a comprehensive look at the new health care reform law to understand its implications for addressing health inequities.
A PDF of the report can be accessed for free here.
Roadmap Step 2: Creating a Culture of Equity
Developing Mission, Vision and Values Statements
The Free Management Library provides free, easy-to-access, online articles to develop individuals, groups and organizations (for-profit and non-profit). It is one of the world's largest and well-organized collections of these types of articles and resources. The Library focuses on practical information that visitors can quickly apply and contains an extensive listing of resources for strategic planning; including multiple resources for how to develop organizational mission, vision and value statements.
Community Advisory Boards
This resource, What is an Advisory Board and Should We Have One?, from the online magazine for non-profits called Blue Avocado, contains a succinct overview of the purposes and best practices for organizational advisory boards as well as some useful recommendations for implementation.
The National Consumer Supporter Technical Assistance Center of the National Mental Health Association provides an easy-to-use, step-by-step, guide for creating, maintaining and evaluating a community advisory board. The guide, How to Develop and Maintain Community Advisory Boards, was created for use by mental healthcare organizations. However, the underlying principles and individual tools within the guide are broadly applicable and useful for any organization wishing to establish an advisory board.
Assessing Organizational Culture
Developed by Johns Hopkins researchers, the COA360 is a multilevel, evidence-based cultural competency tool that dynamically evaluates the readiness of a healthcare organization or clinical unit to meet the needs of a rapidly diversifying U.S. population. Uniquely, rather than focusing on a single health care provider, the COA360 provides a multidimensional and synergistic view of the institution from the perspective of its administrators, healthcare providers, non-provider staff, and patients.
Roadmap Step 3: Diagnosing the Disparity
Involving Patients, Families, and Communities in Care
Patients & Families as Advisors in Primary Care: Broadening our Vision offers different approaches for involving patients and families in the design and delivery of ambulatory care.
A “lessons learned” brief about how to engage patients in ambulatory care quality improvement can be accessed for free here.
Conducting Focus Groups
ETR Associates. Conducting Focus Group Discussions.
Hawe, P., King, L., Noort, M., Giffirt, S. M. & Lloyd, B. (1998). Working Invisibly: health workers talk about capacity-building in health promotion. Health Promotion International, 13(4), p. 285-295.
Kitzinger, J. (1994). The methodology of focus groups: The importance of interaction between research participants. Sociology of Health and Illness, 16(1), p. 103-121.
McLafferty, I. (2004). Focus group interviews as a data collecting strategy. Methodological Issues in Nursing Research, 48(2), p. 187-194.
Omni Institute. A Toolkit for Conducting Focus Groups.
Satterfield, T. R., (2002). Conducting Effective Focus Groups.
Discussing Sensitive Topics
Farquhar, C. & Das, R., (1999). Are focus groups suitable for 'sensitive' topics? In Developing focus group research: Politics, theory and practice, (Barbour, R. S. & Kitzinger, J., Eds.), p. 47-63.
Ingham, R., Vanwesenbeeck, I. & Kirkland, D. (1999). Interviewing on sensitive topics. In Handbook of the Psychology of Interviewing (Memon, A. & Bull, R., Eds.). p. 145-164.
Getting Patient Feedback
This new toolkit showcases how primary care practices are involving patients in quality improvement efforts as part of Aligning Forces for Quality (AF4Q), the Robert Wood Johnson Foundation's signature effort to life the quality of care in targeted communities across the United States. The "Engaging Patients in Improving Ambulatory Care" toolkit features videos and an extensive compendium of adaptable resources from three AF4Q alliances - Maine, Oregon, and Humbodlt County, Calif. - to introduce the concept of partnering with patients and families in primary care and share lessons learned. These three communities were among the first in AF4Q to implement this kind of patient engagement strategy on a broad scale, but others are following suit and a growing number of practices are harnessing patients' involvement in quality improvement work. The compendium of resources includes a variety of tools that health care organizations in these communities have used in their efforts to engage patients. These tools can help recruit, orient, and train patients; clarify roles and responsibilities; and put a structure in place to foster relationships. The accompanying video segments offer lessons and tips for effectively working with patients to improve care.
