November 1, 2018
Speaking truth to power: a lean six sigma approach to addressing health and health care disparities among women
introduction:
During this demonstration, I will describe a feminist evaluation strategy to address health and health care disparities in a large behavioral health care organization. I will take the audience through the process of a Lean Six Sigma project inserting and expanding upon several key opportunities that evaluators have to speak truth to power during the development, piloting and evaluation of clinical products designed to bring evidence based care more rapidly to the implementation environment so that patients can experience higher quality more effective care faster and more consistently. The core idea of a Lean Six Sigma project is determining the value of any given process by distinguishing value added steps from non-value-added steps, eliminating waste so that ultimately every step adds value to the process. The key components of the Lean process that provides influential opportunities for the evaluation team to speak truth to power while adding significant value to the process is during the little talked about assumption testing phase and the more obvious learning and evolution phases. Attendees will be provided a checklist to help frame a way to speak truth to power using a Lean Six Sigma rapid cycle feedback approach. In the paragraphs below I provide an overview of the current problem of health and health care disparities among women with behavioral health conditions, next a business case for addressing disparities, then a description of a Lean Six Sigma evaluation strategy implemented within a behavioral health care context and how the Lean process that includes an evaluation that embeds feminist principles can help illuminate areas of potential or current disparities so that they can be prevented and/or addressed and ameliorated.
HEALTH DISPARITY
To be clear, when I speak of disparities, I am speaking of both health and health care disparities. Disparities in health and health care are related, but not synonymous, concepts. A health disparity refers to a higher burden of illness, injury, disability, or mortality experienced by one group relative to another. A health care disparity typically refers to differences between groups in health insurance coverage, access to and use of care, and quality of care. Health and health care disparities often refer to differences that cannot be explained by variations in health needs, patient preferences, or treatment recommendations.
Health disparities have been documented for more than a century, yet efforts to eliminate them have been ineffective most of the time. Disparities persist in nearly every aspect of health, including quality of health care, access to care, utilization of health care, clinical conditions including morbidity and mortality, and health care settings. Disparities occur across many dimensions, including gender, race/ethnicity, socioeconomic status, age, location, disability status, and sexual orientation. Despite being well documented and researched, significant improvements in public health practice are needed in order to adequately address these wide-spread health disparities. The slow progress is largely due to the multi-factorial causes of these inequalities being inadequately understood and many times even recognized.
In a 2009 Henry J. Kaiser Foundation report gender, racial and ethnic disparities in health care and health status were found in every state in the nation. Specifically, women of color fare consistently less well than White women across a broad range of measures in almost every state. African American women and American Indian and Alaska Native women in particular face many challenges, but Hispanic women also fare considerably less well than White women in almost all states. Second, there is considerable variation across the nation in the experiences of women of color in terms of their health and the factors that affect their health and their ability to access quality care. Minority women in some states are doing much better than their counterparts in other states; however, even in states where minority women fare better, they usually have higher rates of illness, experience more problems gaining access to care, and face social and economic challenges at higher rates than White women. Third, in states where disparities appear to be lower, this difference is sometimes because White and minority women are doing equally poorly, not that minority women are doing any better. Thus, it is important to recognize that in some states women of all races and ethnicities, including White women, face significantly more mortality and morbidity because of health and health care disparities. The following paragraphs discuss a particularly vulnerable group, women with mental health disorders.

It is well known that individuals living with a mental health disorder lose decades of potential years of life. In a 2006 Public Health Research, Practice and Policy article, averages of lost potential life ranged from 13 to more than 30 years depending on the state and year. Individual’s living with a mental health disorder average death ages ranged from 49 to 60 years. Heart disease was the leading cause of death among individuals living with a mental health issue followed by cancer, cerebrovascular, chronic respiratory, diabetes, and influenza/pneumonia. While natural causes are typically the cause of death, individuals living with a mental health disorder more often die as a result of accidents, including automobile accidents and suicide than individuals who do not have a mental health diagnosis. In addition to few social networks and little emotional support they also tend to have higher rates of cardiovascular risk factors such as smoking, obesity, lack of moderate exercise, harmful levels of drug use and alcohol consumption, excessive salt intake and poor diets in general. According to the Harvard Mental Health Letter, individuals living with a mental health disorder despite having higher rates of medical illnesses, do not seek or do not have access to providers that focus on their lifestyle and physical health issues. “Lifestyle, social consequences of mental illness, and difficulties in accessing health care are factors related to managing physical illness in those with mental illness”. Social determinants such as poverty, unemployment, poor housing, stigma and low self-esteem along with the impact of long term use of antipsychotic medication, erratic compliance with health screening and treatment as well as challenges with communication all play key roles in this significant disparity in years of life possible.
Gender has significant explanatory power regarding differential susceptibility and exposure to mental health risks and differences in mental health outcomes. According to the World Health Organization, gender determines the disparity in power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status, access to resources, options and treatment in society as well as their vulnerability and exposure to specific mental health risks. Women predominate in rates of common mental health disorders such as depression, anxiety and somatic complaints. Approximately 1 in 3 women in any given community have a mental health disorder. Unipolar depression, is predicted to be the second leading cause of global disability burden by 2020 and is twice as common among women. Approximately 19 million women in the United States experience clinical depression each year and about 1 in every 8 women can expect to develop clinical depression during her life time, particularly if she is between the ages of 25 to 44 years. Depressive illnesses are serious medical concerns that can happen to any woman at any time regardless of age, race, or income.

