by Risa Lavizzo-Mourey, M.D., M.B.A
President and CEO, The Robert Wood Johnson Foundation
and Minna Jung
Communications Officer, The Robert Wood Johnson Foundation
Ensuring access to quality health care is one of the major goals of the Robert Wood Johnson Foundation (RWJF), as is improving the quality of health care for people with chronic conditions. Working toward this goal means that we must eliminate the unacceptable gaps in health care experienced by racial and ethnic minorities. Research indicates that Americans do not receive half of the care that experts recommend, but we also know that quality gaps are even worse for racial and ethnic minorities.
Disparities in treatment exist across a wide range of chronic conditions, and there is considerable evidence that disparities differ by geographic region and depending on the disease and treatment. This article describes RWJF's approach to reducing disparities using quality improvement (QI) approaches already familiar to the health care field. Our work to reduce racial and ethnic gaps in care has led us to focus on areas where the evidence of racial and ethnic disparities is strong and where the recommended standard of care is clear and evidence-based.
RWJF Disparities Strategy: Building on Quality
For RWJF, developing a targeted strategy for funding work to reduce racial and ethnic disparities in care required an immediate emphasis on discovery and development of replicable solutions. We believe in supporting projects that have measurable impact on health and health care. Since 2002, when the Institute of Medicine published Unequal Treatment, its landmark review of the extensive evidence on racial and ethnic disparities in health care, there have been many promising developments in this area. Many efforts, by necessity, have focused on long-term or hard-to-measure goals (such as the diversification of the health care workforce or eliminating bias and prejudice in the attitudes of health care providers) that may take years to produce concrete, measurable improvements in the quality of health care.
In comparison, RWJF's strategy focuses on obtaining results for the near future by asking health care systems already examining ways to improve quality of care to prioritize, within this context, work on racial and ethnic disparities. We are also asking grantees to use QI methodologies–such as improved data collection and performance measurement – as a starting point for solutions. We believe that health care systems cannot effectively move their QI goals forward without specifically addressing the embedded problem of racial and ethnic disparities in treatment.
For the next five years, the Foundation is committed to making targeted investments in entities that play major roles in America's health care system. In addition, we are supporting research to improve understanding of the contributing factors to disparities between white and nonwhite patients to help identify disparities in care where they occur and design interventions to address them. Factors beyond the influence of the health care system (such as health insurance coverage and personal health behaviors) obviously contribute to gaps in treatment. However, we want to encourage the development of interventions that ensure minority patients receive high-quality care in spite of the constraints of today's health care system and the ongoing societal struggle with issues of equity and race.
What the Strategy Looks Like
RWJF's disparities work is unfolding along three tracks. First, we funded a research agenda to answer pressing questions for the field and aid our strategy development. Our research plans include tracking trends in disparities over time, developing a better understanding of how local quality affects differences in care, and evaluating demonstration projects that are specifically designed to reduce disparities in treatment.
Second, we are launching new demonstrations that help health plans and providers implement targeted efforts to reduce gaps in care between whites and nonwhites. We are supporting two projects to help groups of health plans mine their data for ways to target their QI efforts toward racial and ethnic minority groups. We will announce grantees this September for Expecting Success: Excellence in Cardiac Care, a demonstration project to help hospitals that provide cardiac care to large numbers of minority patients meet high standards for delivery of care to their diverse patients.
Measurement has been a big threshold challenge for these demonstration projects. Though research shows that racial and ethnic disparities vary widely according to region and areas of clinical care, health plans and providers are reluctant to measure racial and ethnic differences in treatment for a multitude of reasons. Nonetheless, QI interventions aimed at reducing disparities can be more effective if one has the capacity to understand which patients receive what types of care.
Some of the reluctance to collect racial and ethnic data is technical–a lack of information system infrastructure, for example–and some is rooted in perceptions that consumers may object to being categorized in these terms. One of the earliest disparities projects RWJF undertook was a poll of consumers' attitudes on this issue. When told that the information would be used for the purposes of improving the quality of their health care, respondents were significantly more likely to support these types of data collection efforts.
Finally, we are committed to spreading information about innovative solutions to potential end users. One of our greatest challenges is to translate and disseminate the results that emerge from our work and the work of others in a way that encourages take-up by those on the cusp of engaging in this problem.
Quality Improvement Alone is Not Enough
Although there is considerable promise for reducing racial and ethnic gaps in care through QI, there is also evidence that generic QI may not be enough to completely close these gaps. For example, many QI initiatives start with elements like provider training on meeting quality benchmarks and setting up patient registries to track care across a patient population without ever addressing other factors that contribute to disparities, like language access and the provision of culturally appropriate care.
If we view quality health care as the right care for the right patient at the right time, fully addressing the six domains of quality health care outlined by the Institute of Medicine's report, Crossing the Quality Chasm, for all patients, means that health plans and providers must and should address these issues. For example, patient-centered care, by definition, is care that is “respectful of and responsive to individual patient preferences, needs, and values.” If a patient with limited English proficiency seeks care and is not granted access to a qualified medical interpreter, it is arguable whether this patient received patient-centered care. Yet many provider networks and hospitals struggle to provide this service to patients on a timely basis.
Feedback from the field suggests that these struggles are not questions of why but how. RWJF learned this lesson when we took an initial step, along with The Henry J. Kaiser Family Foundation and other organizations representing physician, public health, and business groups, to raise awareness among physicians about racial and ethnic disparities in cardiac care.
Although the organizations involved with this initiative–called Why the Difference?–were engaged by the topic, most asked for help in taking concrete steps to reduce disparities within their own particular contexts. Because the tools for targeted QI for diverse populations are still not readily available for end users, we do not yet have an available arsenal to increase cultural competence or language access and make a measurable positive impact on the quality of patient care. One of RWJF's demonstration projects, HablamosJuntos (Spanish for “We Speak Together”), asked grantees to create tools that would help improve the quality and quantity of medical interpreters, improve the use of universal signage in health care facilities, and provide high-quality multilingual materials to patients. Many efforts had to be designed from the ground up due to the state of existing language services.
In coming years, RWJF will look for research and demonstration projects that continue to illuminate the complex factors that contribute to disparities; evaluate potentially replicable interventions aimed at improving the quality of care for minority patients; and blend proven QI techniques with approaches that are especially relevant to patients' cultural, ethnic, and racial backgrounds.
A QI approach to reducing racial and ethnic disparities holds promise because of its potential to bypass or make less confounding some of the issues that have been insolvable within the system for decades, such as bias, prejudice, and unequal patterns of access to health care. These are important issues that we do not shrink from; however, the health care system needs answers–not further debate and controversy–to address inequities in care. By emphasizing quality as an achievable goal and spurring improvement within individual health plans and hospitals that can be held up and ultimately spread as lessons for wider adoption, we believe that health care can be improved for all Americans in our lifetime.
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