Why It Matters
A pregnant person who is black is three to four times more likely to die during pregnancy or childbirth than one who is white. Like all complex or adaptive challenges, no one sector, group, or stakeholder can solve this problem on their own. Instead, multiple stakeholders each hold pieces of the puzzle. Silos contribute to the problem.
To address these challenges, a group of organizations came together in Washington, DC, to engage a variety of stakeholders in redesigning the systems causing these negative outcomes. These stakeholders included black, pregnant persons and those who have recently given birth serving as “context experts” — those who have personal experience with the issues being addressed. The group developed new ideas (including virtual supports for postpartum persons) and then tested and refined them. Over time, they realized they had not only identified potential ways to improve outcomes, but they had also broken down silos and aligned the work of health care systems and providers, community-based organizations, and context experts.
How did they do it? They used an Equity Action Lab.
According to the Equity Action Lab Implementation Guide, an Equity Action Lab is “a flexible and adaptable model that uses a set of activities to bring together a diverse group of community stakeholders to take action in pursuit of equity and community improvement.” The model helps stakeholders act on a complex (adaptive) health topic that does not yet have a known fix or remedy. It requires multiple groups or sectors to work together to test and learn their way into solutions.
IHI based the model on an approach employed by IHI’s Strategic Partner, Community Solutions, that used design thinking and “switch thinking” to quickly get to action and results. As part of our efforts as 100 Million Healthier Lives convener, IHI incorporated improvement science, the psychology of change, systems thinking, co-designing with people with lived experience, and effective approaches for tackling adaptive challenges to create the Equity Action Lab. Most importantly, we tested and refined methods for co-designing solutions with context experts.
We then tested the model multiple times to address dozens of health topics. We evaluated and refined the model as we learned what produced tangible progress and multiple stakeholders aligned to continue making improvements. The result is a highly adaptable and reliable model for making progress on adaptive health challenges.
The Equity Action Lab model is worth considering when you want to:
- Get multiple-stakeholders and multiple sectors to act (and not get stuck in eternal planning) on an adaptive challenge.
- Co-design with all stakeholders, especially context experts/people with lived experience.
- Test your way into solutions when you don’t yet have a change package or proven intervention.
Figure 1. The structure of the Equity Action Lab
Phases of the Equity Action Lab
Prep — This generally lasts two to three months, but can last up to six months. During the prep phase, organizers:
- Collect and analyze data on the topic area. The analysis begins to answer equity questions such as “Who isn’t thriving?” and “What would it take to change that?”
- Refine the topic area (often including developing potential aim statements).
- Put together the team(s) to lead and design the work.
- Plan operational logistics.
In Washington, DC, partners used this time to convene and engage stakeholders, along with reviewing existing data about maternal mortality in their area. The utilized existing reports and were able to build on previous work to set them up to have a successful equity action lab.
Action Lab — This typically lasts one and a half to two days. This can be spread over several days if done virtually. During the Action Lab, participants:
- Use quantitative and qualitative data to better understand the challenge and potential solutions.
- Develop a 100-day aim and/or a long-term aim for their work together. In most cases, this aim is focused on explicitly improving equity.
- Learn about improvement science, design thinking and addressing complex challenges.
- Develop a theory of change on how they will meet their aim.
- Develop many ideas to potentially test.
- Select a core set of ideas to test during the next 100 days.
- Divide into teams to plan and test the selected ideas.
During their Action Lab, the DC partners participated in a series of facilitated activities (e.g., journey mapping, brainstorming sessions, and dot voting) to help them create their aim and initial ideas to test. The team settled on three design teams: Awareness/Access to Quality Services (text line for outreach, support, and resources), Respectful Care (Do No Harm Checklist and mini-respectful care training), and Postpartum (Virtual Mommy Meet Up for postpartum persons to receive peer support).
Sprint — Immediately after the Action Lab, teams begin 100 days of testing their ideas using the Model for Improvement and implementing plans to achieve their aim. Teams meet weekly to report on their completed tests, address challenges and barriers, plan their next steps and next tests, and to begin thinking about how to scale or sustain what is working. Instead of following a static work plan, the model emphasizes iteration, testing, and going into new directions throughout the sprint phase. Throughout the 100 days, teams adjust their plans and update their theory of change (i.e., “What changes can we make that will result in improvement?”) as they learn more.
During this phase, the partners in DC convened weekly. They made refinements and documented their progress and learning along the way. They conducted a series of Plan-Do-Study-Act (PDSA) cycles to iterate on their original ideas.
Sustain — Following the Sprint, all participants reconvene to celebrate their progress and debrief on the challenges they faced. They then either engage in a brief Action Lab to set another aim and launch another 100-day sprint phrase or determine how they will sustain and scale up their progress.
During this phase, the DC partners held a “momentum lab.” They brought together partners from each of the design teams to share progress, challenges, and gather ideas for future sprints to make modifications, ensure continuous improvement, and sustain successful ideas.
Many people believe that the complex challenges in health, equity, and health care — including inequitable outcomes experienced by Black, Indigenous, and People of Color (BIPOC) — are intractable problems. They are, in fact, adaptive challenges that don’t respond well to technical solutions. But adaptive challenges, and the inequitable outcomes caused by structural racism and other unjust systems, can be improved, and even solved over time by bringing together a full range of stakeholders and using methods designed for this level of complexity. Equity Action Labs integrate these methods into an easy-to-implement and adaptable model that helps stakeholders get “unstuck” from planning, and learn how to improve their way to solutions.
Paul Howard (phoward@IHI.org), MPA, is an IHI Senior Director. Shannon Welch, MPH, is an IHI Director.