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Despite being a treatable illness even if women have access to care, many times her mental health issues are not recognized, therefore not treated. Health care providers often communicate with women in a way that is authoritarian and stigmatizing, making disclosure of psychological and emotional distress difficult. Stigma associated with mental health concerns is a factor that causes women to feel uncomfortable, embarrassed and guarded when accessing health care. When women dare to disclose their problems, health care providers can have implicit gender biases which lead them to either over-treat or under-treat women. In its 2003 report, Unequal Treatment, the Institute of Medicine concluded that unrecognized bias against members of a social group, such as women and racial or ethnic minorities, may affect communication or the care offered to those individuals. Implicit bias appears to be common and persistent in our US health care system. Implicit bias operates in an unintentional, even unconscious manner. This type of bias does not require the health care provider to endorse it or devote attention to its expression. Instead implicit bias can be activated quickly and unknowingly by situation cues (e.g., a person’s skin color, mental health status, substance use or accent), silently exerting its influence on perception, memory, and behavior. Because implicit bias can operate without a person’s intent or awareness, controlling it is not a straightforward matter.

Within the last few years, a social movement has emerged to fight the stigma against mental illness. This movement has helped some women experiencing a mental health issue feel she can seek the help that she needs. There is still work to be done however, getting to the root of social problems that contribute to mental illness among women, such a trauma, sexual and domestic violence, bias in the medical industry, discrimination, and toxic masculinity, needs to be a priority to ensure women are living the healthy lives they deserve.

THE BUSINESS CASE FOR ADDRESSING DISPARITY
The marriage of social justice with economics can definitely be viewed through business cases. A business case is an organization’s rationale for investing in a socially responsible action that also promises financial return within a reasonable time frame through cost reductions, increased revenues, or both. In addition to direct cost savings or revenue generated, these efforts can also yield a return for the investing entity in the form of improvements in service delivery, marketing capacity, or sustainability. Thus, a compelling business case would encourage an organization to invest time, effort, and funds in an initiative to reduce health disparities.6 Although the literature establishes a social justice case for addressing health disparities, there is limited evidence of this case being sufficient for most businesses to invest in such initiatives. However, because the Lean Six Sigma approach to product development is closely linked to the concept of value added, the elimination of waste and unnecessary cost, opportunities to give consideration to the business case for addressing disparities at Centerstone has a nice segue. With the input from the evaluation team, Centerstone is poised to address disparities at the organizational level. Krein et al. found that the greatest amount of variation potentially attributable to practice variation that can either perpetuate or dispel disparity is at the organizational level, not the provider level. This would suggest that intervention at an organizational level might be expected to provide greater opportunity to improve quality and reduce disparities than intervention with individual providers.

