Implementing Change

The first five steps of The Road Map to Reduce Disparities cover a lot of material about designing and planning for disparities reduction. But what about implementing an intervention to reduce disparities?

If you’ve worked through the Road Map to Reduce Disparities – you’ve fostered a culture of equity, conducted a Root Cause Analysis (RCA), designed the activity with input from patients, and secured buy-in across the board– then you have the foundation for a successful change. Implementation should be the easiest part. That doesn’t mean the process will be all smooth sailing: as always, unpredictable issues will emerge and you’ll need to adapt and learn from them.

Because equity is a matter of quality, the best way to implement a disparities intervention is to incorporate it into quality improvement. Avoid launching an entirely new project. Instead, adapt your ongoing quality improvement to address the causes of disparities in your organization. Implementing those changes, like implementing any quality improvement change, is about small tests of new ideas.

There are a few components of implementation that are especially important for disparities interventions. Step 6 of the Road Map will highlight these important considerations and essential elements.

Implementing Change in Your Organization

You and your team are the experts at your organization—you know best what will work and what will not. The Road Map helps you understand how to plan a change that will improve quality while reducing disparities. While you need to consider disparities-specific issues as you plan your intervention, implementation will likely be a more familiar process. In fact, implementing your disparities intervention will be a lot like implementing any other quality improvement change.

The best way to introduce change in an organization is to try something small. Go for a low-hanging fruit, a quick win to help your team gain momentum. Plan it well—then give it a try. Measure its effect, and ask your team: “How did it go? What should we change? Should we do it again?” This process is often called a PDSA cycle: Plan, Do, Study, Act.For more information about PDSA and tools for improvement, we recommend visiting the website of the Institute for Healthcare Improvement

Pilot Test

We pilot test to learn what works and what needs tweaking. In fact, pilot testing is the natural result of PDSA cycles: you test something small, then you learn from it, adapt, and try something a bit bigger.

Why pilot test?
  • Pilot testing will help ensure that your intervention is successful once you’re ready to roll it out across the organization.
  • Pilot testing can identify early wins, which give everyone a sense of accomplishment and motivate people to continue the effort.
  • The data you collect while you pilot test can help you make the case for institutionalizing your program and making it sustainable.

Tips for pilot-testing disparities interventions
You’re most likely familiar with pilot testing, but here are a few tips related to disparities reduction.
  1. Test the activity with the priority population. You’ve worked hard to tailor the program to their needs, and this is one of the final steps to ensure the intervention is relevant and successful.
  2. Run pilot tests with diverse patients. Your priority population may be diverse in and of itself (e.g. in age, sexual orientation, literacy, acculturation). In addition, your intervention may affect other patient populations. Piloting with a diverse group will help you identify needs that may vary. For example:
    • Do older patients need different versions of forms, possibly with a larger font?
    • Does an additional staff member need to be involved to support patients with limited English proficiency?
  3. Focus on process measures. It takes time to see changes in outcomes, so your early wins will likely be process-oriented. Make sure you talk to your stakeholders about this, so you can manage expectations.
  4. Pilot test your data collection. A key component of any PDSA cycle is measuring the changes you make. But measuring can be complicated, and you’re likely to run into snags the first time around. Be sure to practice collecting the data you’ll use for ongoing evaluation. The more data collection is built into implementation, the less it will feel like an additional burden as you scale up.
  5. Strike a balance between adherence and adaptability. As you process feedback, try to find a compromise that stays true to your vision while meeting the needs of those requesting revisions.  The most successful programs find that balance through an iterative process – the PDSA cycle will help you. Use standardized checklists to monitor adherence and update those lists as the activity is adapted. That process is important not just for piloting, but for maintaining and improving the intervention over time—it’s part of a culture of quality.

Measuring Your Change

The only way to understand how you improve is to measure change. With disparities interventions, it’s critical to measure not only overall quality improvement, but changes in disparities.  This was described in detail in Step 1 of the Road Map:  Are you closing the gap in care?

Measuring Disparities Reduction
There are some important tips to keep in mind when you’re trying to measure a disparities intervention. While these are relevant for any program evaluation, they are especially important for measuring differences in care.

  • Focus on process measures initially. Process measures tell you whether a plan is being implemented as it should. That plan could be many things: for example, a new form asking about patients’ race/ethnicity/language at the front desk, or a timely referral for a colonoscopy. Process measures will help you understand if and how changes are being put into practice. They will help you demonstrate the impact of your intervention in the short term, before health outcomes improve.
  • Understand satisfaction scores in their context. When patients are aware that the clinic is working towards improvement, their expectations may increase and satisfaction scores may decrease, which is a natural part of raising the bar for everyone.  As an intervention is implemented, and patients see the effects of your changes, these scores usually improve.
  • Plan long-term follow-up. Moving the dial on clinical outcomes often takes longer than expected: keep in mind how often patients will interact with your intervention (e.g. do most patients come in once every three months?) and develop a reasonable timeline by consulting multiple stakeholders. Work with your team to identify what kinds of improvement you will define as success. Communicate with your leadership about this timeline so they know what kinds of results to expect when. If you’re rigorously researching an intervention, you may need to track patients for several years to demonstrate statistically significant improvements in health outcomes.
  • Don’t forget to measure the gap. While overall improvement is promising, it may or may not indicate a reduction in disparities, as discussed in Step 1 of the Road Map. To promote equitable care, you need to consider the causes of an identified disparity, design an intervention that will address those causes, and commit to measuring how your intervention affects those differences in care.

For basic information on how to measure improvement: We recommend the Institute for Healthcare Improvement’s (IHI) page on The Science of Improvement: Establishing Measures. IHI outlines the differences between measurement for research and measurement for process improvement, as well as the types of measures you should consider and tips for effective measures.