The “Waze” of Inequity Reduction Frameworks for Organizations: a Scoping Review

  • Sivan Spitzer-ShohatEmail author
  • Marshall H. Chin



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.

Study Design

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.

Key Results

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.


inequities disparities organizational change frameworks implementation 


Funding Information

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. 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. [doi]
  2. 2.
    Chin MH. Quality improvement implementation and disparities: the case of the health disparities collaboratives. Med Care. 2010;48(8):668-675. [doi]
  3. 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. [doi]
  4. 4.
    Jha AK, Zaslavsky AM. Quality reporting that addresses disparities in health care. JAMA. 2014;312(3):225-226. CrossRefPubMedGoogle Scholar
  5. 5.
    Hunt B, Whitman S. Black:White Health Disparities in the United States and Chicago: 1990-2010. J Racial Ethn Heal Disparities 2015;2(1):93-100. CrossRefGoogle Scholar
  6. 6.
    McDonald KM, Schultz EM, Chang C. Evaluating the state of quality-improvement science through evidence synthesis: insights from the closing the quality gap series. Perm J. 2013;17(4):52-61. CrossRefPubMedGoogle Scholar
  7. 7.
    Ogbolu Y, Fitzpatrick GA. Advancing Organizational Cultural Competency With Dissemination and Implementation Frameworks: Towards Translating Standards into Clinical Practice. ANS Adv Nurs Sci. 2015;38(3):203-214. CrossRefPubMedGoogle Scholar
  8. 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.
  9. 9.
    Chin MH, Goldmann D. Meaningful Disparities Reduction Through Research and Translation Programs. JAMA. 2011;305(4):404. CrossRefPubMedGoogle Scholar
  10. 10.
    Scott RW. Institutions and Organizations: Ideas, Interests, and Identities. 4th edn. SAGE Publications; 2013.Google Scholar
  11. 11.
    McNulty T, Ferlie E. Reengineering Health Care : The Complexities of Organizational Transformation. Oxford University Press; 2004.Google Scholar
  12. 12.
    Rafferty AE, Jimmieson NL, Armenakis AA. Change Readiness: A Multilevel Review. J Manage. 2013;39(1):110-135.Google Scholar
  13. 13.
    Jacobs G, Van Witteloostuijn A, Christe-Zeyse J. A theoretical framework of organizational change. J Organ Chang Manag. 2013;26(5):772-792. CrossRefGoogle Scholar
  14. 14.
    Burnes B. Introduction: Why Does Change Fail, and What Can We Do About It? J Chang Manag. 2011;11(4):445-450. CrossRefGoogle Scholar
  15. 15.
    Burnes B, Jackson P. Success and Failure In Organizational Change: An Exploration of the Role of Values. J Chang Manag. 2011;11(2):133-162. CrossRefGoogle Scholar
  16. 16.
    Warner Burke W. Organization change: theory and practice, 5th edn. Sage Publications; 2017.Google Scholar
  17. 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. 18.
    Ferlie E. Analysing health care organizations: a personal anthology. Routledge; 2016.Google Scholar
  19. 19.
    Benzer JK, Charns MP, Hamdan S, Afable M. The role of organizational structure in readiness for change: A conceptual integration. Heal Serv Manag Res. 2017;30(1):34-46. CrossRefGoogle Scholar
  20. 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. [doi]
  21. 21.
    Pettigrew AM, Woodman RW, Cameron KIMS. Studying Organizational Change and Development: for Future Research. 2001;44(4):697–713.Google Scholar
  22. 22.
    Poole MS, Van de Ven AH. Handbook of Organizational Change and Innovation. Oxford University Press; 2004.Google Scholar
  23. 23.
    Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. CrossRefGoogle Scholar
  24. 24.
    Heather LC, Levac D, O’Brien KK, Straus S, Andrea CT, Perrier L, Kastner M, Moher D. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014;67(12):1291-1294. CrossRefGoogle Scholar
  25. 25.
    Anderson S, Allen P, Peckham S, Goodwin N. Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services. Heal Res Policy Syst. 2008;6(1):7. CrossRefGoogle Scholar
  26. 26.
    Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. CrossRefPubMedGoogle Scholar
  27. 27.
    Brien SE, Lorenzetti DL, Lewis S, Kennedy J, Ghali WA. Overview of a formal scoping review on health system report cards. Implement Sci. 2010;5(1):2. CrossRefPubMedGoogle Scholar
  28. 28.
    Armenakis AA, Bedeian AG. Organizational Change: A Review of Theory and Research in the 1990s. J Manage. 1999;25(3):293-315. Google Scholar
  29. 29.
    Pettigrew AM. What is a processual analysis? Scand J Manag. 1997;13(4):337-348. CrossRefGoogle Scholar
  30. 30.
    DeMeester RH, Xu LJ, Nocon RS, Cook SC, Ducas AM, Chin MH. Solving Disparities Through Payment And Delivery System Reform: A Program To Achieve Health Equity. Health Aff. 2017;36(6):1133-1139. CrossRefGoogle Scholar
  31. 31.
    Albers Mohrman S, Tenkasi R V, Mohrman AM. The Role of Networks in Fundamental Organizational Change A Grounded Analysis. Role Netw J Appl Behav Sci. 2003;39(3):301-323. CrossRefGoogle Scholar
  32. 32.
    Czarniwska B, Joerges B. Travels of Ideas. In: Czarniawska B, Sevon G, eds. Translating Organizational Change. New York: Walter de Gruyter; 1996:13–48.CrossRefGoogle Scholar
