An equity impact assessment (EIA) is a tool that can be used to identify unintended potential impacts (positive or negative) of a policy, program, or initiative on historically marginalized groups. Organizations can then proactively mitigate negative impacts and maximize positive impacts. The goal is to reduce existing disparities, prevent further inequities, and enable more equitable solutions.

An EIA is a valuable tool to bring attention to groups that are typically overlooked in decision-making. However, an EIA is not a stand-alone tool and is not a substitute for meaningful input from marginalized communities. Organizations should design initiatives with and not just for marginalized communities, leveraging existing processes like community engagement, co-design, and participatory decision-making.

EIAs can be used to evaluate initiatives designed for employees, patients, or the wider community. An EIA prompts users to:

1. Identify marginalized groups to consider
2. Assess the unintended impacts of a planned initiative on marginalized groups
3. Outline efforts to minimize negative impacts
4. Create a plan for monitoring mitigation efforts if an initiative is enacted
5. Share results and recommendations

Here are some example scenarios of how health care organizations can use equity impact assessments:

Patient initiative

An urban hospital plans to launch a new clinic to increase access to prenatal care to improve maternal health outcomes. Program leaders use an EIA to identify potential unintended impacts on the area’s large population of women who are recent immigrants from Latin America, many of whom are low-income. Using the EIA, program leaders realize that many of these women work multiple jobs and won’t be able to visit a clinic during traditional hours. Further, many of these women feel most comfortable communicating in Spanish and won’t choose to visit an English-only clinic. To mitigate these potential negative impacts, the hospital decided to alter the hours of the clinic and provide Spanish-language services. They also identify a potential positive impact to amplify: They decide to employ women immigrants as interpreters and community liaisons to provide economic opportunity.

Employee initiative

A health system decides to implement a new policy to give nurses more exposure to different care settings; some nurses will rotate through several inpatient department and outpatient clinics throughout the year. Before rolling out the new policy, leaders conduct an EIA, focusing on young, single caregivers, who make up a big portion of their nursing workforce. The EIA illuminates a potential negative impact: These nurses plan their shifts based on when they can find childcare—a rotational schedule may force caregivers to leave the health system if they’re unable to find flexible affordable childcare. In response, the health system makes the rotational program optional and provides a stipend for childcare services to participating nurses.

Nonprofit organization Race Forward defines institutional racism as “the routine, often invisible and unintentional, production of inequitable social opportunities and outcomes. When racial equity is not consciously addressed, racial inequality is often unconsciously replicated.”

While most health care leaders strive to provide positive experiences for all employees and patients, acknowledging and eliminating these routine, invisible, and unintentional disparities is not yet a regular component of decision-making.

EIAs can change that by helping health care leaders bring attention to and consciously address disparities that may otherwise be unintentionally replicated or even amplified by decision makers.

EIAs can help health care leaders:

1. Identify potential unintended impacts (positive or negative) of a planned initiative on marginalized groups
2. Support equity-based improvements in program or service design to mitigate negative impacts and maximize positive impacts on marginalized groups
3. Embed equity across an organization’s decision-making models, so that it becomes a core value and part of the criteria behind every decision
4. Raise awareness about equity as a catalyst for change throughout the organization and reinforce equitable behavior as a leadership expectation

By proactively assessing the potential impacts of proposed initiatives and redesigning accordingly, health care organizations can avoid implementing initiatives that disadvantage certain populations, thereby reducing institutionalized inequity.

Use these six strategies to embed EIAs in decision-making across your organization:

1. Recognize the trade-offs you’re willing to make to embed EIAs. Conducting EIAs—and adapting initiatives accordingly—may require additional resources, including time and financial investment. Leaders must clearly explain that the long-term benefits (services that better align with patient/employee needs and reduce disparities) are worth the up-front investment. Leaders must also be willing to adjust decision-making processes (for example, extending planning deadlines) in order to make conducting EIAs feasible.
2. Identify the marginalized populations to be considered when conducting an EIA. The right populations will depend on your community’s demographics, history, and existing inequities. Marginalized groups will even vary from one initiative to another. Leaders can customize the tool for different use cases, but it helps to have a common starting point based on known community inequities.
3. Embed EIAs into standard project management and decision-making processes. EIAs should be conducted as early as possible in the planning stages to inform decisions and enable adjustments to any initiatives.
4. Develop criteria for when projects require an EIA. While you may eventually conduct an EIA for every new initiative, consider starting with projects over a certain budget or impacting a certain number of patients or employees. In addition to using EIAs to assess individual initiatives, you may also apply EIAs at a macro-level to assess your mix of current or planned services.
5. Provide implementation training and support to ensure the tool is used correctly. Start with key stakeholders involved in decision-making or planning services for patients or employees, such as your C-suite, strategy, project management, business development, quality improvement, HR, and/or population health department. Consider who will “own” the tool to provide consultative support on request.
6. Pair EIAs with other approaches to meaningfully engage systemically marginalized people in decision-making. Continue to reinforce that the EIA should not be used as a stand-alone resource, and consider what other methods can be used to enable authentic representation and meaningful involvement.

For detailed guidance on how to conduct an EIA, see our Equity Impact Assessment Template and User Guide.

Determine what data or qualitative evidence sources you should leverage to identify which patients and/or employee population groups to include in EIAs.

Consider what types of policies, initiatives, or programs your organization should prioritize for equity impact assessments.

Discuss how to support and incentivize leaders and teams to use EIAs when evaluating proposed initiatives.

Determine how to meaningfully involve systemically marginalized populations in planning and decision-making.

Download our Equity Impact Assessment Template and User Guide for a ready-to-use template and step-by-step instructions.