The Institute provides leadership to advance the understanding and practice of patient- and family-centered care in hospitals and other health care settings.
Roadmap Step 4: Designing the Activity
Intervention Design and Implementation
Brach C, Lenfestey N, Roussel A, Amoozegar J, Sorensen A. Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations. Prepared by RTI International under Contract No. 233-02-0090. Agency for Healthcare Research and Quality (AHRQ) Publication No. 08-0051. Rockville, MD: AHRQ; September 2008.
Available for free here.
The goal of this Guide is to promote evidence-based decision-making and help decision makers determine whether an innovation would be a good fit—or an appropriate stretch—for their health care organization. Guided by a framework that regards adoption as a process, rather than an event, the tool is based on a modified version of the core concepts in Rogers’ Diffusion of Innovations (Rogers, 2003). It is designed to help organizations answer the following questions: Does the innovation fit? Should we do it here? Can we do it here? How will we do it here?
Integrating Chronic Care and Business Strategies in the Safety Net. (Prepared by Group Health’s MacColl Institute for Healthcare Innovation, in partnership with RAND and the California Health Care Safety Net Institute, under Contract No./Assignment No: HHSA2902006000171). AHRQ Publication No. 08-0104-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2008.
This resource is a toolkit designed by Group Health’s MacColl Institute, RAND, and the California Health Care Safety Net Institute to help safety net organizations implement the Chronic Care Model (CCM) effectively and sustainably. The toolkit provides a step-by-step practical approach to guide teams through quality improvement. A companion Practice Coaching Manual that outlines the approach and provides orientation to other national efforts is also available. This resource may be particularly useful in providing ideas and guidance for how to design equity-focused quality improvement interventions that incorporate the organization’s overall financial and reimbursement infrastructure. Three specific financial environments are considered and are accompanied by real-world case studies; practices that are reimbursed primarily on a capitated basis, practices that are reimbursed based primarily on a fee-for-service structure that are generally reimbursed services provided by ancillary, non-physician providers and practices that are reimbursed based primarily on a fee-for-service structure that are not generally reimbursed services provided by ancillary, non-physician providers.
Roadmap Step 5: Securing Buy-In
Resources for Building Partnerships with Stakeholders
Employers and Health Plans
Center for Prevention and Health Services and National Business Group on Health
Issue Brief - September 2009
Addressing Racial and Ethnic Health Disparities: Employer Initiatives
Available for free here.
This is a follow-up to the February 2009 Issue Brief: Eliminating Racial and Ethnic Health Disparities; A Business Case Update for Employers.
Presents several case studies and highlights from employers sharing how they view disparities and what they are doing to address them. Identifies common themes that emerged from these interviews, including challenges and successes in addressing disparities. The appendix of this brief shares the results of a National Business Group on Health member survey on disparities.
AON Consulting, Report
Employers are now in a position to analyze their own health care data to identify and reduce costly disparities and strive for a more equitable health care system. We use the term “Culturally Competent Health Care” to describe an approach to health care that offers all participants equal access and opportunity to receive quality care and medical purchasing efficiency through elimination of structural barriers and respect for the cultural context of each individual. Cultural context refers to race, language, age, gender, lifestyle, ethnicity, faith, location, and/or socioeconomic status, which influence individual decisions about health and medical care.
This approach provides employers with an opportunity to improve quality, reduce short- and long-term medical costs, and improve workplace productivity. Employers who are willing to demonstrate leadership in this area stand to gain competitive advantage.
Culturally Competent Health Care is not a new diversity program. Rather, it is a prism for employers and their health plan partners to look through to better promote employee health and medical purchasing efficiency in an increasingly multicultural society. This paper provides background on Culturally Competent Health Care and includes steps that employers can take to phase it into their existing health care programs.
National Health Plan Collaborative to Reduce Disparities and Improve Quality (in collaboration with AHRQ, RWJF, CHCS and RAND), Toolkit
The National Health Plan Collaborative has created this toolkit of resources, lessons, best practices and case studies to help other health plans join the effort to reduce disparities. The toolkit shares what the Collaborative’s members have done to develop and test new methods of measuring and addressing racial and ethnic disparities so that other health care decision makers and leaders can learn from this work, implement these best practices and make the case for addressing the unacceptable differences in health care and health outcomes for health plan members throughout the country.
