Can continuous quality improvement transform healthcare equity?

View all podcasts

Leticia Reyes-Nash is a principal in HMA’s community strategies practice and an expert in healthcare equity and innovation in healthcare service delivery. Leticia shares her inspiring journey from political and community organizing to her work in health policy, highlighting the importance of addressing health equity and the challenges within healthcare systems. She discusses strategies for integrating equity into business practices, emphasizing the need for continuous quality improvement, humility, and patience in healthcare initiatives.

Jennifer Colamonico: Welcome to HMA's vital viewpoints on healthcare, concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely american systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and health care. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future.

Jennifer Colamonico: Subscribe now and together we will explore.

Jennifer Colamonico: The hard earned wisdom that could change the way you think about your professional challenges. Our guest today is Letitia Reyes Nash.

Jennifer Colamonico: She is a principal in HMA's community strategies practice and she is a resident expert in health equity and innovation in healthcare service delivery. Letitia started out in political organizing and then moved into government service in state health policy and then made a mark at Cook County Health, where she collaborated with cross functional teams to improve community health outcomes. And Letitia was named a Robert Wood Johnson Foundation Culture of Health leader in 2017. Letitia, we're glad to have you with us.

Jennifer Colamonico: Thanks for being here.

Leticia Reyes-Nash: Thank you.

Jennifer Colamonico: So, as you look back on your career, which has spanned several different interesting areas, how did you make the leap from political and community organizing to health policy?

Leticia Reyes-Nash: Growing up, my grandmother was a significant influence in my life. She came to the United States at the age of 16 as a migrant worker, and she was a hard worker. She was widowed with six children and had a passion for justice. She taught me that no voice was too small to be heard. She taught me of the importance of taking action to serve my community, and she taught me about the importance of mentoring and building up others. And my grandmother, Delmita inspired me to find opportunities where I could make the most impact for the most people. That really kicked off my career in working in electoral politics because I really felt like I could make a big impact in bringing elected leaders into office who aligned with the priorities that I had. My experience working on campaigns allowed me to work in seven states leading large field operations, and I learned how to engage with diverse communities across the country. I learned to listen to people and to really understand how policy decisions impacted people on the ground I decided to transition to government after working on the ground in politics because I wanted to move from ideas and concepts to implementation. Focusing on health and health care is my passion. And working for government for the last 16 years provided an opportunity for me to work on conceptualizing and implementing big, bold ideas to improve health within the confines of the bureaucracy, but also working with community partners outside of those bureaucracies to improve health.

Jennifer Colamonico: That's so great. I don't think I fully realize your political background until doing research on you for this. And I very much relate to parts of your story. So it's, I think people underestimate what you learn about humanity working on political campaigns. So let's talk about health equity. Certainly since President Biden was elected, we've seen equity really as a centerpiece of their health policy agenda in any facet, many facets. And it seems like that it's a double edged sword. On one hand, we're making progress, we're quantifying things, we're looking at things. But also it maybe has become a bit partisan because it's so associated now with his agenda. How do you explain the conundrum here? Why is this such a big deal, and why does this kind of put these issues at risk?

