Identify A Health Equity Focus

What is this and why does it matter?

Identifying a health equity focus means selecting a specific issue or disparity for your initiative to address. Health and healthcare inequities vary across populations, regions, and systems — and in multi-organization collaboratives, partners may have different views on which to prioritize. A clear, well-defined focus keeps interventions targeted and actionable, and allows your team to align resources, design effective interventions, and track meaningful progress.

Your focus might center on a social driver of health (e.g., housing instability) or a specific health outcome (e.g., blood pressure control among Black patients with hypertension).

How should you work through this component?

Begin with the Identify a Health Equity Focus Base Deck, which introduces core concepts — the relationship between quality, disparities, and equity; intersectionality; systems thinking; and targeted universalism. Built-in discussion prompts and breakout activities guide your team through identifying a focus area and using data effectively to drive equity-centered care transformation.

Next, review two key resources:

Applying an Equity and Anti-Racist Lens to Quality Metrics and Data explains how presenting health data without a racial equity lens can unintentionally reinforce racism. It offers guidance for presenting stratified data in ways that highlight systemic causes rather than individual deficits — including choosing equitable benchmarks, naming root causes explicitly, and using strengths-based framing.

Using Data to Reduce Disparities and Improve Quality outlines a step-by-step process for using stratified data to identify disparities, design equity-focused interventions, and measure impact. It covers integrating quantitative and qualitative data, communicating findings with stakeholders, and sustaining equity work over time, with real-world examples and evaluation tools.

Finally, use the Health Equity Focus Worksheet to assess available data, identify disparities, and determine where to focus your efforts. Key steps include:

• Stratifying quality data by race, ethnicity, language, age, gender identity, disability status, socioeconomic status, and other demographic factors
• Incorporating qualitative data — such as patient and provider experiences, community feedback, and historical context — to complement quantitative findings
• Engaging key stakeholders (e.g., patients, community leaders, providers, policymakers) to gather insights and validate focus areas
• Leveraging external sources like community health needs assessments, local media, and public health reports to understand broader community priorities

When does it make sense to work through this component?

This component should be one of the first steps in any health equity initiative. Without a clear focus, teams risk designing interventions that are too broad, ineffective, or fail to address the most pressing inequities. It is especially critical to work through this component when:

• Launching a new health equity initiative – Ensuring the team has a shared understanding of the problem.
• Reviewing or revising organizational priorities – Aligning equity efforts with existing quality improvement work.
• Observing disparities in outcomes but unsure of root causes – Using data to pinpoint the issue before implementing solutions.
• Responding to patient and community concerns – Addressing inequities identified through direct feedback from those most affected.

Curriculum to be completed for this component:

Self-Assessment Topics and Questions:

This self-assessment tool will help you identify, anticipate and address common challenges implementing the Roadmap.  Using it will increase your chances of successfully reducing and eliminating health and healthcare inequities. Each Roadmap component will have a set of questions and topics in their respective sections; AHE recommends utilizing the assessment questions in two ways:

• As an initial readiness assessment BEFORE working on a component of the Roadmap.
• For ongoing assessment as you implement each Roadmap component.

1. Questions to consider if your team is considering refining or revising your health equity focus: Has your team identified a health equity focus?:

If yes…

1. How did the team arrive at the current health equity focus?
2. What quantitative data did the team assess to make this decision?
   • What are the potential biases and weaknesses of this data?
3. What qualitative data did the team assess to make this decision?
   • What are the potential biases and weaknesses of this data?
4. Describe the role(s) that patients/members or community-based organizations played in making the decision.
5. Who else was involved in making this decision?
6. Were any key stakeholders left out of the decision making process? Is there a respectful way to address this oversight as the team revises its health equity focus?

2. Questions to consider if your team wants to identify a health equity focus:If no…
   • Has the team or any of the partner organizations identified key motivations and desires for a health equity focus?
     • Please describe.
   • Describe how any of the partner organizations have incorporated equity into their current quality improvement activities.
   • Are there other health and/or healthcare equity-focused initiatives currently underway at any of the partner organizations?
   • Are there other health and/or healthcare equity-focused initiatives scheduled to begin in the next 1-2 years at any of the partner organizations?
   • What health and healthcare equity activities are taking place in the communities of the patients/members that you serve?
   • What healthcare and health equity topics have community based organizations or coalitions prioritized?

3. How does the team plan to utilize qualitative and/or quantitative data to identify a health equity focus?
   • What quantitative data can the team access and analyze to make this decision?
     • What are the potential biases and weaknesses of this data?
   • What qualitative data can the team access and analyze to make this decision?
     • What are the potential biases and weaknesses of this data?
   • Identify  the role(s) that patients/members or community-based organizations can play in making the decision.
   • Who are other key stakeholders that should be involved in making this decision?
     • How can you respectfully partner with them to identify health equity focus?See questions 1 ai through and 2 1bvi.

4. The following is a list ofIs the team experiencing any of these common data challenges.  How can the ?  If yes, how can the team proactively anticipate and address the challenges?
   • Data interpretation is not informed by perspectives of the people served.
   • Data interpretation is not informed by the perspectives of the people who first collected and entered the data into the database(s) or electronic health record.
     • Note thatThe teams can easily misinterpret data and draw flawed conclusions from data analyses when those who initially collected and entered data are not included in data discussions.  Individuals who collected and entered data can help the team understand why data might be missing or low quality, more easily identify inaccuracies in the data, and reveal instances where similar or better data might be available, and easily spot instances when team members are misinterpreting the meaning of the data. 
   • Team members do not agree on which data to use .
   • Initial review of the data is flawed.
   • Lack of buy-in from data “owners”.
   • Permission to share data is lacking.
   • Large proportions of “other”, “missing”, or “do not wish to disclose” for any of the metrics?
   • Difficulties interpreting the meaning of data from small sample sizes and how to utilize qualitative data and external quantitative data to facilitate data interpretation.

Goal and Objective Setting:

About the Roadmap Goal and Objective Setting Tool

This tool is designed to facilitate goal setting and completion for your team. The tool will allow your team to:

1. Record goals which align with the various Roadmap components
2. Record objectives, time frames, and target completion dates, among other important items for each goal
3. Monitor progress of goals per Roadmap component

Your team is welcome to engage with this tool as much or as little as it would like, and is helpful, in the development, implementation, and evaluation of your health equity initiative. We encourage you to use this tool to ensure clear goal setting and promote consistent communication, accountability, and progress within your team. This tool is designed to be used over time as your team progresses through the Roadmap and your initiative. This is in no way intended to be used one way by all teams. This is meant to help you progress through the Roadmap component(s) on which you are working at a given time and you may reach your goals in any order. We welcome you to consult your AHE TA lead on getting started with this tool.

Each Roadmap component is listed as a separate tab. Navigate to the desired Roadmap component via the task bar at the bottom of the webpage to add, edit, or view goals. Hide certain tabs as needed to narrow your view to specific Roadmap components or the snapshot. Changing the status of a goal will automatically shift the Snapshot view for the specific Roadmap component.