Phase 2

Topics & Objectives

Implement Quality Improvement to Meet the Joint Commission's Requirements for Health Equity

1.  Review the Joint Commission's Health Equity new requirements for health care organizations (effective July 1, 2023)                                       
2. Discuss examples of quality improvement (QI) projects which align with the Joint Commission's requirements
3. Recognize the ways in which different roles can contribute to QI projects to promote health equity

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Key Takeaways:

• Effective July 1, 2023, The Joint Commission’s Standard LD.04.03.08, which addresses health care disparities as a quality and safety priority, will be elevated to a National Patient Safety Goal for ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals. This goal includes 6 elements of performance to increase the focus on
  improving health care equity as a quality and safety priority.
• The Achieving Equitable Health Outcomes in Nebraska program will focus on applying QI tools to improve health equity in alignment with new Joint Commission requirements.
• Program content is directly applicable to meeting the Joint Commission’s requirements through quality improvement projects focused on improving health equity and cultural sensitivity.
• Program sessions will discuss how executives, health equity leads, and front-line staff can contribute to quality improvement projects to promote health equity.

Topics & Objectives

Getting Leadership Buy-In

1. Summarize strategies for engaging leadership in Quality Improvement projects
2. Demonstrate how the Joint Commission's requirements for health equity can inform conversations with leadership
3. Practice implementing strategies for engaging leadership in case discussion

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Key Takeaways:

• Effective change in leadership requires a balance of structure and flexibility. John Kotter’s eight-step framework, outlined in his article “Why Transformation Efforts Fail,” is a highly adaptable and effective guide to this process.
• Kotter’s “See-Feel-Change" approach tells us that behavior fueled by emotion is more likely to last than behavior fueled by analysis because it will be resistant to negative emotions.
• To maximize the likelihood of successfully implementing a change, start by identifying the needs of core audiences and where/how these are aligned or misaligned.
• Your needs for leadership buy-in are likely to change over time, and your approach to securing this buy-in should change with them. The tools and frameworks presented in this session can help you plan ahead for these changes.

Topics & Objectives

Scoping QI Projects for Health Equity

1. Articulate the value of having diverse perspectives in scoping changes
2. Practice developing problem statements focused on health equity
3. Incorporate diverse perspectives into improvement projects in case discussion

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Key Takeaways:

• Clearly defining the problem to be solved is a critical first step in any quality improvement project. This often entails choosing from among multiple problems that could be addressed.
• A good problem statement describes the issue that needs to be addressed without offering theories on potential causes or solutions.
• The narrower the scope and more specific the description, the easier it will be to identify root cause(s) and to solve the problem deemed most important.
• Different audiences may have different conceptions of what a problem is based on their backgrounds, roles, and experiences.
• Problem statements may evolve over time as data are gathered, practices are better understood, or information on other problems comes to light.

Topic: Using Data to Understand Inequity

Learning Objectives:

1. Describe the role that data play in understanding health disparities and the impact of changes on health equity.
2. Explain how this knowledge has been applied to improve our understanding of health disparities related to long COVID-19/post-COVID conditions.
3. Apply this knowledge to clarify the impact of health disparities in the context of a case example.

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Key Takeaways:

• There are pronounced racial and ethnic disparities in acute COVID cases, hospitalizations, and deaths in the US. Many of these disparities apply to long COVID symptoms as well.
• The demographics of people employed in occupations with an increased risk for COVID-19 infection overlap with those for people with a higher risk of severe COVID-19.
• Risk factors for Long COVID include female sex, underlying co-morbid conditions, not having received a COVID-19 vaccine, and having previously had severe COVID-19.
• Among social determinants of health, socioeconomic context, political context, and socioeconomic position are structural determinants of long COVID. Material circumstances, behaviors, biological factors, and psychosocial factors are intermediary determinants of long COVID. All of these determinants impact
  health outcomes for those with long COVID.
• A higher frequency of perceived discrimination is associated with longer duration for neurological and mood symptoms of long COVID.
• Interdisciplinary management of care is essential to providing quality care for long COVID.
• Prominent barriers that need to be addressed to improve access to long COVID care include insurance coverage, transportation, financial barriers, and health literacy.

Topic: Conducting an Equity-focused Needs Assessment

Learning Objectives:

1. Explain how a needs assessment informs the scope of a Quality Improvement project.
2. Apply definitions of reliable practice to health equity improvements.
3. Describe how system-level factors contribute to unreliability and inequity in case examples.

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Key Takeaways:

• A needs assessment aims to 1) identify potential causes of failure where a process is not reliable, and 2) facilitate the prioritization of potential solutions to test based on their benefits and requirements.
• A reliable process requires a common understanding of the problem it aims to solve, the steps that need to happen, and the places where errors are most likely to arise.
• Prerequisites for conducting an equity-focused needs assessment include a focused problem statement, knowledge of existing data sources and/or data needs, a population of focus, and a timeframe for when you need to see results.
• Three tools that can be used to learn more about the sources of error in a process quickly are 1) direct observation of the process, 2) review of an existing process map, and 3) a fishbone diagram.
• When evaluating potential solutions to a problem impacting health equity, always consider the impact/benefit, the level of effort, and the disparity that these solutions should address. You may also consider the probability of achieving impact/benefit within your time frame, the political implications of choosing this solution, and how this solution would position you for future tests of change.

Topic: Having Better Conversations about Change    

Learning Objectives:

1. Articulate the importance of identifying and accepting ambivalence to change.
2. Identify resistance to change in case examples.
3. Practice strategies for managing resistance to change in the context of health equity.

