Fellow’s Corner: Moving from Identifying to Addressing Disparities: Equity-focused Quality Improvement

Early in my clinical training, I learned that as a clinician, treating diseases relied not only on my knowledge of pathophysiology and evidence-based medicine, but also on thoughtful evaluation and understanding of each patient’s unique social and environmental factors and the interactions with a patient’s race and ethnicity. I initially approached the problem of disparities through the lens of health services research, which allowed me to identify and describe disparities and their risk factors. I have more recently started wondering: How can we move from describing disparities to addressing inequities? As a neonatal-perinatal fellow and master’s student at the University of Pennsylvania, I began exploring different methodologies, specifically quality improvement.

Quality improvement offers a compelling approach to addressing disparities. Teams work to identify root causes of a problem and test interventions iteratively and systematically. However, does everyone benefit equally from interventions? Ideally, a QI initiative improves everyone’s care, especially the community experiencing the disparity. However, QI initiatives have the potential to leave disparities unchanged or can even worsen them, especially if stratified data are not monitored and/or the root causes of a disparity are not considered in project and intervention design.

Equity-focused quality improvement offers an action-oriented framework where equity is integrated throughout the fabric of a QI initiative to address a disparity intentionally and collaboratively. Stratifying local data by demographic variables, such as race, ethnicity, preferred language, or insurance status, is a critical first step to identify a disparity. Once identified, stakeholders brainstorm root causes, focusing on systems and processes, including racism in healthcare systems and policies. Key stakeholders include patients and families and relevant community partners, with a focus on the group(s) experiencing the disparity.

We have begun using this framework locally at the Hospital of the University of Pennsylvania (HUP), part of the CHOP Newborn Care Network. While only 4% to 6% of White patients never introduce breastmilk, 19% to 22% of Black patients never introduce breastmilk to their infants. Under the mentorship of Lori Christ, MD, and Jennifer Peterman, BSN, RN, IBCLC, we created the HUP Neonatal Health Equity Taskforce in 2020 to better understand and address these disparities in breastfeeding rates through improved education and support for Black parents. We have partnered with community organizations, including Breastfeeding Awareness and Empowerment, Maternity Care Coalition, and Reclaim Black Motherhood, to perform a community needs assessment, collaboratively brainstorm root causes of this disparity, and design our interventions. This work has been generously supported by the CHOP Division of Neonatology and a grant from the National Association of County & City Health Officials.

Our goal in equity-focused quality improvement is to ultimately bridge the gap between disparities research in quality of perinatal and neonatal care to action with the provision of equitable care for all patients, especially our most vulnerable populations.

References and suggested readings

Reichman, V, Brachio, SS, Madu, CR, Montoya-Williams, D, & Peña, MM. (2021). Using rising tides to lift all boats: equity-focused quality improvement as a tool to reduce neonatal health disparities. Fetal Neonatal Med. 2021;26(1):101198.

Lion, KC, Raphael, JL. Partnering health disparities research with quality improvement science in pediatrics. Pediatrics, 2015;135(2), 354–361.

Contributed by: Michelle-Marie Peña, MD