Leticia Reyes-Nash: The reality is, regardless of politics. Well, first, I'll just say that I am pleased that Biden has had an agenda that's embedded equity across the various government agencies. And the administration has worked to embed equitable approaches and policies through CMS and through the Medicaid program and Medicare program. So I'm glad that that's in place. And I also think that a lot of it has been built in the systems and structures that are more difficult to disassemble within government. So I'm hopeful. But I also feel like I'm glad that we've been building not just side projects around building equity and building health equity. We're really tackling and looking at it from a systematic perspective and a systematic approach in building systems and policies that will endure regardless of administration. So I'm optimistic in that way. But I do think that regardless of politics, there's no question that in healthcare, we have to do a better job to serve people, and in particular we have to do a better job of serving communities that have been underserved for generations. We're battling structural racism and inequalities. And in order to battle those, you have to disassemble those structures. And we're in process in some ways getting to disassembling those structures. But while we're disassembling those structures. We need to build processes and systems that embed equity into our work. And I think that the work that's been done to date to build equity into our systems and processes within healthcare. Simply stated, we have to deliver high quality healthcare services for people in communities. That is, at minimum, what our healthcare system should be delivering for the people that we serve. And to me, that's a clear mandate that we have to continue the work that we're doing, which includes collecting data, analyzing that data, disaggregating the data. We need to figure out where we need to do better, and work with communities and individuals to figure out solutions to better serve those communities. So regardless of politics, we have a mandate. We have to deliver high quality care. That's paramount. We have accreditation bodies and trade organizations that are aligning in this way. We have NCQA, the Joint Commission, American Medical association, the American Hospital association, that set forth guidance for organizations to build holistic equity strategies that intend to have tangible improvements in quality of care. So at the end of the day, these standards will not go away, and the demand to deliver high quality health care will not go away. So I'm optimistic that we'll be able to work and endure whatever happens in the politics of our world. We'll be able to continue to do this work if we keep our eye on the data and the quality of care that we're providing for people in communities.

Jennifer Colamonico: Yeah, well, and you raised so many important threads there. I mean, equity has become a buzzword insofar it's become partisan. It's become associated with certain elements of equity. But equity is about correcting gaps in care that shouldn't exist. Right? I mean, at its very core, if you have reasons why some people aren't doing as well as others, like as scientists, we should be looking at that, right? Do we have to broaden the definition in order for it to become an enduring commitment?

Leticia Reyes-Nash: Yeah, I mean, I think that as we continue our work to address equity, equity includes a lot of things. And I think we need to continue to talk about how health outcomes are deterministic or driven by race, gender, where we live. All of these different components contribute to our ability to navigate, our ability to be healthy. And it's important to understand that we all sit within those contexts, and we have to think about that when we're thinking about solutions. And we can't sit in a silo trying to solve our problems just in a clinical setting. We really have to think about holistically around what people need and identify ways to connect people to those things if they sit outside the healthcare delivery system. And we need to think about building glide paths for success, for individuals to get the care that they need, when they need it, and where they need it. And so I think that as we continue to do this work, we have to keep our eye on improving quality of care, meeting the needs of the people we serve, and continue to think about the people we serve in a holistic way. And if we do that, I think we're going to continue to move the needle on improving equity in our service that we do. I also think that the advantage we have, or the opportunity is that across the country, state Medicaid contracts have embedded strategies to directly address health. Know, we know that those will be in place for at least five years, because as we all know, reprocuring Medicaid contracts is not a significant lift, is a significant lift. And we don't like to do that all the time. And so within that context, contractually, we'll have these programs who are going to be directly addressing these disparities. In addition, we have new requirements from CMS where there's a requirement to screen for health related social needs in the inpatient settings. And as I mentioned before, we have a number of health plans who are working to achieve NCQA health equity plus accreditation, and are building those systems and processes to achieve health equity for the people they serve. So I'm optimistic that the value of delivering high quality care will continue to drive improvements in our systems, to reduce disparities.

Jennifer Colamonico: So in terms of building those structures.

Jennifer Colamonico: Let'S talk about incentives.

Jennifer Colamonico: Obviously, in healthcare, I guess in everything, incentives matter, right? So we've made progress. And you talked about the indicators, the quality measures. What kind of incentives do we have to build into our systems? Health systems, health care systems, the whole gamut. What kind of incentives do we have to think about in order to encourage people to do the right thing?

Leticia Reyes-Nash: I mean, I think that really the start for incentives is around accountability. So I think that in order for us to even think about how to incentivize improving quality of care, we need to continue to collect the data, to be able to see where our interventions are making improvements. We need to have continuous quality improvement lens in the work that we do so that we can see when things are not working, how we can quickly adapt and change and be able to meet the needs of people that we serve. And so I think that as we continue to do this work, the value proposition is very clear. If we have a certain population that we serve, and that we're able to connect them to the things that are needed to help them to be and stay healthy. The value proposition is that we're going to have reduced costs, we're going to have better health outcomes, and we're going to have healthier communities, and in turn, that will continue to help communities thrive. And I think that's a very big picture perspective on it. But I think the key thing here is that health equity is not a side project. It is something that needs to be embedded in our business practices. It needs to be embedded in the way we work so that we're constantly looking to see where we may be creating disparities or where we're improving. And having that continuous quality improvement lens allows us to be able to adapt and change based on if things are working or not. And so I think that as we continue to understand that we have an opportunity to improve the health of communities and the people we serve and improve those outcomes, the value proposition is clear. It's cost savings, it's better health, and it's improved health in communities where individuals can thrive.

