Table 2 ICON meso level – attributes, attribute definitions and sample features

Organizational climate and structures

Economic arrangements

“Economic Arrangements” refers to the income and expenditures relating to service delivery within organizations

• Funding model

• Costs of healthcare delivery

• Funding/

endowment

• Does the funding model/process consider equity?

• Do the economic arrangements support accessible care for communities or populations who would otherwise not be able to afford it?

• How can the funding organizations ensure that researchers/stakeholders meaningfully engage equity-deprived populations in studies or planning programs?

• Does the organization ensure it is allocating and supporting programs that serve equity-deprived populations based on their needs?

• Are there varied voices and perspectives in decisions regarding funding?

Elements of organizations

“Elements of organizations” refers to the characteristics of units and organizations. This attribute is akin to sociodemographic characteristics for individuals

• Type of ownership

• Location

• Organizational size

• Setting/type of environment

• Physical structures

• Programs (differentiation)

• Does the type of ownership affect what care is offered and accessible and the quality of care provided?

• Does the location of the organization (for example, rural/urban areas, low- or high-income communities, distance of setting from the communities or populations served) affect health equity?

• Are the healthcare services accessible to communities or populations with different needs (for example, are there ramps? Do they have flexible opening times? Are they accessible by public transit)?

Organizational climate

“Organizational climate” refers to shared recurring patterns of behaviour, attitudes and feelings which characterize life in that organization [39]

• Climate (atmosphere)

• Team climate

• Conflict

• Is the health services team diverse and inclusive?

• Is the social climate (atmosphere) welcoming to all?

• Does the organization encourage self-reflection on unconscious bias toward equity-deprived populations?

• Does the organization encourage tolerance and open discussion of different perspectives?

Physical and technological resources

“Physical and technological resources” refers to physical structures and technological resources of an organization that are required to deliver services

• Space

• Equipment and supplies

• Technology

• Online resources

• Evidence-based resources

• Documentation

• Reminders

• Are the physical and technological resources accessible (for example, formats that are readable; are there alternative for persons with low vision)?

• What accommodations might be needed to make resources accessible?

• Are information materials available in different languages?

• Do consumers have input or co-create resources?

Organizational social behaviour

Internal relationships

“Internal relationships” refers to the ways in which two or more people or groups within an organization regard and behave toward each other [40]

• Social networks

• Social capital

• Partnerships (collaborative practices)

• Does the organization encourage self-reflection of unconscious bias toward equity-deprived populations? Do they provide training for self-reflection and self-reflection of unconscious bias?

• Does the organization encourage tolerance and open discussion of different perspectives?

• Are patients/clients/consumers included as stakeholders in care and service decisions, and policy-making and research?

• Does the organization have trusting relationships with equity-deprived populations?

Organizational culture

“Organizational culture” refers to the normative beliefs and shared expectations that govern the work behaviour of an organization [41]

• Cultural norms

• Shared expectations

• Does the organization encourage reflections on its own cultural norms/shared expectations?

• Does the organization promote reflection on the influences of

norms/expectations on service providers and patients’ behaviours?

• Are there processes to co-create and encourage shared expectations?

Organizational response to change

Organizational change processes

“Organizational change processes” refers to the process of altering an organization’s strategies, processes, procedures, technologies and/or culture to improve service delivery [42]

• Formal change systems and processes

• Quality improvement processes

• Engagement

• Champions/opinion leaders

• Are there processes to consider the needs of all stakeholders including equity-deprived populations?

• Does the organization have processes to ensure inclusion of all stakeholders, including equity-deprived populations, in change processes?

• Are the champions/opinion leaders representative of the diversity of the organization?

Receptivity to change

“Receptivity to change” refers to an openness and responsiveness to ideas, impressions or suggestions, and a readiness or fit of critical features of the environment as they specifically relate to a targeted practice [43]. Receptivity to change may occur at multiple levels (for example, patients, healthcare professionals/providers, leaders and organization)

• Change culture

• Tension for change

• External pressure for change

• Readiness for change

• Compatibility

• Change saturation

• Are assessments of readiness for change inclusive, and do they consider the diversity of the community or population?

• Are the priorities of the service providers compatible with the priorities of the patients/

clients/consumers?

• Does receptivity to change include equity considerations?