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Key Takeaways:

• We often treat resistance to change as a singular conversation. There are many reasons for change resistance, and the recommended interventions for these are very different.
• All people are ambivalent about change. When change isn’t happening, we can look for ambivalence by listening for sustain talk, which Miller and Rollnick define as “the person’s own arguments for not changing, for sustaining the status quo.”
• A person needs to be aware of the value of change, capable of implementation, and feel supported in operationalizing it to be ready to make a change.
• The value of a change includes its value to the individual, their work, their patients or community, and their team or organization.
• The capability to implement a change requires both knowledge of the change as well as confidence in that knowledge.
• The support required for operationalizing a change includes resources to make change possible in an individual’s role as well as resources to support change across the team or organization

Topic: Patient and Community Engagement in Health Equity
Learning Objectives:

1. Examine how to apply Quality Improvement (QI) tools to the evaluation of change ideas
2. Summarize strategies for engaging patients in health equity priorities
3. Incorporate patient feedback to create more equitable changes as part of a case discussion

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Key Takeaways:

• Patient engagement is both process and behavior and is shaped by the relationship between the patient and provider and the environment in which healthcare delivery takes place.
• Community engagement is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.
• Quality Improvement (QI) provides an effective set of tools for the evaluation of change ideas which impact patient and community engagement in health equity improvements.

Learning Objectives:

1. Describe why measurement is an important part of scoping a Quality Improvement project.
2. Discuss how process, outcome, and balancing measures provide insight into health disparities
3. Apply process, outcome, and balancing measures in the context of health equity case discussion

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Key Takeaways:

• An effective approach to measuring the success of improvements starts with a problem statement which offers a concise and focused description of the issue that needs to be addressed.
• Outcome measures detail the results that you are looking to achieve in your organization. Leadership or management should be held accountable for meeting outcomes-level goals.
• Process measures detail the actions which you believe will lead to your outcomes. The frontline staff making the changes should be held accountable for gathering process data and meeting process-level goals.
• Balancing measures detail unintended consequences outside of our process that might impact the viability and sustainability of our change. Frontline staff should be held accountable for gathering and reporting data on balancing measures.

Learning Objectives:

1. Identify the characteristics of effective aim statements.
2. Apply the characteristics of effective aim statements in the context of health equity related improvements.
3. Demonstrate the ability to distinguish effective from ineffective aim statements in the context of a case discussion.

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Key Takeaways:

• An Aim Statement is a written, measurable, time sensitive statement of the expected results of a system redesign/quality improvement project.
• Measures and Aim Statements inform one another. Measures inform Aim Statements by telling you what to aim for. Aim Statements help you refine those measures and decide on what else to measure to understand improvement.
• The Impact/Effort Matrix is a tool that can help you assess how the potential impact of a solution and the effort it will require fit with your needs.

Topic: Focusing Changes to Improve Health Equity

Objectives: 

1. Articulate how different Quality Improvement (QI) tools can be used to scope tests of change.
2. Summarize how aim statements are used to focus QI projects.
3. Discuss how contextual factors such as audience, environment, and resources impact decisions on where to test health equity changes.

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Key Takeaways:

• Many of the Quality Improvement (QI) tools covered as part of this ECHO can be used to help you scope tests of change, including Aim Statements, Plan-Do-Study-Act Cycles, Process Mapping, Impact/Effort Matrices, and Hierarchies of Actions.
• Contextual factors such as audience, environment, and resources often impact decisions on where to test changes.
• The process of establishing, validating, and vetting outcome measures for your project can and should directly inform its scope, in part by enriching your understanding of inequities in your communities.
• Leadership buy-in is essential for improvement. Challenges in securing buy-in should be factored into the scope and focus of improvement projects.

Topic: Refining Changes and Managing Expectations

Objectives: 

1. Differentiate spread and scale in the context of QI projects
2. Discuss how changes can be adapted as they are spread and scaled
3. Identify strategies for managing buy-in and change resistance as interventions evolve in new settings

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Key Takeaways:

• Spreading a change involves implementing a tested approach in a new setting or audience. In cases where spread is most appropriate, a spread plan helps with preparation for testing by identifying assets, barriers, and critical differences across settings and/or audiences.
• Scaling a change means expanding its scope across multiple settings and/or audiences. This requires addressing issues that are not essential to spread, including infrastructural constraints, greater resource needs, greater complexity, relationships between adopters, and a lower level of control.
• Changes often need to be adapted in order to spread or scale. Adaptations may include who completes the tasks involved, the workflow required to implement a change, and/or the timing or location for required tasks.
• To maximize the likelihood of successfully implementing a change, start by identifying the needs of core audiences and where/how these are aligned or misaligned.

Topic: Sustaining Progress: How to Continue Advancing Health Equity through a QI Lens

Objectives:

1. Characterize how summary resources from this project can be used to support health equity work in your organization.
2. Summarize best practices in sustaining improvement from short-term tests of change. 
3. Discuss next steps in participant health equity improvement projects.

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Key Takeaways:

• Sustainable partnerships for health equity improvement require relationships and commitments among the partners involved; knowledge, capacity, and values generated from partnerships; and funding, staff, programs, and policy change to support partnership.
• Just because a change is effective does not mean that it will be sustained. Sustainability planning starts with measurement, including monitoring process and outcomes metrics for negative signals and planning for how measurement will change over time.
• Sustainable changes require clear ownership. There may be different owners for the daily work associated with a change and the measurement that supports sustainment.
• Our project faculty have developed a Health Care Facility and Health Department Health Equity Accreditation Resource that is intended to support health care facilities and health departments in meeting Joint Commission and Public Health Accreditation Board health equity accreditation requirements.