Commentary on “The “Waze” of Inequity Reduction Frameworks for Organizations: a Scoping Review. Journal of General Internal Medicine.”

Mar 18,2019 | Lisa DiMartino Featured Articles

The month’s featured article by Spitzer-Shohat and Chin1 first identifies existing equity frameworks that aim to assist organizations in reducing inequities in patient care and outcomes and then assesses the extent to which the frameworks address key organization change elements. Similar to the Waze driving navigation software, organizations can employ multiple frameworks to enact change in policies and practices to enhance equity. However, it is often challenging to implement frameworks due to the many complexities of health care organizations. Efforts to reduce inequities require transformational change in policies, practices, and processes targeting multiple levels of the organization (patients, clinical staff, administrators).

The authors conducted a scoping review of the literature to understand whether current equity frameworks address key issues related to successful implementation of organizational change. The conceptual model guiding their review was based on four multilevel and multifaceted constructs of organizational change: context, process, outcomes, and time. Context refers to both the outer organizational context (e.g., economic, social, political environments of the organization) and inner organizational context (e.g., organizational structure, culture, readiness for change).  Process refers to how the initiative is translated and diffused across the organization. Outcomes can include the changes an organization experiences in culture, employee satisfaction, as well as patient performance. Time refers to sustainability and institutionalization of the change efforts.

They included 14 inequity reduction models in their analysis. Overall, they found most frameworks focused only on the outer organizational context. Only a few models addressed the inner organizational context. Likewise, most models only address the implementation process at the “macro” level of the organization; none addressed implementation at the “meso” (or departmental) level. None addressed outcomes related to organizational culture or structure, and few addressed sustainability.

The authors make several recommendations for future frameworks. First, for organizations to effectively implement change, the inner organizational context needs to be assessed in order to understand what the barriers are for implementation. For example, within the realm of health equity interventions, this could mean needing to incorporate cultural competency training and discussions about institutional racism and how it impacts organizational processes. Second, frameworks should  provide more guidance on the implementation process across departments and staff levels, including training for managers or support systems for frontline staff to effectively implement change initiatives. Lastly, frameworks should include guidelines and strategies to ensure sustainability of the equity interventions over time.

The issues raised by the authors are relevant not only for interventions seeking to reduce inequities in health care organizations, but also universal across many organizational change efforts. As the author’s note, organizational change is difficult. The authors provide concrete ways that equity intervention frameworks can address issues related to organizational change. Which strategies to use to ensure the sustainability of change (and defining what exactly that means within an organization) remains an ongoing question and challenge for implementation research.

Read the full abstract


(1) Spitzer-Shohat S. & Chin M.H.  The “Waze” of Inequity Reduction Frameworks for Organizations: a Scoping Review.  Journal of General Internal Medicine.