• To what degree are equity factors integrated in changing care and services, policy and research conduct? For example, approaches related to actions on gender equity and health can be described as a continuum from gender unequal to gender blind to gender sensitive to gender specific and then gender transformative [62]

Organizational processes

Communication processes

“Communication processes” refers to the imparting or exchanging of information or news (for example, between professionals/

providers, patients, management, etc.) within an organization [44]

• Formal communication

• Informal communication (social interactions)

• Social influence

• Advocacy

• Does the organization advocate for health equity?

• Are communication strategies tailored to equity-deprived populations?

• Does the organization co-create messages with clients/

consumers/patients to ensure that the terminology used, or the phrasing of the message, is respectful and inclusive?

• Does the organization have processes to identify the individuals or partners who can

co-create and impart messages to equity-deprived populations who might otherwise be underserved?

• Does the organization ensure that there are communication channels that individuals can use without fear of discrimination or judgement after disclosure of being a member of an equity-deprived population (for example, anonymous lines)?

Evaluation activity

“Evaluation activity” refers to the systematic collection of information about the activities, characteristics and outcomes of programs, services, policies or processes in an organization, to make judgements about the program/process, improve effectiveness and/or inform decisions about future development in that organization [45]

• Quality improvement monitoring

• Performance Measurement

• Performance feedback

• Review of employee performance (staff/manager)

• Patient/client/consumer feedback to staff

• Does the organization collect equity-related indicators/factors?

• Does the organization evaluate gaps in access, quality of care and services, and health status amongst equity-deprived populations?

• Does the organization evaluate the reach of interventions targeting equity-deprived populations?

• What are the ethical considerations/obligations that organizations consider when collecting and presenting data related to equity and equity-deprived populations?

• Do the equity-deprived populations have data sovereignty over their data?

• Does the organization evaluate and meaningfully incorporate patients/clients/consumers/staffs/

managers' effort and perspectives in co-creating more equitable care and services?

• Does the organization reflect on and learn from past experiences to facilitate building relationships with equity-deprived populations and prevent repeating mistakes that were detrimental to these populations?

Governance

“Governance” refers to the rules, policies, systems, structures and processes by which an organization is controlled and directed [46]

• Organizational mission, goals & priorities

• Organizational authority structure

• Power

• Standard of practice or care

• Internal policies

• Incentives and disincentives

• Do the organizational mission, goals and priorities consider equity?

• How is power shared in the organization?

• Do the standards of practice and care incorporate equity and the perspectives of patients/clients/consumers?

• Are internal policies inclusive of individuals with varied needs?

• Are there incentives and/or disincentives to promote equity in the workplace?

Leadership

“Leadership” refers to the types and styles of leaders within an organization

• Leadership styles

• Formal leaders

• Senior leaders

• Role models

• Mentors

• How diverse is the leadership team?

• Are there role models and mentors within the organization from diverse backgrounds?

Management

“Management” refers to the process of dealing with or organizing things or people in an organization [47]

• Formal planning

• Management support

• Use of resources

• Does the organization consider equity during policy planning, work planning, strategic planning and setting annual goals?

• Does the organization meaningfully engage diverse groups of individuals in formal planning?

• Do the processes related to resource allocation consider equity?

Organization of work

“Organization of work” refers to arrangement of tasks, responsibilities and resources within and between service providers working in the organization [48]. This attribute reflects individuals when considered as a group rather than as individuals, thus all features considered for inclusion here had to be generalizable to an organization

• Workload

• Adequacy of staff composition

• Support personnel

• Teamwork

• Scheduling

• Workflow

• Work tempo

• Time

• Does the organization have individuals who provide expertise regarding equity and its integration in care and services, policy and research?

• Does the organization have a diverse workforce?

• Does the organization celebrate the diversity of its staff and encourage individuals to express themselves freely?

• Does the organization support its staff to consider equity in their work?

System processes

“System processes” refers to the processes required to deliver services within an organization

• Quality assurance process

• Project Management

• Optimizing standardization of care

• Continuity of Care

• Organizational training and education

• Process complexity

• System complexity

• Do current system processes incorporate equity?

• Does the organization provide training for self-reflection and awareness of unconscious bias?

• Do standards of care consider the diversity of care needs unique to each community or population?

• Are there system processes in place to allow the organization to respond to circumstances that are incompatible or harmful to equity-deprived populations?