CONTEXT: INTEGRATED BEHAVIORAL AND PHYSICAL HEALTH CARE ORGANIZATION
Centerstone provided the context for this paper. Centerstone is a 60 year old not-for-profit health care organization that serves more than 170,000 children, adolescents, adults, seniors and their families annually. Centerstone provides integrated physical and behavioral health care, mental health therapy and substance use disorder treatment, education and support to communities in Florida, Illinois, Indiana, Kentucky, and Tennessee. Additionally, life skills development, employment and housing services is provided for individuals with intellectual and developmental disabilities and specialized programs are implemented for service members, veterans and their families. A special branch of Centerstone is its research institute. Centerstone’s Research Institute established a Center for Clinical Excellence (CCE) in 2012. This Center is a mission supported department and is tasked with rapidly developing research-based, value added clinical model frameworks, pathways, training and technical assistance to Centerstone operations’ efforts in order to implement high quality models of care and to excel in new value based reimbursement environments. As originally conceptualized, evaluation was not part of this work, however with the addition of an evaluation team in 2017, opportunities to bring a feminist lens to the process was possible.
LEAN EVALUATION VIA A FEMINIST LENS
A feminist evaluation can take place within the context of a lean approach to clinical product conceptualization, development, measurement, learning and evolution. In our integrated behavioral and physical health context, products might be anything from an integrated behavioral and physical health care clinical model for rural women living with a substance use disorder and serious mental illness to a suicide pathway for urban minority transitional age women with depression and/or suicidal intention. Design teams develop clinical products in response to some identified problem. When giving consideration to product development an initial step is to articulate the assumptions behind why this product should be or needs to be developed. Using a feminist lens, evaluators are uniquely positioned to raise questions about disparities that currently exist across the organizations and potential disparities that could occur in the process of implementing a new clinical model.
The evaluation team also has distinct opportunities to speak truth to power by designing our evaluations using a feminist lens that embed feminist theory, methodologies and analysis techniques that are implemented throughout the measurement cycle of the process and designed to consistently shine a light on the powerful array of social determinants of health (e.g., social, economic, environmental, political and/or cultural factors), often ignored but can significantly contribute to health inequities and disparity. We are also uniquely positioned to critically look at systems of power that create and support inequity, oppression and injustice as we facilitate the clear explication of how original assumptions made by payers, CEOs, COOs, design teams, etc. are or are not linked to the realities of those most in need of care.
Specifically, evaluators are in a position to identify decisions made at early stages of product development that have the potential to increase the likelihood of disparities in outcomes thus systematically perpetuating inequity (e.g., absence of gender responsive treatment, inadequate attention to trauma histories, lack of childcare, inadequate data (gender, race, sexual orientation) to identify disparities, etc.). My evaluation team is committed to evidence based reporting so that during the learning phase of the process, evidence can be used to determine the level to which marginalized populations have actually achieved a better quality of life and better physical and mental health outcomes because of the product that was created and their exposure to it. During the evolution stage, again we have the opportunity to speak truth to power through the data that is disseminated that illuminate health disparities and/or poor health outcomes. Because the lean process demands rapid cycles of learning, we have frequent opportunities to speak power to truth with the design team as well as to Centerstone and Clinical Excellence leadership, contracting, and grant writing.

TOOLS FOR ADDRESSING DISPARITY
MECHANISM TOOL
Evaluation Questions Centerstone Disparity Checklist
Data Health Capital Scale
Opportunity Analysis
Testing Assumptions Logic Model
Electronic Health Record NetSmart (myAvatar)
DISCUSSION
The bottom line in this message is that best efforts and good intentions are not enough. Despite what it seems in the moment, disparity is not typically caused by people acting maliciously. (It seems that way only because of a psychological phenomenon called the fundamental attribution error.) In reality, health and health care disparity is systemic in nature. It needs to be solved in the boardroom by making an organization-wide commitment to understanding, effectively addressing and preventing disparity. Prioritizing policy changes that focus on reducing health disparities is vital. Policymakers can appeal to stakeholders by presenting this work as an avenue to reduce costs and improve quality, while protecting revenue. Elevating the importance of addressing health disparities necessitates policymakers consider a multipronged effort to spur stakeholder engagement, including: (1) instituting data-gathering requirements to measure the presence of health disparities; and (2) creating incentives to reduce disparities in addition to rewarding quality. With value-based payment arrangements on the rise, organizations’ willingness to invest in initiatives to reduce disparities as a lever to control costs and/or improve quality may grow spontaneously; however, policy changes may provide an accelerant.

In conclusion, health and health care disparities persist in the United States, leading to certain groups being at higher risk of being uninsured, having more limited access to care, experiencing poorer quality of care, and ultimately experiencing worse health outcomes. While health and health care disparities are commonly viewed through the lens of race and ethnicity, they occur across a broad range of dimensions and reflect a complex set of individual, social, and environmental factors. Disparities not only affect the groups facing disparities but also limit continued improvement in overall quality of care and health for the broader population and result in unnecessary costs. It is increasingly important to address disparities as the population becomes more diverse. Over the past decade, there has been increased focus on reducing disparities and a growing set of initiatives to address disparities at the federal, state, community, and provider level. Unfortunately, current changing federal priorities may lead to insurance coverage losses that would reverse recent progress reducing health and health care disparities.

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