The Intersection of Health Equity and High Reliability Care: You Can’t Achieve One Without the Other

Many healthcare organizations strive to provide highly reliable care, meaning patient care is consistently excellent and safe over long periods across all services and settings.

However, not all patients are the same, and many face unique challenges and barriers. That’s why it’s impossible to promote highly reliable care without addressing health equity as well. 

“There’s so much overlap between the two,” says Krista Stepney, MHA, principal and vice president of operations at Chartis Just Health Collective. “The most successful healthcare organizations are thinking about this overlap and how to leverage it.”

Setting the Stage: Making Health Equity a Strategic Priority

The first step toward addressing health equity is to embrace a C-suite-driven approach, says Jennifer Beloff, RN, MSN, APN, principal at Chartis. “Health equity should never be an afterthought,” says Beloff. “It should be a part of how healthcare organizations do business. This requires carefully crafted messaging from the top down.”

For example, healthcare leaders can clarify what it does—and doesn’t—mean to achieve health equity, says Andrew Resnick, MD, director and chief medical and quality officer at Chartis. “There are no takeaways in the world of equity,” he says. “It’s about supporting people where and when they need it so we can solve challenges for every patient population.”

Healthcare leaders should also include health equity in the organization’s strategic plan. Doing so entails evaluating each strategic priority from an equity-grounded framework. Such a framework would ensure that the voice of those who have been marginalized is centered, that strategic decisions do no harm, and that work has been undertaken to eliminate systems that may inadvertently cause disparate impact to certain demographic groups.

Many organizations are creating robust offices of diversity, equity, and inclusion and are hiring senior leaders to oversee this work. While this is essential and can be very impactful for an organization, a truly transformational approach would also involve embedding health equity into all healthcare operations. “We need strong leaders in health equity and we need equity to be everyone’s job,” says Resnick. “Just like clinical quality, patient safety, patient experience, and all clinical operations.”

“There are uncomfortable conversations that structural racism still exists and that systemic oppression and racism have a direct impact on healthcare equity and patient outcomes,” Stepney notes. “Healthcare leaders need to understand that equal care is not equitable care.” 

Digging into the Data

To provide highly reliable care, healthcare organizations also need data—and lots of it. 

“High reliability care is about consistency of outcomes for all patients,” says Christian Dankers, MD, principal and associate chief medical and quality officer at Chartis. “The problem is that inconsistency and poor outcomes can be hidden in aggregate data. When we stratify data by patient demographics, we see problems and inequities we wouldn’t have otherwise noticed. It’s about having an equity-informed perspective.”

This includes data about race, ethnicity, ancestry, and language (REAL) as well as data about sexual orientation and gender identity (SOGI) and social needs, says Stepney. 

“These are just some of the options to start identifying where disparities might exist so you can have broader conversations,” she adds. 

“Identification of differences by demographic allows specific actions to close these gaps, ultimately improving care for all patients,” says Resnick.

Informed conversations are critical. “When you don’t look at outcomes-based metrics through an equity lens, you assume that everyone is the same and that the treatment and processes for every patient will be the same—and it’s not,” says Beloff.

Beloff provides the example of wound assessments. Many nurses learn how to assess wounds using textbooks featuring patients with light-colored skin. “It’s about opening your mind to acknowledge that pressure ulcers will manifest differently depending on the color of your skin,” she says. “If you’re not attuned to that in the beginning, you could underassess the risk of darker skin patients to develop a worse pressure injury over time.”

Another example is maternal outcomes, specifically whether mothers choose to exclusively breastfeed their babies. 

“When women don’t speak English as their primary language, talking about lactation with an English-speaking lactation consultant can be daunting,” says Beloff. “This is a very intimate conversation that can’t happen when there’s a language barrier, and it often requires reliance on consultants who speak the patient’s language.”

All operational, quality, and safety metrics and dashboards should include demographic data, says Resnick. “This forces you to look at the differences in patient populations to inform initiatives that can close care gaps,” he says. “If you look for equity in every patient safety event, you’ll discover a whole host of vulnerabilities. There’s a lot of rich detail that can help you notice trends and solve things on the front lines.”

Looking at the data in this way is a departure from how organizations might have viewed it previously in a color- or demographics-blind way, says Resnick. “This isn’t to say you treat one population differently from another, but if you’re not aware of the demographics, you can’t understand different outcomes. REAL and SOGI data add more context so you can ask questions, identify gaps in care processes, and improve care for all.”

Looking Ahead

Highly reliable care is only possible when organizations simultaneously commit to health equity. 

Just because a healthcare organization hits their quality or patient safety target doesn’t mean they’ve provided high reliability care, says Beloff. “It’s only when every subpopulation meets the target that you can celebrate and move on,” she says. “There are people behind these metrics, and the aggregate data doesn’t tell the whole story.”

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