By Dominic Cappello
In the world of health equity and addressing health disparities, power plays a pivotal role. When one assesses a community and finds high rates of child maltreatment, unemployment, high school drop out, domestic violence, and substance use-related injury and illness, you may also find that it’s because of an imbalance in power. Community members in low-income areas often lack it. Agency and political leaders may hold it—often tightly.
To address disparities, including lack of access to quality medical, dental and mental health care, secure housing, jobs, transportation, and child care, we must partner with local communities to support them in their quest for more local control to increase the quality and quantity of basic services.
In health equity work, when we are invited to collaborate with communities with a long history of disparities, it may be that a big part of our job is building trusting relationships. When we are visitors to communities forgotten by our leaders we must act like all good guests do—being respectful of local history, cultures and show a willingness to listen carefully. When asked to collaborate, we should be ready to share the resources, skills, and connections we may have.
We can also provide a tool for generating local power—through the use of data. While quantitative data can indicate levels of disparities using numbers, qualitative data can come from the local stories of community members.
To provide the best chance for achieving measurable results with community members, we should share a data-driven framework, one that relies on both gathering numbers and personal insights, as a way to achieve better health outcomes for residents. The data-driven framework is called continuous quality improvement (CQI). The four phases of CQI are assessment, planning, action, and evaluation. In Data Leadership courses, we guide community members through the CQI process, identifying key tasks.
Phase One: Assess
• Identify the challenge to be addressed.
• Use data to better understand the problem.
• Use data to confirm that the challenge is a priority.
• Use data to drill down to root causes of the challenge.
Phase Two: Planning
• Identify which components of the challenge you will prioritize.
• Research evidence-informed solutions to the challenge.
• Identify a timeline, roles and responsibilities, costs, and other elements related to the overall implementation.
• Develop a logic model that outlines the theory of change and how progress will be measured.
Phase Three: Action
• Secure buy-in from key stakeholders and those who may be impacted.
• Begin implementation.
• Monitor activity in the plan-making adjustments as needed.
• Ensure data are collected throughout the action phase.
Phase Four: Evaluation
• Analyze all relevant data gathered.
• Determine the strengths and weaknesses.
• Determine the impact on the challenge.
• Communicate with all stakeholders the results and return to the assessment phase.
When I receive a call for assistance from child welfare, public health, or a community-based project facing challenges, the first question I ask is, “What do we know about the problem and what is the capacity of the agency or community to address it?” This question is the first of four steps in CQI—assessment.
In the assessment phase, we must bring to our partnerships a shared understanding of what a data-driven process of assessment is and why it matters. This means that if we see data that indicate high rates of drug overdose or suicidal behaviors in a community, we also need data to identify the quality of mental health care accessible to residents.
The second phase of CQI brings us to planning that involves using research to identify evidence-based strategies shown to solve a particular problem. In the Data Leadership program I facilitate, the planning stage is where projects coalesce—and logic models are created to identify a project’s hypothesis, goals, purpose, activities, and desired outcomes. Phase three is action, always informed by data. Lastly, social change projects end with CQI’s last phase of evaluation.
The CQI process provides a framework for doing short and long-term work to address disparities and other challenges in the arenas of public health, child welfare, and education. And each phase is guided by a series of questions.
What follows are the key questions we work with our community partners to answer. The answers—focused on the four stages of CQI, have been shown to weave together a plan for moving from point A to point Z. This process of reflecting on and answering questions guides us to real solutions focused on increasing local services to improve the quality of life and reduce disparities. This process can start a project to increase behavioral health care, safe playgrounds, affordable child care, and effective job training and placement. To understand how CQI can help develop a meaningful and measurable solution to address a local problem, pick any challenge and then start reviewing the following questions with that particular challenge in mind.
CQI: ASSESSMENT PHASE
Question 1: What is the challenge you identified?
Question 2: What data did you use to identify the challenge?
Question 3: What do data tell you about the size of the challenge?
Question 4: What do data tell you about which populations are being impacted by the challenge?
Question 5: What do data tell you about the current capacity of your agency, community, or county to address the challenge?
Question 6: Which data can confirm that your challenge is a priority?
Question 7: What data and/or research illustrate the root causes of the challenge?
CQI: PLANNING PHASE
Question 1: Which component of the challenge will you address with a local innovation or change initiative?
Question 2: What is your review of research focused on your challenge?
Question 3: What potential evidence-based solutions exist in the research?
Question 4: What is the hypothesis that illustrates how your actions might solve the challenge? (As in: “If you do A, then B will happen.”)
Question 5: What are your key steps, timelines, roles, and responsibilities related to your innovation or change initiative?
Question 6: What unintended consequences might you encounter?
CQI: ACTION PHASE
Question 1: How will you secure buy in for the innovation or change initiative in your workplace and/or community?
Question 2: Which, of all your proposed activities, are the most vital?
Question 3: How will you begin implementation of the innovation or change initiative?
Question 4: How will you record and monitor activities as your innovation or change initiative unfolds?
Question 5: What will your process be for making adjustments to your innovation or change initiative?
Question 6: How will you ensure data is collected along the way as your innovation or change initiative unfolds?
CQI: EVALUATION PHASE
Question 1: How will you analyze and share all relevant data with those working on the innovation or change initiative?
Question 2: How will you ensure that your data and evaluation are presented in an easy to understand manner?
Question 3: How will you determine the strengths and weaknesses of the innovation or change initiative?
Question 4: How will you determine the impact of the innovation or change initiative on your challenge?
Question 5: How will you identify the unintended consequences?
Question 6: How will you measure if people (employees and/or residents impacted by the innovation or change initiative) are better off?
Question 7: How will you ensure that you communicate with all stakeholders on the results of the innovation or change initiative?
THE POWER OF DATA TO POWER THROUGH
As can you see from the questions above, the CQI framework is one of collecting vital data about local challenges in order to design solutions.
It needs to be acknowledged when beginning a data-driven project in the community, that data can be abused or misinterpreted. It can be used to make an argument that won’t hold up to scrutiny. Data is political. For these reasons, there are local community members who distrust data.
Our work in the arena of disparities prevention is to rebuild trust around data use. It’s also about seeing data as a tool for strengthening community power-the power to shine a spotlight on challenges that refuse to go away. In the right hands, data can reveal trends toward homelessness, untreated mental health care, unemployment, and child maltreatment. Data can pin point where the challenges are and the root causes of long standing health and safety problems.
Data can also build support for solutions. Data can show how a local school based health center with behavioral health care can address all types of challenges—from suicidal behaviors to drug misuse. Data can show how an intervention like home visitation can reduce child maltreatment.
Data can substantiate that a significant percentage of kids who have a long term mentor will delay drug and alcohol use and avoid dropping out of school. Data can guide local community innovations and change initiatives focused on preventing disparities.
For data to be a force for health equity, we must all commit to using it wisely and transparently. With the right data, which includes personal stories from local residents, we can increase local power to solve challenges once viewed as unsolvable.
Dominic Cappello is the Senior Director Quality Improvement and Design for Healthy Gen. He also leads the implementation of the Child Welfare Data Leaders and Quality Improvement Initiatives in New York, New Mexico and Connecticut, funded by Casey Family Programs. He worked for the NM Department of Health’s Epidemiology and Response Division and the NM Protective Services-Research, Assessment and Data Bureau. He has a Master of Arts in Liberal Studies with an emphasis in Language and Communication from Regis University.