Jennifer Colamonico: So sort of like there's two parts. So you're saying that really it's about quality. And if we're measuring and acting on quality, continuous quality improvement, we're finding the gaps. And then we're asking ourselves, why are there gaps? And we're addressing them. And then it almost sounds like then the second part is, well, then how do you fix the gaps? And sometimes that's complicated, right? It's one thing if it's, oh, they're not taking the right medication, boom, change the prescription, fine. It's another thing if they don't have a refrigerator at home or they don't speak the language well enough to understand what the doctor told. I mean, all of those are very real barriers that are complicated to fix. But the quality piece is the part where we have to take that hard look and acknowledge and admit, right, where we're not meeting those quality standards. There's part of me that says, why haven't we been looking at this all along? Right? Why did this become a thing? And obviously, this is where it gets complicated. But is it just because the data wasn't presentable and analyzable, or were we just kind of not paying attention to the right things?

Leticia Reyes-Nash: I think that this has been a journey, and this journey didn't start just in the last several years. There have been lots of folks for many, many years who have, especially in the public health sector, who have been talking about the disparities that are within communities and health outcomes. So it isn't new that communities that are underserved have poor health outcomes. It's not new that redlining created lots of underinvestment within communities and drove a lot of challenges for communities across the country, which was based on race. All of that are things that we know. But I think within the healthcare sector, the work around addressing inequities has been a journey that really was started in around 2009 and moved while the Affordable Care act went in place, that then cultivated and started to build the strategies around addressing disparities. And I'm talking about from the federal level, the federal level, there's been work that's been churning and moving for the last, I don't know, 15 years to help us to have the systems and structures in place, to be able to see the inequities and to be able to then address them. So I think it's important to note that the work amongst communities. Communities have been working to identify needs and to meet those needs. And that's been happening regardless of the intervention of government. But government has been identifying that what are the systems that we need to build and how are we going to build them to be able to ensure that we see these inequities and address them. And I think that as we are continuing to move forward in creating policies that are addressing these inequities, the public health sector for the last 2030 years has been raising the flag that we have inequities in outcomes and disparities in health outcomes for communities for a very long time. So there are lots of folks who've been doing that work and have been raising the flag on this for a long time. I think that in the last 15 years, the federal government has been working to build and create structures to support us, to be able to more effectively see where these disparities lie and to then help create pathways and systems and incentives for us to be able to address those inequities. Some of those things are like having in 2009, having EHRs, right? Ehrs have not been in place forever. But when they came into place, that was specifically not only an effort to, of course, create structure for billing, it was also around collecting data so that we can start to see where these inequities lie. And then as you move through the work that's been done at the federal level, there's been a lot of different efforts that have been pilot testing different methods of addressing health related social needs, different strategies around improving quality for communities that are experiencing disparities. And there have been investments in, in different ways. So there's been work that's been happening. I, of course, think that the pandemic illuminated and really said, look, we know that these inequities are there, and now look, when we're in a time of crisis, they are clearly illuminated. And that's where I think there was a moment where we all said, oh my goodness, we knew it was there, but it became very abundantly clear during the pandemic. And the disparate impact of COVID-19 on communities of color is undeniable. And so I think that created the call to action for us to then continue this work. But it's a journey. I think that we have a long way to go, but we've also come a long way in addressing these inequities. And I'm hopeful that we are, as a system, creating enough checks and incentives and opportunities for collaboration to be able to more effectively serve our communities.

