Developing a Sociotechnical Systems Analysis Approach for Investigating Systems Inequities

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While structural inequities exist in a broad range of systems, there is emerging evidence that health systems are plagued by systemic biases. Prior research has identified over 175 studies documenting racial/ethnic disparities in healthcare. Inequities designed into the system through biased algorithms, poor process design, continued use of racist medical practices, medical devices unreliable for people of colour, and implicit bias and culturally insensitive care. Characterizing systems biases are extremely difficult due to a lack of a well-defined conceptual model, challenges in the availability and quality of data (including insensitive measures), and ill-defined data analysis approaches. Industrial and systems engineering (ISE) approaches have been utilized to improve system design in many domains and would be exceptionally well-suited for identifying underlying systemic issues contributing to disparate outcomes. ISE provides a strong theoretical basis for examining systems equity, having long documented systemic deficiencies that can result when the design processes fail to account for key groups of users, including marginalized communities ignored or denied representation in the design of the health systems. This research is innovative in combining ISE-with its traditional emphasis on safety-and leveraging intersectionality for understanding disproportionate risks on marginalized communities. One specific healthcare context where equity challenges are particularly salient is maternal health. Maternal mortality and severe maternal morbidity (SSM) have increased in Canada in the past 20 years. Racial and ethnic disparities are prevalent across all causes of maternal mortality and SSM. In the US, Maternal mortality and SMM are also associated with billions of dollars in healthcare expenditures. Half of all maternal deaths and SMM are preventable through timely and risk-appropriate care. The presence of substantial and persistent disparities after controlling for patient and hospital factors suggest systemic inequities in the design of the maternal care systems. Utilizing maternal care as a paradigm, this work will investigates inequity in health systems using ISE. The work seeks to develop a well-defined ISE methodology that can applied to identify system inequities, identify causal factors contributing to these inequities, and monitor variations as part of ongoing system safety efforts. As the Canadian population continues to diversify, understanding how health systems do or do not work for the populations they serve is essential for redesigning clinical pathways to provide safe, equitable care, and cost-effective care. Focusing on clinical system contributors to disparities is a novel underlying thread of this research aligning conceptually with population health and healthcare engineering frameworks and offering profound implication that extend far-beyond maternal health disparities for any health system.