This presentation examines the link between quality cancer care and equity. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Quality Cancer Care for All
An Equity Toolkit
Bob Gardner
Signature Event: Removing Barriers to Cancer Care
for All
Cancer Quality Council of Ontario
November, 2013

2. Problem to Solve → What Success Looks
Like
Social determinants of health:
 Inequitable gradient of prevalence &
burden
 Inequitable personal/community resources
to cope with cancers
Inequitable care/patient experience:
 Discrimination
 Inequitable rates of screening
 Inequitable barriers along the patient
journey:
screening, diagnosis, treatment, posttreatment support
 Specific barriers: language, costs of
medication, transportation & ancillary
services
Inequitable gaps in continuity of care:
 Availability
 Continuum of care
 Integration of services
 Provider Awareness of options available to
patients
no inequitable access
barriers
• all along the patient
trajectory
• all across an integrated
system
best quality for all
• and geared to
different/greater needs
of health disadvantaged
populations
→ best outcomes for all
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3. Towards Solutions
If we can identify those gaps and
barriers and unmet needs, we can act on
them
•
will set out a toolkit of ideas,
directions and tools to build equity
into cancer care planning and
delivery
•
solidly based in research evidence
and years of best practices
•
action-orientated and manageable
•
measureable – so can monitor and
assess progress
•
adaptable to specific organizational
and local contexts
the particularly good news = don’t need
to start from scratch
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4. 1. Start from Solid Foundations
• high-performing healthcare systems – whether
cancer care or province-wide -- build equity into all
planning and service delivery
•
•
doesn’t mean all programs are all about equity
does mean all programs and planning need to take equity
into account
• need clear strategic commitment to build equity into
system as a whole
•
•
cascading throughout all providers and programs so that
equity becomes part of working culture across the system
commitment has to be backed up by resources for equity
planning and operationalization
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5. 2. Into Practice Through Equity-Focused
Planning
• addressing disparities in access to or quality of cancer care
requires a solid understanding of:
• the contours and scale of inequitable outcomes
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• key barriers to equitable access to high quality care along
patient journey
• at delivery level = considering equity in all program planning
• e.g. given importance of communications and understanding to
quality care → need to ensure cultural competence, access to
interpretation wherever needed, etc.
• need effective and practical equity-focused planning tools
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6. 3. Collect Equity Data
need solid equity-orientated data
• to identify gaps and needs of
disadvantaged patients
• to measure and monitor progress
pilot project in 3 Toronto hospitals (and
Toronto Public Health) to collect patient
SDoH type data
scaled up to all hospitals in Toronto
Central LHIN
valuable website of resources on how to
collect and use this data
Action idea = adapt and use framework in
all cancer care settings
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7. 4. Build Knowledge We Can Act On
research base includes:
•
epidemiological – scale of disparities,
disadvantaged communities/groups
•
community-based research =
especially unique understanding of
needs and interests of marginalized
or excluded populations
•
ethnographic = nuances of
experience along patient journey
•
evaluation – need to know what
works well, for which populations, in
varying contexts
Action idea = widen the types of research
supported
systematic data collection + ability to
measure/monitor /evaluate + rich
research evidence = knowledge to
guide/ground action