Jennifer Colamonico: You, when we think about the types of changes that are needed given where we've been, given where we're going, if you had a magic wand, what one thing would you fix to get this on a better track to where we can continue to make the kind of progress that we need to make?

Leticia Reyes-Nash: Yeah, I think that's a great question. And of course, with the magic wand, there's a lot of things that you'd want, but. So I'll try to pick one. I do think that we have so many great folks that are across the healthcare system, both in health plans, in healthcare systems, people who are working in community health and public health, who are deeply passionate about addressing inequities and are deeply knowledgeable about how to create solutions with communities. And I really think that if I had a magic wand, I would wave the wand so that all of those folks who are practitioners in the field on the ground would be able to effectively implement the strategies they need to do to be able to help improve health in their communities. And I think that a lot of the work that I do is helping to be a partner and supporting folks who are on the ground doing the work and aligning with them to help them meet the needs and to be able to set the business strategies forward that they need and to help bring together the story that helps them build the value proposition to do this work. While I think that the value proposition is clear, the value proposition is different in each of those settings. To be able to make the case for why this work is important and why it's important to embed it into the business practice and not have it be a side project. And so if I had a magic wad, I would waive that so that all those practitioners would have what they need to be able to continue the work that they're doing in whatever context that they're in. And so I think that would be what I would want, because I just know that there's so many great folks doing this work out there, and I want to help amplify their work and help them to be successful.

Jennifer Colamonico: So in what the magic wand would.

Jennifer Colamonico: Be doing, is it transferring resources from.

Jennifer Colamonico: The top to the bottom? I mean, what you're describing, I think, is kind of a grassroots approach to solving this. So is it that they lack the resources, and therefore you would bring the magic wand to give them the resources that they need? Or is it that they're not connected into the system in a way they need to be connected to make those value propositions kind of meaningful?

Leticia Reyes-Nash: I think it's a both. And because I think there are folks, we have kind of an emergence of various chief health equity officers and folks who are focusing on this in different settings. And in those settings, in some cases, they are given the appropriate influence and appropriate scope to be able to do the work that they need. For those folks, it's not necessarily to me, I think that to say that we need more resources is a little bit of a misnomer. It's really about how they are building their strategies into the business and leveraging the resources that are already in play to effectively and more effectively serve the populations that they serve. So yes, that may require some resource, but I think that a lot of this is around alignment and building business processes within the systems that they work to be able to effectively have a holistic equity strategy for community partners. I think that the community partners, we need to figure out ways to resource them, but also more effectively connect them to the healthcare delivery system so that both can be more effective and to better serve folks. And so I think that building those connections and linkages, we do need infrastructure and resources to have the capacity within the community organizations that we are dependent on to help address those health related social needs. Those organizations, I think, need to have support for infrastructure and resources to help them connect more effectively to the healthcare delivery system. But acknowledging that those community based organizations have the expertise that we just don't have in the healthcare system that needs to be leveraged to effectively serve folks.

Jennifer Colamonico: Yeah, I think it's so interesting. I'm glad to see all of these chief health equity officers and that sort of acknowledgment. But it almost does seem if it's not connected to the folks doing the work and the folks that are closest to the people in need, then it becomes more symbolic, kind of more than functional. And I've heard I had a client who also kind of talked about to put it in, like, one person's job description to fix this is one person can't fix this, right. It has to kind of be not only top to bottom distributed, but also kind of left to right distributed side to side across the organization to really make a difference. So it seems like there's a lot of learning happening about how to do.

Jennifer Colamonico: Hard things, really, at the end of the day.

Jennifer Colamonico: Right?

Leticia Reyes-Nash: Absolutely. And I think that you're exactly right that it's one person's job to kind of maybe lead the strategy and to help monitor the strategy, but it isn't only one person's job in the organization to execute the strategy. And I think that's the part where we're building towards that. And I think it's not like any other change management process in that just stating something doesn't mean it will happen. It requires the nitty gritty change management process in which you're socializing the change, you're training the change, and then you're monitoring the change and ensuring that it's happening. And so that's the thing. I think sometimes I see that misstep of like, well, we said that this was going to change or we added this new code or we did this and no one adopted it. And it's like, okay, well, I get it. It didn't get adopted because we didn't have a strategy to ensure that adoption occurred. And so that's the part where I think it is work. It is tough, but once it gets embedded into those systems and processes, then it becomes part of your business. And that's where I think there's a little bit of a learning curve. But anytime you have a change in a clinical setting or in a health plan, that's the way it is. And most of those folks know that. It's just ensuring that we build those strategies so that we have that stickiness and we have that adoption.

