How Will This Toolkit Help Me?
Learning Objectives
Identify ways to prepare yourself and your team for conversations about health equity, racial equity, racism, and anti-racism with colleagues, patients, and other practice stakeholders
Describe the importance of data and how to improve the quality of your data to further racial and health equity efforts
Explain how to advance racial and health equity in your practice using SMART goals and quality improvement efforts
As the commitment to advance health equity and racial equity grows across many sectors, motivated physicians and other health care professionals in smaller practice settings may wonder how best to pursue these goals through their day-to-day work.
Now more than ever, you and your colleagues might be asking questions like:
Do preventive screening rates, treatment recommendations, or other measures of the quality of our patient care differ by race, ethnicity, and/or language?
Does everyone in our practice understand how institutionalized racism shapes clinical practice and patients' health outcomes? How can we do better?
Do all patients feel welcome by our team members and comfortable in our clinic?
Does our practice's payer mix reflect or even exacerbate institutionalized racism?
Since health equity and racial equity are not only outcomes but also ongoing inter-related processes, this toolkit adapts a practice transformation framework to offer 5 STEPS that can help move practices forward to advance racial and health equity for co-workers, for patients, and for the communities you serve. Recognizing that the path to equity is a dynamic, long-term journey, this toolkit focuses on initial catalytic steps and associated resources that motivated physicians and practices can use to translate that commitment to equity into action. These recommended STEPS are part of a larger cycle of continuous learning, improvement, and accountability that seeks to advance racial and health equity through transformation efforts at the practice, community, and societal levels.
Other resources to support your racial and health equity efforts are listed at the end of this toolkit in the Further Reading and References sections.
Five STEPS to Advancing Racial and Health Equity in Your Practice
Commit to Do the Work
Start Shifting Group Norms by Learning About What You Don't Know
Get a Handle on Your Data
Develop a Shared, Clear, Compelling Vision and Goals
Launch Targeted Improvement Efforts
STEP 1 Commit to Do the Work
Like every practice transformation effort, advancing racial and health equity requires leadership. It also requires courage—courage to approach this work with genuine respect, to facilitate and create a safe space for difficult conversations, to find comfort in discomfort, and to commit to meaningful action.
This effort may start with you whether you are the owner of your practice, medical director, or one of many colleagues working together in a small practice.
Talking about racism, racial equity, or health equity in clinical practice may make some of your colleagues, leaders, and other stakeholders uncomfortable. While it's important to approach conversations about racial equity with respect, expect discomfort and even some degree of conflict. After all, advancing racial and health equity in clinical practice necessarily involves challenging norms and interrupting patterns that maintain structural advantages and disadvantages—from patient-facing issues such as access to care and population health management to organizational issues such as hiring, advancement, and pay equity.1 To help leaders and colleagues in your practice become more comfortable with the discomfort inherent to racial equity work, share the ThemPra Social Pedagogy “Learning Zone” model with them and review this guide from the Southern Poverty Law Center.
A good place to start is by asking questions. Consider asking team members and colleagues questions that invite honest self-assessment as a practice:
Do we know whether access to care, preventive screenings, treatments, or other quality measures differ by patient race, ethnicity, and language?
When was the last time we asked patients and team members whether and how racism has impacted their health and the care they've received over the course of their lives?
If we don't have a plan to identify and reduce racial inequities for our patients and community, how do we know that our practice isn't contributing to the problem?
These questions can help identify opportunities for improvement as well as secure leadership and team commitment to make this work a priority and devote dedicated time for teams to engage in learning and improvement efforts that seek to advance racial equity.
A Tool Kit for Productive Conversations on Race (231 KB)Learn about the Mass General Brigham “See. Hear. Act.” approach to discussing race.
STEP 2 Start Shifting Group Norms by Learning About What You Don't Know
Name it, frame it, explain it.