8. 5. Beyond Planning: Embed Equity Into
Targets, Deliverables and Performance
Management
• clear consensus from research and policy literature, and
consistent feature in comprehensive health equity policies
from other jurisdictions:
• developing realistic and actionable indicators for more
equitable service delivery and outcomes
• setting targets for reducing access differentials, improving
health outcomes of particular populations, etc
• monitoring progress against the targets and indicators
• disseminating the results widely for public scrutiny
• aligning performance with funding incentives and resource
allocation
• Action idea = embed equity into comprehensive
performance measurement and management strategy
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9. 5 a. Success Condition = Effective Equity Targets
• innovative work underway to develop equity indicators – but
don’t need to wait
• pick what is most relevant to your context:
• do rates of post-treatment recovery and hospitalization
vary inequitably – by geography, ethno-cultural
background, socio-economic status?
→ equity target = reduce inequitable differences
• build equity into existing targets:
• e.g. increasing rates of screening and reducing wait times
between diagnosis and treatment are system goals
→ equity target = reduce inequitable differences in rates
between different populations or areas
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10. 6. Embed Equity Into Organizational and
System Drivers
• quality improvement is major provincial and system priority → embed
equity
• part of quality + equity = customized care to meet differing needs
• social determinants disadvantaged populations face greater barriers
beyond the hospital walls
• availability/cost of transportation, childcare, poor living conditions,
inequitable access to community services, discrimination, being able to
afford medication)
→ effective continuum of care and effective navigation/transitions is
especially important for marginalized
→ e.g. more intensive case management, referral planning and postdischarge follow-up for those in more challenging/isolated conditions
• tool = take a social history as well as medical history
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11. 6 a. Use Proven Tools: Equity Standards
Canadian Health Equity Standards Working
Group
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12. 6 b. Indispensable Foundation for Equity Into
Quality = Cultural Competence
• in an increasingly diverse society, high quality care = culturally
competent care
• means building equity and diversity into all facets of service
delivery:
• means customizing care to address language and other barriers people may
face and to their cultural preferences and needs
= where structural analysis and knowing your patients meets quality care
• not just service delivery, but everywhere – e.g. security, receptionists
•
+ organizational commitment
• supported by resources – esp. for training
• linked into concrete performance expectations and deliverables
• diversity equity and other ‘soft’ services can be vulnerable in tough fiscal
times
•
Action idea: ensure cultural competence strategy, resources and
targets work well across the cancer care system
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13. 7. Use Available Levers To Embed Equity
• providers are required to develop QIPs = major lever for driving QI
• equity should be one of dimensions providers must report on – but
wasn’t really in hospital plans so far = missed opportunity
• no reason why individual providers can’t decide to incorporate equity
into their QIPs
→ immediate benefits of embedding equity into quality improvement
→ necessary cross-hospital collaborations and discussions will help to
embed equity in every-day working culture
• Action idea: all cancer care programs and institutions to build equity into
their QIPs
• providers sign accountability agreements on cancer care to be delivered,
funding, etc.
• Action idea: build equity deliverables into provider accountability
agreements
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14. 8. Target Access and Quality Barriers
improving equity requires identifying and addressing specific
equity barriers
• within delivery – language, lack of understanding of different cultures,
differential treatment, prejudice and discrimination, accessibility
• beyond the hospital – e.g. sent home with follow-up prescriptions, but
don’t have a drug plan; can’t come into clinic for follow-up because of
family responsibilities
• most important barriers will vary → back to importance of data and
understanding health needs of community
tools = population health profiles, health equity audits to
identify most important barriers and gaps in your settings
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15. 8 b. Barrier = Under-Served Populations
Solution = Focused Community Partnerships
•
•
lower screening rates in
particular ethno-cultural or
disadvantaged groups
e.g. South Asian women in Peel
→ community-based research to
assess why
→ broad partnerships of Public
Health, providers and trusted
community organizations to get
beyond barriers
→ outreach to diverse community
settings where women live, work
or go
Action idea: explore innovative
community-based models like
‘peer health ambassadors’

16. 9. Build Community Partnerships
addressing wider social determinants of
health and roots of healthier
communities means working in broad
partnerships
more immediately for good cancer care,
partnerships :
• can better reach under-served
• collaboration with community
agencies = essential to effective
follow-up and referrals
• the good continuity of care,
navigation and transitions for the
most vulnerable requires web of
community support
• community-based support can
help mitigate harsher effects of
poor living conditions and
isolation
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17. Pull All This
Together into a Strategic
Roadmap
•
•
•
•
•
from a large toolkit, develop
a roadmap of what sector
will do
can’t be a rigid
blueprint, needs to be
adapted and implemented
flexibly to contexts and
circumstances
but need clear sense of
direction and overall goals
needs to pull various
initiatives into a coherent
and connected plan
Action idea: CCO, CQCO and
stakeholders to develop a
system wide equity plan

18. Goal Today: Land on Action Initiatives
1. adapt and implement equity-relevant cancer care data
→systematically collect across the system
→build into measurement and monitoring
2. build equity into system and provider performance
management
•
•
adapt most relevant indicators, deliverables and incentives for
this context
use proven tools like standards, HEIA to operationalize
3. build community partnerships
•
•
to address access barriers, unmet needs and populations left
behind
to build a web of support for people with cancer
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