Health equity as a quality metric: the sixth domain of quality
Although equity is one of the six domains of health quality, it is often considered the ‘forgotten aim’. Equity as a domain of quality is defined as ‘provision of care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status’. Currently, equity metrics are not widely used for hospital benchmarking, such as by the American College of Surgeons (ACS) National Surgical Quality Improvement Program or TQIP. Equity is only weighted at 5% of the composite benchmarking score in Vizient, a member-owned health services company that focuses on improving patient outcomes at reduced costs. Nonetheless, equity metrics may carry more weight in the future given recent announcements by the Joint Commission and CMS around their prioritization of and commitment to health equity.24
The ACS has a long-standing history of promoting healthcare quality through its verification programs. The ACS has described their four key pillars of continuous quality improvement: (1) setting standards to guide practice, (2) building infrastructure, (3) collecting data to measure performance, and (4) verifying performance through external peer review.25 For trauma centers, the standards of care outlined in the ‘Resources for the Optimal Care of the Injured Patient’ serve as the basis for the Verification, Review, and Consultation (VRC) program.24 In reviewing the existing VRC standards, the only standard that explicitly addresses equity is 5.13 which states: ‘In all trauma centers, the decision to transfer an injured patient must be based solely on the needs of the patient, without consideration of their health plan or payor status.’24 Thus, there is an opportunity to integrate equity considerations across all of the VRC standards.
With regard to infrastructure to promote equity, the VRC does not currently provide guidance to trauma centers. However, as part of the ACS Quality Verification Program, a non-subspecialty-specific program, infrastructure guidance focuses on institutional administrative and leadership commitment and on program scope and governance, creating a culture of patient safety and high reliability.26 Leadership commitment is essential to ensure equitable care and promoting a safe culture. With regard to program scope and governance, the Quality Verification Program calls for a surgical quality officer and for a surgical quality and safety committee. Institutions should build a similar infrastructure around equity, and in fact, many institutions are already doing so, such as by designating a leader in diversity, equity, and inclusion.
Other organizations committed to quality and equity have released guidelines around infrastructure that can be used by hospitals. For example, the Institute for Healthcare Improvement published a white paper describing a health equity framework which has five components: (1) make health equity a strategic priority; (2) develop structure and processes to support health equity work; (3) deploy specific strategies to address the multiple determinants of health on which healthcare organizations can have a direct impact; (4) decrease institutional racism within the organization; and (5) develop partnerships with community organizations.27
While trauma centers can address one or more of these components, they are not currently formally required to do so. TQIP does not report equity metrics and does not collect data on SDOH. While there are pros and cons of adjusting for SDOH, such information should be collected and used in reporting and evaluating hospital quality.
Evaluating equity as a domain of quality should be included in the trauma verification process. As the number of trauma center-affiliated, community-facing hospital-based violence intervention programs (HVIPs) grows, so do hospital–community partnerships.28 Strengthening HVIPs through the creation of medical–legal partnerships in trauma centers will fuse injury prevention and SDOH work with civil rights law.29–31 Thus, there are multiple opportunities for making equity an integral component of quality across trauma centers.
Ultimately, as with adjustment for SDOH, accrediting bodies need to monitor for unintended consequences—that is, for exacerbation of healthcare disparities through exclusion of high-risk patients. Thus, metrics might include representativeness of the center’s patient population as compared with the population in the communities being served and proportion of high-risk patients being transferred to other centers. To promote a meaningful change, centers will need to be evaluated for leadership commitment to, processes around, and infrastructure for equity, not just outcomes. There are multiple opportunities for making equity an integral component of quality across trauma centers which aligns with the Joint Commission’s new requirements to reduce healthcare disparities within ambulatory healthcare, behavioral healthcare and human services, critical access hospitals, and hospital accreditation programs effective January 1, 2023.32 This mandate will require dedicated leadership to implement strategies for reducing health disparities; screening patients for SDOH; and developing an action plan that describes how it will address identified health disparities in its patient population. Finally, for CMS, payment determination will be tied to mandatory reporting of SDOH.