Before making a plan to improve racial and health equity, it's important for everyone in your practice to develop a better, shared understanding of racism and anti-racism. This process requires a combination of individual and group learning to find out what you don't know. Read and share articles and resources like those listed below. Use dedicated time as well as informal opportunities at work to talk with colleagues.
Review the ways white supremacy culture influences organizational culture. Approach conversations with respect, listen and be open to questions, and be sure to discuss the difference between institutionalized racism and interpersonal racism. Share lessons from “bright spots”—other practices that have started the journey to racial equity. Consider hiring an experienced consultant to facilitate group conversations and normalize a commitment to racial equity. If your budget doesn't allow you to hire a facilitator, resources in this toolkit can assist you.
Here are some questions you may consider using during the patient visit:
STEP 3 Get a Handle on Your Data
Quiz Ref IDTo chart a course forward on racial equity, it's important to know where you are. This STEP starts by discussing a basic question as a practice—what does our data tell us about racial health disparities among our patients?
It is important to routinely collect and analyze patient and practice performance data by race and/or ethnicity. The COVID-19 pandemic has revealed that many clinics and health care institutions, as well as state and federal governments, fail to consistently capture race and ethnicity demographic information on patients. The omission of data on race is just one way that structural racism manifests in health care. Support patient self-recording of race and ethnicity data through the use of patient-facing tools online and/or at the point of service in your practice.8
STEP 4 Develop a Shared, Clear, Compelling Vision and Goals
With a focus on a few key actionable measures, the next step is to create a shared vision and goals to reduce or eliminate racial disparities in care delivery and practice performance. There are 2 components to remember when developing a compelling vision and goal for racial equity:
First, work with a small group of your most motivated colleagues to develop a draft quality-improvement-based project charter. Be sure to involve and ask at least one practice leader to review the draft charter and serve as an executive sponsor.
Second, draft SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals based on your data analysis. Using our illustrative example of patients with uncontrolled hypertension for example, we could set the following SMART goals—Within 12 months, we will:
Achieve a 20% increase from baseline in hypertension control among all adult patients ages 30-65, including Black women and Latino men and,
Decrease disparities in uncontrolled hypertension rates between Black women, Latino men, and other groups by 20% from baseline.
Keep racial equity front and center as you develop your project charter. A key element of being an anti-racist clinical practice is “centering the margins.” This means “making the perspectives of socially marginalized groups, rather than those belonging to the dominant race of culture, the central axis around which discourse on a topic revolves.”14 To center your project charter in “the margins,” invite individuals from socially marginalized groups—including patients, team members, and/or community residents—to discuss and review your charter and to validate or invalidate your practice's ideas about how to reduce racial health disparities.
STEP 5 Launch Targeted Improvement Efforts
Instead of simply identifying and accepting that racial health inequities exist, the preceding steps will help everyone in your practice expand a shared understanding of why they exist and develop a shared commitment and plan to eliminate them. The next step in practice transformation is to launch focused quality improvement (QI) efforts that explicitly aim to advance racial and health equity.
Several studies have demonstrated the positive impact of disparities-targeted quality improvement on improving racial equity in care delivery and practice performance.16 For example, in the landmark national Health Disparities Collaborative, community health centers used quality improvement to reduce racial, ethnic, and socioeconomic disparities in care over the short-term (1-2 years) and key health outcomes over longer 2-4 year periods.17 Similarly, health systems have also deployed disparities-targeted QI efforts to reduce racial health disparities for a range of issues, from COVID-19 care to cancer treatment.11,18 The key is not to use a “one-size-fits-all” approach in which quality improvement interventions are broadly targeted to the general population.
Here are some considerations for developing equity-focused quality improvement goals and interventions:
If a QI effort only assesses potential improvements in baseline measures for a patient subgroup without comparing to others, it may have no impact on actual gaps in care between patient populations and may even inadvertently worsen racial health disparities.
