The Doctor’s Advocate | Second Quarter 2024
An Ounce of Prevention

Choose Your Most Important Quality Measure, Examine for Equity, and Begin

Mark D. Smith, MD, MBA, Clinical Professor of Medicine, UCSF; Founding President, California Health Care Foundation

Medical professionals witness firsthand how the social determinants of health (SDOH) affect their patients’ lives. For instance: How did the patient grow up? Where does the patient live? How easily can the patient access fresh food, transportation, or medication? In recent years, ongoing research has resulted in a renewed focus on social risk factors. Between 2015 and 2019, more articles referenced SDOH than in the entire previous 30 years.

SDOH, which are deeply entwined with disparities in health outcomes, raise questions around equitable care. I always put health equity in the frame of quality. More than 20 years ago, the Institute of Medicine (IOM), now the National Academy of Medicine (NAM), developed and promulgated what I think is still the best description of healthcare quality: Care should be (1) safe, (2) effective, (3) efficient, (4) timely, (5) patient centered, and (6) equitable.1 Although “equitable” appears as the sixth domain in defining healthcare quality, it is a part of each measure.

Six Domains of Quality Care

Every practitioner, clinician leader, and organizational decision-maker has a responsibility to guide our systems toward providing more equitable high-quality care. Consider these connections between equity and high-quality care:

Safe—We know that safe care starts with access to care, so we need to ask how our funding models reflect assumptions about who needs what. If you are building risk adjustment models based on retrospective views of utilization, the results may be skewed by funding for care. The evidence suggests that moving from fee-for-service models to population-based payment models may shift resource allocations in ways that combat disparities.2 Although the average employed clinician cannot single-handedly shift the economics of an entire healthcare system, we must remain aware of this point.

Effective—Part of the reason that quality measurement and improvement have stalled in some settings is that the measures being used are not clinically specific enough to have salience to both patients and practitioners. For instance, I am an AIDS doctor, so I care about my patients’ T-cell counts and HIV suppression. I am less concerned about their forced expiratory volume. For my colleagues who care for patients with lung disease, their focus is exactly the opposite. Each of us within our own organizations and professional societies can take opportunities to advocate for more clinically relevant quality measures.

Efficient—Some equity questions are efficiency questions: How long does it take to connect patients to medical interpreters? How much energy do practitioners expend submitting appeals for prior authorizations—and to which payers?

Similarly, some efficiency questions pertain to institutional management. When I gave a talk at a big national conference on diversity and equity, I asked: “How many of you are on your institution’s equity committee?” Most raised their hands. I then asked, “How many of you are on the quality improvement team?” Perhaps three people responded. I then posed two more questions: “Who do you think has a budget? How are you going to employ processes to deal with the problems you find?” We need to connect the social energy for equity work with each organization’s quality improvement apparatus.

Timely—I recently spoke with someone whose hospital had just discovered that its Chinese American patients were experiencing delays before CT scans compared to other patients presenting to the emergency department (ED) with possible stroke. A language gap was the first thought, but the challenge for this hospital (and for all of us engaged in similar efforts) is to resist the allure of easy answers while carefully sifting through data.

Patient Centered—Patient-centered care means treating each patient holistically with an awareness of the individual’s culture, beliefs, and circumstances. This can present a challenge when a patient holds views that are at odds with our own. We must always strive to overcome our own barriers to providing patient-centered care.

Equitable—Care should not vary between individuals based on their characteristics. But which characteristics? We could list gender, race, or ethnicity, first language, educational background, religion, sexual orientation, and others. Literally hundreds of studies throughout medical practice have documented distressing differences in treatment based on such characteristics.

For example, researchers who studied physical restraints in pediatric emergency care found that Black patients ages 16 and under were nearly twice as likely to be physically restrained as their White counterparts.3 That finding should lead us to ask: What are the numbers where I work?

Regardless of where an inequity is found in healthcare—such as in reinfection rates, aggressiveness in pursuing collections, pain control, or discharge from the ED without medical treatment—the same thoughtful approach used for the other five quality domains must also be applied to equity.

Substantive Changes

A look at our own institution’s outcomes data should help us prioritize efforts. The specifics will vary by specialty and role: Surgeons might look at infection rates; administrators, readmission rates or complaints. If we start with quality measures that are relevant to our roles, and then we analyze them by characteristics such as race, gender, first language, and zip code, we will find inequities that show us where to begin our work.

Our thanks to Mark D. Smith, MD, MBA, Clinical Professor of Medicine at the University of California, San Francisco. Dr. Smith, who maintains a clinical practice in HIV at the Positive Health Practice at Zuckerberg San Francisco General Hospital, was elected to the National Academy of Medicine in 2001, where he chaired the Learning Healthcare System Committee. Dr. Smith was the founding President and former Chief Executive Officer of the California Health Care Foundation. He also served as Co-Chair of the Guiding Committee of the Health Care Payment Learning and Action Network.


  1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. The National Academies Press. 2001. doi:10.17226/10027
  2. McWilliams JM, Weinreb G, Ding L, Ndumele CD, Wallace J. Risk adjustment and promoting health equity in population-based payment: concepts and evidence. Health Affairs. 2023;42(1). doi:10.1377/hlthaff.2022.00916
  3. Yale study finds Black children most likely to be physically restrained in emergency department visits. Yale School of Medicine. Published September 13, 2021.

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