The “Waze” of Inequity Reduction Frameworks for Organizations: a Scoping Review
Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks.
To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable.
Fourteen inequity frameworks from scoping literature review 2000–2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time.
We conducted member check interviews with framework authors to verify our assessments.
Frameworks stressed assessing the organization’s outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks.
Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.
KEY WORDSinequities disparities organizational change frameworks implementation
Dr. Spitzer-Shohat was supported by a Rivo-Essrig Fellowship from the Department of Population Health, Azrieli Faculty of Medicine, Bar-Ilan University. Dr. Chin was partially supported by the Chicago Center for Diabetes Translation Research (grant number NIDDK P30 DK092949), the Robert Wood Johnson Foundation Finding Answers: Solving Disparities Through Payment and Delivery System Reform Program Office, and the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
- 1.Clarke AR, Goddu AP, Nocon RS, et al. Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013;51(11):1020-1026. https://doi.org/10.1097/MLR.0b013e3182a97ba3 [doi]
- 2.Chin MH. Quality improvement implementation and disparities: the case of the health disparities collaboratives. Med Care. 2010;48(8):668-675. https://doi.org/10.1097/MLR.0b013e3181e3585c [doi]
- 3.Balicer RD, Hoshen M, Cohen-Stavi C, et al. Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention. Health Serv Res. 2015. https://doi.org/10.1111/1475-6773.12300 [doi]
- 8.Barksdale CL, Rodick Iii WH, Hopson R, Kenyon J, Green K, Jacobs CG. Literature Review of the National CLAS Standards: Policy and Practical Implications in Reducing Health Disparities. J Racial Ethn Heal Disparities. 2016. https://doi.org/10.1007/s40615-016-0267-3
- 10.Scott RW. Institutions and Organizations: Ideas, Interests, and Identities. 4th edn. SAGE Publications; 2013.Google Scholar
- 11.McNulty T, Ferlie E. Reengineering Health Care : The Complexities of Organizational Transformation. Oxford University Press; 2004.Google Scholar
- 12.Rafferty AE, Jimmieson NL, Armenakis AA. Change Readiness: A Multilevel Review. J Manage. 2013;39(1):110-135.Google Scholar
- 16.Warner Burke W. Organization change: theory and practice, 5th edn. Sage Publications; 2017.Google Scholar
- 17.Battilana J, Leca B, Boxenbaum E. How Actors Change Institutions: Towards a Theory of Institutional Entrepreneurship. Acad Manag Ann. 2009;3(1).Google Scholar
- 18.Ferlie E. Analysing health care organizations: a personal anthology. Routledge; 2016.Google Scholar
- 20.Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):992-1000. https://doi.org/10.1007/s11606-012-2082-9 [doi]
- 21.Pettigrew AM, Woodman RW, Cameron KIMS. Studying Organizational Change and Development: for Future Research. 2001;44(4):697–713.Google Scholar
- 22.Poole MS, Van de Ven AH. Handbook of Organizational Change and Innovation. Oxford University Press; 2004.Google Scholar
- 34.Weick KE. Sensemaking in Organizations. Thousand Oaks: Sage Publications; 1995.Google Scholar
- 36.Maitlis S, Christianson M. Sensemaking in Organizations: Taking Stock and Moving Forward. Acad Manag Ann. 2014;8(1).Google Scholar
- 38.Andrew B, Sutton Anthea PD. Systematic Approaches to a Successful Literature Review. SAGE Publications; 2016.Google Scholar
- 42.National Quality Forum. A roadmap for promoting health equity and elimiting disparities. The Four I’s for Health Equity; 2017. http://www.qualityforum.org/Home.aspx. Accessed September 2017
- 43.Cattacin S, Chiarenza A, Domenig D. Equity standards for healthcare organisations: a theoretical framework. Divers Equal Heal Care. 2013;10(4):249-258.Google Scholar
- 46.Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Acheiving Health Equity: A Guide for Healthcare Organizations. IHI White Paper. Cambridge; 2016. ihi.org. Accessed September 2017
- 47.Health Research Educational Trust. Equity of care: a toolkit for eliminating health care disparities ®. 2015.Google Scholar
- 48.Office of Minority Health. National standards for CLAS in health and health care: a blueprint for advancing and sustaining CLAS policy and practice. 2013. https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf#page82. Accessed September 2017
- 49.National Health Service. A refreshed equality delivery system for the NHS: EDS2 making sure that everyone counts. 2013. https://www.england.nhs.uk/wp-content/uploads/2013/11/eds-nov131.pdf. Accessed September 2017
- 50.Rural and Regional Health and Aged Care Services. Cultural responsiveness framework. 2009. www.health.vic.gov.au/cald. Accessed September 2017
- 51.Laderman M, Whittington J. A Framework for improving Health Equity. Healthc Exec. 2016;31(3):82,84-85.Google Scholar
- 53.Seeleman C, Essink-Bot M-L, Stronks K, Ingleby D. How should health service organizations respond to diversity? A content analysis of six approaches. BMC Health Serv Res. 2015;15:510. https://doi.org/10.1186/s12913-015-1159-7
- 57.Chin MH, King PT, Jones RG, et al. Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States. Health Policy. 2018;0(0). https://doi.org/10.1016/j.healthpol.2018.05.001
- 63.Weech-Maldonado R, Dreachslin JL, Brown J, et al. Cultural competency assessment tool for hospitals: evaluating hospitals’ adherence to the culturally and linguistically appropriate services standards. Health Care Manage Rev. 2012;37(1):54-66. https://doi.org/10.1097/HMR.0b013e31822e2a4f CrossRefPubMedGoogle Scholar