Useful resources featured in this toolkit include:
- Health plan case studies
- Sample tools, forms, policies and resources for implementation
- Videos of experts talking about the importance of reducing disparities and about first hand experiences in developing and implementing interventions; and
- A compilation of resources in this field
Mathematica Policy Research, Inc, July 2009, Policy Brief
Health plans and employers rarely work together to address racial and ethnic (r/e) health care disparities in the workforce. However, such collaborations have the potential to strengthen the quality of data used for disparities measurement and the development of targeted programs to reduce disparities. Drawing on interviews with large employers, health plan representatives, government officials, and national experts, this policy brief assesses current health plan/employer partnerships addressing disparities, provides an overview of barriers that prevent partnerships from forming, and discusses strategies to encourage increased involvement of employers in the future.
The Joint Commission Journal on Quality and Patient Safety, May 2008, Journal article
This article describes an innovative effort to overcome some of the considerable challenges to progress. The National Health Plan Collaborative (NHPC) to Reduce Disparities and Improve Quality is a novel partnership between nine health plans and public- and private-sector entities that have come together to address racial/ethnic disparities in care. We describe the genesis of the NHPC, its progress to date, and lessons learned.
Health Affairs, 2008, Journal article (Subscription may be required)
ABSTRACT: The authors consider the challenges to quantifying both the business case and the social case for addressing disparities, which is central to achieving equity in the U.S. health care system. They describe the practical and methodological challenges faced by health plans exploring the business and social cases for undertaking disparity-reducing interventions. Despite these challenges, sound business and quality improvement principles can guide health care organizations seeking to reduce disparities. Place-based interventions may help focus resources and engage health care and community partners who can share in the costs of—and gains from—such efforts.
Practices and Provider Groups
Center for Health Care Strategies (in collaboration with RWJF/AF4Q), 2011, Conference
A joint meeting of CHCS' Reducing Disparities at the Practice Site (RDPS) initiative and the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program was held in Portland, Oregon in November 2011. Participants from AF4Q Alliances and from three RDPS state teams - Michigan, Oklahoma, and Pennsylvania - came together to review progress, share experiences, and look down the road at the future of primary care in light of the goals and gains of both RDPS and AF4Q. This URL links to the CHCS website page with an archive of select meeting presentations.
Center for Health Care Strategies (in collaboration with RWJF/AF4Q), 2008, Past Initiative
Small provider practices play a critical role in caring for Medicaid beneficiaries, particularly those who are racially and ethnically diverse. The Reducing Disparities at the Practice Site initiative was developed by CHCS to support quality improvement in small practices serving this population. The three-year project is helping Medicaid agencies and health plans partner with small practices to reduce racial and ethnic disparities and improve overall outcomes.
Center for Health Care Strategies (in collaboration with RWJF/AF4Q), 2009, Conference
The Second National Meeting of the Reducing Disparities at the Practice Site initiative was held in Detroit in October 2009. Participants from the four state teams -- Michigan, North Carolina, Oklahoma, and Pennsylvania -- came together to review progress, share experiences, and plan for the second year of the initiative. This URL links to the CHCS website page with an archive of select meeting presentations:
General Resources for Multi-Organization Collaboration and Partnerships
Health Research and Educational Trust (in collaboration with AHA), 2003, Toolkit
The Institute of Medicine's report on quality and equity and their rationale for integrating the two.
The Collaboration Primer: Proven Strategies, Considerations, and Tools to Get You Started
The Health Research and Educational Trust (HRET) has learned some valuable lessons about collaboration over the last 10 years through the National Community Care Network Demonstration Program and Evaluation. The Program has provided HRET an opportunity to examine and learn from the field what successful collaboration takes. Here we share:
Ways to think about the degree to which you’re ready to collaborate.
Nuts-and-bolts as well as more abstract elements of the partnership that help make it successful.
A checklist of questions and issues to consider before embarking on a collaborative arrangement.