Jennifer Colamonico: So maybe you just answered this, but my last question is just kind of, is there anything that people should be thinking about or understanding? Is there anything that you kind of think to yourself, if people really only understood this, they would kind of get the path forward or better understand the urgency or the complexity here? What do you think people kind of misunderstand about this issue of health equity reducing disparities?

Leticia Reyes-Nash: Well, I think the number one thing is that we're not going to see cost savings in three months. We may not see it in six months. And we really need to understand that to disassemble kind of the harm and the underinvestment, it takes time. All of it takes time. And I think that's the number one piece that I would say is kind of not appreciated. In addition to, it just takes time for us to see the change on the strategies we may be implementing. The other part is that it takes time to build relationships and partnerships. And if you're working to better link folks to housing opportunities, just believing that needs to be done and saying it needs to be done isn't sufficient. You need to build the relationships with the housing partners within the community you're seeking to serve. You need to understand how those relationships are going to work. You need to really foster those relationships and build trust to be able to effectively partner. And so I think that overall this work takes time. It takes intention, it takes implementation, and the changes will come over time. And I think that the learning, having a continuous quality improvement lens allows you to have that learning through the process and it will help you to be effective. And the other piece I think is we really need. I remember there was an RFP, I have the privilege of reading lots of Medicaid RFPs across the country, and one that really struck me was one that talked about having do you co create solutions with community? And it was really interesting because that was a question I don't think that health plan had ever thought about. And the reality is we had to do some teaching around what it means to be co creating. And that means that you come to the community without the solution and you build a solution together. And that takes time and it's hard to do. But oftentimes when you build programs in that way, you do have solutions that people utilize and you have solutions that can be effective for them because it was designed collaboratively with them. At the end of the day, this is hard work. It takes time. But having that continuous quality improvement lens allows for the learning to be able to continue to improve and to better serve people.

Jennifer Colamonico: So continuous quality improvement plus humility, plus patience kind of sounds like the recipe. It's a really interesting point about coming without solutions. It's probably something that healthcare stakeholders are just not used to doing right. They assume that they have the answers and so that's really key. Well, thank you so much for this conversation. Always enjoy talking to you and working with you, and I'm really glad to bring this to our listeners because it's such an important issue that is really important to understand the nuances that you raise. So we appreciate you.

Jennifer Colamonico: Thank you so much.

Leticia Reyes-Nash: Thank you. It's a pleasure.

Jennifer Colamonico: This episode of Vital Viewpoints on Healthcare is brought to you by HMA Grant Prospector is your organization looking for behavioral health grant funding? HMA's grant prospector is your ultimate solution to streamline your grant search time and maximize your grant seeking success. Get started today and unlock your organization's potential. For more information on the grant prospector, visit hmais healthmanagement.com thank you for tuning.

Jennifer Colamonico: In to another enlightening episode of HMA's Vital viewpoints on healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit healthmanagement.com forward slash podcast until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself, Jennifer Colamonico, along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.

Listen on your favorite platforms

Vital Viewpoints is hosted by HMA Director of Thought Leadership, Jennifer Colamonico.

Meet your featured speakers

Leticia Reyes Nash

Leticia Reyes-Nash

Chicago, IL
Quality & Accreditation

Receive timely expert insights on topics you care about.

Select Topics

HMA is providing this podcast as a public service, but it is neither a legal interpretation nor a statement of HMA policy. Reference to any specific product or entity does not constitute an endorsement or recommendation by HMA. The views expressed by guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed by HMA employees are those of the employees and do not necessarily reflect the view of HMA or any of its officials. If you have any questions about this disclaimer, please click here.