Don't involve a large number of patients in your quality improvement effort right out of the gate. The Model for Improvement takes the standard Plan, Do, Study, Act (PDSA) cycle from continuous quality improvement and emphasizes the goal of rapid cycle improvement—testing an intervention on a small group of patients to allow assessment and then revision of an intervention.17,19
These 5 STEPS are meant for clinicians ready to work with their practice colleagues, patients, and communities to advance racial equity. This toolkit can help you develop shared understanding and commitment, set data-driven goals, and embark on a journey of continuous learning and improvement for racial and health equity.
Journal Articles and Other Publications
Race, racism, and equity: GeneralLearning for Justice (formerly Teaching Tolerance). Let's talk: discussing race, racism and other difficult topics with students. Accessed April 10, 2021. https://www.learningforjustice.org/sites/default/files/general/TT%20Difficult%20Conversations%20web.pdf
The Eliminating Disparities in Child and Youth Success Collaborative, the Coalition of Communities of Color, and All Hands Raised. Tool for organizational self-assessment related to racial equity. October 2013. Accessed April 10, 2021. https://nhchc.org/wp-content/uploads/2019/08/organizational-self-assessment-related-to-racial-equity_oct-2013.pdf
Jones K, Okun T. White supremacy culture. In: Dismantling Racism: A Workbook for Social Change Groups. ChangeWork; 2001. http://www.cwsworkshop.org/PARC_site_B/dr-culture.html
Wilkerson I. America's enduring caste system. New York Times. July 1, 2020. Updated January 21, 2021. Accessed April 12, 2021. https://www.nytimes.com/2020/07/01/magazine/isabel-wilkerson-caste.html
Saad LF. Do the work: an anti-racist reading list. The Guardian. June 3, 2020. Accessed April 12, 2021. https://www.theguardian.com/books/booksblog/2020/jun/03/do-the-work-an-anti-racist-reading-list-layla-f-saad
Kijakazi K, Schwabish J, Simms M. Racial inequities will grow unless we consciously work to eliminate them. Urban Wire: Race and Ethnicity, the blog of the Urban Institute. July 1, 2020. Accessed April 12, 2021. https://www.urban.org/urban-wire/racial-inequities-will-grow-unless-we-consciously-work-eliminate-them
Race, racism, and equity: Health careWyatt R, Tucker L, Mate K, et al. A matter of trust: commitment to act for health equity. Healthc (Amst). 2023;11(1):100675. doi:10.1016/j.hjdsi.2023.100675
Sivashanker K, Gandhi TK. Advancing safety and equity together. N Engl J Med. 2020;382(4):301-303. doi:10.1056/NEJMp1911700
Endo, JA. Addressing race in practice. Institute for Healthcare Improvement blog. September 27, 2016. Accessed April 10, 2021. http://www.ihi.org/communities/blogs/addressing-race-in-practice
Williams JC. Double jeopardy? An empirical study with implications for the debates over implicit bias and intersectionality. Harv J L & Gend. 37;2014:185-242. https://repository.uchastings.edu/faculty_scholarship/1278/
Southern Jamaica Plain Health Center. Liberation in the exam room: racial justice and equity in health care. Institute for Healthcare Improvement. Accessed April 12, 2021. http://www.ihi.org/resources/Pages/Tools/Liberation-in-the-Exam-Room-Racial-Justice-Equity-in-Health-Care.aspx
Videos and Webinars
Websites
Race, racism, and equity: GeneralSmith D. The 10 R's of talking about race: how to have meaningful conversations. Net Impact. June 3, 2020. Accessed April 10, 2021. https://www.netimpact.org/blog/talking-about-race
ThemPra Social Pedagogy. The learning zone model. Accessed April 10, 2021. http://www.thempra.org.uk/social-pedagogy/key-concepts-in-social-pedagogy/the-learning-zone-model/
The model's “comfort, stretch, panic” framework assumes that to learn and improve, we all have to venture out from our comfort zone, where familiar norms and practices remain unchallenged, into a learning zone, where we can make new discoveries. That's essential for racial health equity, which is a continuous learning process.
Racial Healing and Reconciliation Project. The work. http://www.racialrec.org/work/