Examples of model collaboratives to help you visualize what
your collaborative may look like, given the resources in your community.
A tool to assess the status of your collaborative effort, identifying areas of strength and areas for improvement.
Compassion Capital Fund (DHHS), 2010, Toolkit
Overview: As pressures on faith-based and community organizations (FBCOs) increase and the issues we face become more complex, the idea of partnerships can hold much promise. Through partnerships we can contribute our small part and reap the benefits of everyone’s effort; we can accelerate learning and distribute skills and knowledge; and we can add depth and breadth to our community impact. To make real the promise of partnerships, however, we must be prepared to build, sustain, and evaluate them in a thoughtful way.
This guidebook will help organizations answer several key questions:
- Why are effective partnerships important?
- What are the different forms that partnerships can take?
- What are key steps to establishing effective partnerships?
- What are key steps to mananging effective partnerships in order to achieve mutually agreed-upon outcomes?
Roadmap Step 6: Implementing Change
Wholey, J. S., Hatry, H. P. & Newcomer, K. E. (Eds.) (2010). Handbook of Practical Program Evaluation (3rd edition). San Fancisco, CA.
This handbook covers a variety of approaches to analyzing the operations and results of past and current programs. Guidance for designing ongoing program performance monitoring systems is provided, along with advice on designing and implementing studies of program processes and program outcomes. A variety of evaluation approaches are discussed, including both qualitative and quantitative approaches for evaluating program impact.
Wisconsin Department of Health Services (DHS) Office of Policy Initiatives and Budget, Policy & Research Section (2010). Evaluation Resource Guide.
The resources available here were developed to help Wisconsin Department of Health Services staff evaluate and monitor the performance of their programs. However, the resources are applicable to a wide variety of settings and projects. Resources in the Guide range from evaluation manuals providing basic information to books with detailed information on specific topics such as logic models, data analysis or sampling. Also included are resources on identifying effective programs/best practices, evaluation standards, and contracting for evaluation. The resources listed are intended to be useful to a wide audience, to provide practical advice and to be easy to obtain.
Basic Guide to Outcomes-Based Evaluation for Nonprofit Organizations with Very Limited Resources
The Management Assistance Program for Nonprofits makes available this online document on the basic planning and implementation of an outcomes evaluation in nonprofit organizations. Prepared for small nonprofits with limited resources, this guide is based on and complements the United Way’s Measuring Program Outcomes: A Practical Approach.
The CDC’s Evaluation Working Group web site includes a comprehensive set of links to evaluation resources, including standards, manuals, reports, and information on logic models.
This practical handbook, produced by the WK Kellogg Foundation, offers an explanation of the philosophy of program evaluations, provides action steps for grantees, and general planning strategies for getting started.
The Administration on Children, Youth, and Families developed this guide to explain program evaluation –what it is, how to understand it, and how to do it. It contains excellent information on addressing common staff concerns about evaluation, including cost. This page supported by the International Consortium for the Advancement of Academic Publication lists resources for methods in evaluation and social research. The focus is on "how-to" do evaluation research and the methods used: surveys, focus groups, sampling, and interviews.
NQF is a nonprofit organization that operates under a three-part mission to improve the quality of American healthcare by: 1) Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them; 2) Endorsing national consensus standards for measuring and publicly reporting on performance; and 3) Promoting the attainment of national goals through education and outreach programs. NQF also has a portfolio of endorsed performance measures that can be used to measure and quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality care. Once a measure is endorsed by NQF, it can be used by hospitals, healthcare systems, and government agencies like the Centers for Medicare & Medicaid Services for public reporting and quality improvement.
Richard Krueger, a professor of program evaluation and research methods at the University of Minnesota, prepared this easy to read material on program evaluation, applied research and focus groups. The web site’s section on program evaluation includes details on logic models, outcome evaluations, and measuring outcomes, as well as tips on designing instruments.
Financial Incentives to Reduce Disparities
A Health Policy Brief released by the robert Wood Johnson Foundation and published in Health Affairs. New payment systems reward doctors and hospitals for improving the quality of care, but studies to date show mixed results.