  33. 33.
    Maitlis S. The Social Processes of Organizational Sensemaking. Acad Manag J. 2005;48(1):21-49. CrossRefGoogle Scholar
  34. 34.
    Weick KE. Sensemaking in Organizations. Thousand Oaks: Sage Publications; 1995.Google Scholar
  35. 35.
    Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4(1):67. CrossRefPubMedGoogle Scholar
  36. 36.
    Maitlis S, Christianson M. Sensemaking in Organizations: Taking Stock and Moving Forward. Acad Manag Ann. 2014;8(1).Google Scholar
  37. 37.
    Buchanan D, Fitzgerald L, Ketley D, et al. No going back: A review of the literature on sustaining organizational change. Int J Manag Rev. 2005;7(3):189-205. CrossRefGoogle Scholar
  38. 38.
    Andrew B, Sutton Anthea PD. Systematic Approaches to a Successful Literature Review. SAGE Publications; 2016.Google Scholar
  39. 39.
    Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl 1:181-217. CrossRefPubMedGoogle Scholar
  40. 40.
    Betancourt JR, Green AR, Carrillo JE, et al. Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Rep. 2003;118(4):293. CrossRefPubMedGoogle Scholar
  41. 41.
    Betancourt JR, Tan-McGrory A, Kenst KS, Phan TH, Lopez L. Organizational Change Management For Health Equity: Perspectives From The Disparities Leadership Program. Health Aff (Millwood). 2017;36(6):1095-1101. CrossRefGoogle Scholar
  42. 42.
    National Quality Forum. A roadmap for promoting health equity and elimiting disparities. The Four I’s for Health Equity; 2017. Accessed September 2017
  43. 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
  44. 44.
    Castillo RJ, Guo KL. A framework for cultural competence in health care organizations. Health Care Manag (Frederick). 2011;30(3):205-214. doi: Google Scholar
  45. 45.
    Thompson-Robinson M, Reininger B, Sellers B, Saunders R, Davis K, Ureda J. Conceptual framework for the provision of culturally competent services in public health settings. J Cult Divers. 2006;13(2):97-104.PubMedGoogle Scholar
  46. 46.
    Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Acheiving Health Equity: A Guide for Healthcare Organizations. IHI White Paper. Cambridge; 2016. Accessed September 2017
  47. 47.
    Health Research Educational Trust. Equity of care: a toolkit for eliminating health care disparities ®. 2015.Google Scholar
  48. 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. Accessed September 2017
  49. 49.
    National Health Service. A refreshed equality delivery system for the NHS: EDS2 making sure that everyone counts. 2013. Accessed September 2017
  50. 50.
    Rural and Regional Health and Aged Care Services. Cultural responsiveness framework. 2009. Accessed September 2017
  51. 51.
    Laderman M, Whittington J. A Framework for improving Health Equity. Healthc Exec. 2016;31(3):82,84-85.Google Scholar
  52. 52.
    Tynan M, Smullen F, Atkinson P, Stephens K. Aboriginal cultural competence for health services in regional Victoria: lessons for implementation. Aust New Zeal J Public Heal. 2013;37(4):392-393.CrossRefGoogle Scholar
  53. 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.
  54. 54.
    Batras D, Duff C, Smith BJ. Organizational change theory: implications for health promotion practice. Health Promot Int. 2014;129(5 Pt 1):dau098. CrossRefGoogle Scholar
  55. 55.
    Weiner BJ, Amick H, Lee S-YD. Review: Conceptualization and Measurement of Organizational Readiness for Change. Med Care Res Rev. 2008;65(4):379-436. CrossRefPubMedGoogle Scholar
  56. 56.
    Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Serv Res. 2014;14(1):99. CrossRefPubMedGoogle Scholar
  57. 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).
  58. 58.
    Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463. CrossRefPubMedGoogle Scholar
  59. 59.
    LUScher LS, Lewis MW. Organizational Change and Managerial Sensemaking: Working Through Paradox. Acad Manag J. 2008;51(2):221-240. CrossRefGoogle Scholar
  60. 60.
    Parand A, Burnett S, Benn J, Pinto A, Iskander S, Vincent C. The disparity of frontline clinical staff and managers’ perceptions of a quality and patient safety initiative. J Eval Clin Pract. 2011;17(6):1184-1190. CrossRefPubMedGoogle Scholar
  61. 61.
    Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards? Med Care. 2010;48(12):1080-1087. CrossRefPubMedGoogle Scholar
  62. 62.
    Gómez ML, Charnigo R, Harris TT, Williams JC, Pfeifle W. Assessment of National CLAS Standards in Rural and Urban Local Health Departments in Kentucky. J Public Health Manag Pract. 2016;22(6):576-585. CrossRefPubMedGoogle Scholar
  63. 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. CrossRefPubMedGoogle Scholar
  64. 64.
    Chin MH. Creating the Business Case for Achieving Health Equity. J Gen Intern Med. 2016;31(7):792-796. CrossRefPubMedGoogle Scholar
  65. 65.
    Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implement Sci. 2017;12(1):110. CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  1. 1.Department of Population Health, Azrieli Faculty of MedicineBar-Ilan UniversitySafedIsrael
  2. 2.Center for Health and the Social SciencesUniversity of ChicagoChicagoUSA
  3. 3.Section of General Internal MedicineUniversity of ChicagoChicagoUSA

Personalised recommendations