Date Published: March 14, 2018
Publisher: Public Library of Science
Author(s): Sivan Spitzer-Shohat, Efrat Shadmi, Margalit Goldfracht, Calanit Key, Moshe Hoshen, Ran D. Balicer, Tomi F. Akinyemiju.
Disparity-reduction programs have been shown to vary in the degree to which they achieve their goal; yet the causes of these variations is rarely studied. We investigated a broad-scale program in Israel’s largest health plan, aimed at reducing disparities in socially disadvantaged groups using a composite measure of seven health and health care indicators.
A realistic evaluation was conducted to evaluate the program in 26 clinics and their associated managerial levels. First, we performed interviews with key stakeholders and an ethnographic observation of a regional meeting to derive the underlying program theory. Next, semi-structured interviews with 109 clinic teams, subregional headquarters, and regional headquarters personnel were conducted. Social network analysis was performed to derive measures of team interrelations. Perceived team effectiveness (TE) and clinic characteristics were assessed to elicit contextual characteristics. Interventions implemented by clinics were identified from interviews and coded according to the mechanisms each clinic employed. Assessment of each clinic’s performance on the seven-indicator composite measure was conducted at baseline and after 3 years. Finally, we reviewed different context-mechanism-outcome (CMO) configurations to understand what works to reduce disparity, and under what circumstances.
Clinics’ inner contextual characteristics varied in both network density and perceived TE. Successful CMO configurations included 1) highly dense clinic teams having high perceived TE, only a small gap to minimize, and employing a wide range of interventions; (2) clinics with a large gap to minimize with high clinic density and high perceived TE, focusing efforts on tailoring services to their enrollees; and (3) clinics having medium to low density and perceived TE, and strong middle-management support.
Clinics that achieved disparity reduction had high clinic density, close ties with middle management, and tailored interventions to the unique needs of the populations they serve.
Disparity reduction efforts, focusing on minimizing differences in health and health care, have been the focus of health care systems for over 30 years. Although evidence of success is accumulating[2–4], programs vary in how well they achieve their goals, with some even showing increased disparities over time[5,6]. To better understand how success is achieved, recent research calls for in-depth investigation of how programs work, evaluating the factors associated with success on a variety of outcomes, and understanding the processes that lead to attainment of disparities reduction[1,7–9].
Our study focused on identifying mid-range theories and the causal linkages between context, mechanisms, and outcomes achieved in a disparity-reduction program. The first phase of the study identified QI as the program theory underpinning the disparity reduction efforts and guiding the ideas and assumptions of teams implementing the program. Understanding that QI is the guiding framework enabled us to identify the mechanisms and contexts in which the program was implemented, as well as the boundaries in which teams operated, i.e., their ability to benefit from the structure and framework of QI as well as their need to tailor their approach and tools for achieving disparity reduction given the limitations of QI. The QI approach benefited the teams by directing their actions through highlighting the measures that required improvement in their clinic’s population. However, as quality indicators focus on specific elements of care, rather than how care should be delivered  teams were tasked with developing and culturally adapting care strategies to meet their specific population’s needs. The advantages and limitations of the QI approach are reflected in the two broad mechanisms identified: (a) A focus on the provider, especially improving teamwork and service delivery design, and (b) A focus on the patient and tailoring programs to meet patient and community needs. These mechanisms explain the reasoning, actions and responses of teams to organizational program focused on achieving quality improvement disparity reduction .
Our study shows that theorizing the logic of QI disparity-reduction programs and understanding how it relates to both the individuals involved and the context in which programs are implemented may help us understand not only whether a program works but also how it works, and under what circumstances disparity reduction can be achieved . Our study identifies the context in which QI disparity-reduction strategies should be applied by linking identified mechanisms with program activities and observed outcomes. We show that clinics that achieved disparity reduction had highly dense teams, close ties with subregional management, and identified the unique needs of the populations they serve.