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Shaping Policy to Measure and Improve Equity in Health Care Systems

By Ilima Loomis

Five members of CHEA team
CHEA team members

Between 2017 and 2023, the number of Penn Medicine patients who identify as non-binary increased from 14 to more than 4,000.

The reason? Providers simply started asking patients about their gender identity. These patients had always been cared for in the system, of course; Penn just worked to add a non-binary gender option to the electronic medical records software. This effort not only focused on gender identity, but was part of a larger initiative to optimize Penn’s capture of patient data on race/ethnicity, ancestry, and preferred language.

For Jaya Aysola, MD, MPH, an associate professor of Medicine and Pediatrics in the Perelman School of Medicine at the University of Pennsylvania, it’s an example of how seemingly small changes in health care processes can lay the foundation for profound shifts in equity and inclusion. Those steps matter not just for gender and LGBTQ equity and inclusion, but also to make health care more equitable for patients of all racial and cultural backgrounds.

“It’s a technical, behind-the-curtain fix, but it has such meaning,” she said, “because you’re identifying people who were never recognized before in your organization, and for the first time these patients are feeling seen within their health care system.”

Aysola is also the founder and executive director of Penn Medicine’s Center for Health Equity and Advancement (CHEA). Through CHEA, she has led efforts to bring greater equity to the health system since 2015 — years before equity and inclusion became major priorities for improvement in other health systems. Now, Penn Medicine’s efforts are helping provide a road map for policy for equitable health care, with a new statewide program that issues incentive payments to hospitals for taking key steps for equity.

Implementing a Health Equity Plan within a Health System

Jaya Aysola and PJ Brennan
Jaya Aysola, MD, MPH, and PJ Brennan, MD

That work is a long way from where CHEA started. In 2016, Aysola was named the inaugural associate designated institutional official (DIO) of health equity and inclusion, within the graduate medical education (GME) office, and tasked with looking for ways to develop greater equity and inclusion in the resident training program at Penn Medicine, in response to a mandate from the Accreditation Council for Graduate Medical Education (ACGME). But making real progress required expanding the program’s mission, since equipping physicians in training to advance equity means making change within the larger health care ecosystem.

With the support of Penn leadership, including the GME office, Jeffrey S. Berns, MD, vice president and associate dean of Graduate Medical Education, and PJ Brennan, MD, chief medical officer, Aysola developed the Blueprint for Health Equity and Inclusion, a five-year strategic plan intended to bridge the gap between thought leadership and hands-on practice.

She also established CHEA within the office of Penn’s chief medical officer — with executive sponsorship from Brennan and Eve Higginbotham, SM, MD, ML, vice dean for Inclusion and Diversity — a position that was unique at the time, and earned the program national recognition in outlets like Forbes magazine.

That positioning would prove to be essential in implementing system-wide changes, she noted.

“Centers for equity often live health system adjacent,” she said. “They’re in research centers or institutes, and they’re thinking about these problems from the vantage of an academic. We’re bridging that gap, taking what we’ve learned about equity, and operationalizing it, but at the same time developing the system science of how to achieve health equity within our clinical operations.”

Collecting Data to Improve Health Equity

A key first step in CHEA’s plan was to change how patient demographic data was collected and analyzed, to better understand existing gaps in care, in partnership with Penn’s LGBTQ Health Program.

That included documenting more detail about patients’ racial and ethnic backgrounds, as well as introducing new questions about sexual orientation and gender identity. That work helped identify where the system fell short in delivering equal, safe, and high-quality patient experience and lay plans to bridge those divides.

Proposed changes covered a wide range of personal details, optimizing how to ask patients about their race and ethnicity, written and spoken language, gender identity inclusive of options beyond sex assigned at birth, relationship status beyond marriage, pronouns, and name preferences beyond the patient’s legal name.

To explain the importance of the change to both patients and providers, Aysola partnered with Rosemary Thomas, MPH, associate director for the LGBTQ Health Program, who is now also CHEA’s director of operations, for an education campaign, “The More We Know the Better We Can Care for You.”  It demonstrated how gathering demographic data was an evidence-based practice that led to better patient care.

In 2017, the system was updated, and non-binary patients — and others — were able to have important aspects of their identity recognized in their records for the first time. This was a crucial first step to help clinicians and other staff communicate with patients more respectfully and to aid in providing the most appropriate care.

Policymakers Put Health Care Equity in the Spotlight

The COVID-19 pandemic brought new attention to health disparities in America. Government agencies and hospitals around the country began examining their approaches and looking for ways to catch up.

That’s when Aysola was asked to serve on a steering committee with the state Department of Human Services and the Hospital and Healthsystem Association of Pennsylvania. It was an opportunity to advance equity at the policy level, helping develop financial incentives for hospitals doing equity work.

Aysola advocated for process incentives to be introduced earlier, linking rewards to process changes, and not exclusively performance outcomes such as reducing avoidable hospital admissions.

“What we showed at Penn was that there are building blocks that have to first be in place for health systems to effectively identify gaps and then address them,” she said. “If you jump ahead and only incentivize the end goal, you may not achieve it.”

The program eventually established incentives for steps like tracking demographic and social needs data, and forming a community advisory board to help guide performance improvement goals. As a result, Penn, along with many health systems across the state, received millions in Pennsylvania Hospital Quality Incentive Program awards to support advancing equity — with more to come.

Penn Medicine continues its work to transform its care systems to become more equitable: through an enterprise-wide collaborative with representatives from all hospital entities, health equity dashboards and data analysis, partnering with departments on research initiatives, educational programming for the workforce, and more.

The efforts to enshrine health equity improvements in policy help Aysola stay focused on the work ahead to ensure permanent change.

“Sometimes we spend a lot of time focusing on the ocean of work that’s yet to be accomplished,” she said. “The heightened attention — and the heightened potential to leverage such attention to shape policy — also gives me a renewed sense of urgency.”

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Views expressed are those of the author or other attributed individual and do not necessarily represent the official opinion of the related Department(s), University of Pennsylvania Health System (Penn Medicine), or the University of Pennsylvania, unless explicitly stated with the authority to do so.

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