A Federally Qualified Health Center-led Ethics & Equity Framework & Workflow Checklist: An Invited Commentary in Response to a Relational Public Health Framing of FQHCs During COVID-19

Abstract With disparate rates of morbidity and mortality among minoritized communities, COVID-19 illuminated the need for equity-informed practices in public health. Pacia et al posit FQHCs as entities that addressed inequity when others failed. This commentary further situates how FQHCs address the public health crisis of institutional racism and related health inequities every day and presents a FQHC-led Ethics and Equity Framework and Workflow Checklist to guide ethical and equitable engagement with FQHCs.


Background: Relational Public Health and FQHCs in COVID-19
With disparate rates of morbidity and mortality among low-income and minoritized communities, COVID-19 illuminated the need for equity-informed resource distribution, access to care, and decision-making. 1 In "Enacting Relational Public Health: Federally Quali-fied Health Centers During the COVID-19 Pandemic," Pacia and colleagues used the public health relational framework to spotlight how federally qualified health centers (FQHCs) met important public health needs during COVID-19, reaching at-risk populations and with substantial barriers to care. 2 As scholars/practitioners based in FQHCs and FQHC-partner institutions, we value this framing.The authors illustrated the civil rights history, mission, and value-driven strategies of FQHCs.FQHC trustworthiness, framed as relational personhood, was featured as a driver of collaboration with churches and other community organizations to reach critical segments of the population.Community-responsive initiatives, framed as social justice, were illustrated through transportation scheduling and weekend clinics with daycares.These strategies are grounded in FQHC's mission to "uplift the marginalized members of the communities they serve" and featured proactive population health initiatives, like reserving and delivering sufficient vaccines for Hispanic farmworkers, to reflect relational solidarity.
Pacia et al. posit FQHCs as entities that addressed inequity when others failed.Among FQHCs and their communities, community health centers (CHCs) are well known as fearless leaders, advocates, and innovators in community-led and -responsive models of healthcare.The COVID-19 crisis illuminated the visionary mission and leadership of FQHCs.However, those who are directly engaged with FQHCs know this is how they address the public health crisis of institutional racism 3

FQHCs: Leaders in Ethics & Equity
Established in 1965, FQHCs operate, by design, to be community responsive and address community access and needs.The FQHC health center compliance manual 4 provides a guiding ethics and equity framework for health centers.United by this national model, shared history rooted in civil rights, and mission of being community-led and -engaged, 5 FQHCs provide care to community members regardless of their ability to pay, are governed by a 51% representative consumer-led board of directors, and deliver quality, patient-centered, comprehensive and coordinated care.FQHCs prioritize hiring from the local community resulting in representation throughout the organization, furthering FQHCs' authentic community engagement, partnership, and trust.FQHCs are necessarily agile and focused on rapid implementation of action-oriented quality and policy improvements that maximize limited resources to achieve health equity. 6acia et al situate their analysis of "FQHC actions, policies, and cultures" during COVID-19 as critical to understanding their role in "ensuring public health policy [that] is effective and equitable." 7Within this climate and structure, we developed an FQHC-led ethics and equity framework and workflow checklist 8 through the NIH Rapid Acceleration of Diagnostic Testing in Underserved Populations (RADx) 9 initiative, highlighting the underlying fabric of health centers' historic and adaptive leadership in the delivery of equity-informed care.

RADx-MA: An FQHC-engaged Implementation Science Collaboration during COVID-19
RADx-MA was an implementation science community-academic partnership between Harvard Implementation Science Center for Cancer Control Equity, Massachusetts League of Community Health Centers, the Kraft Center for Community Health, and six Massachusetts CHCs.FQHCs were critical partners in expanding equitable access to and delivery of COVID-19 testing to underserved populations.
Each participating FQHC established a local community advisory group (LCAG) to guide health center strategies for increased access to testing.We developed an actionable ethics and equity framework and work-  The FQHCs and their LCAGs identified defining terms to guide ethics and equity (box on left).Four domains emerged to guide initiatives that are FQHC-engaged and ethics and equity informed (circle quadrants).In sum, 1)the FQHC needs to be a leader and power dynamics equalized by supporting dynamic leadership across a wide range of team members (entry level through executive); 2) the process should be community engaged and transparent with attention to tailored response and communication reflective of the community served; 3) the initiative should be partnership driven with strategic planning to support inter-institutional resource sharing as needed taking into consideration the need for rapid translation of needs and data into action and weighing the capacity and bandwidth of the staff/resources against the burden of the need; and 4) Race/ethnicity and language data and FQHC policy should be used to guide the approach following FQHC best practice of quality improvement and equity-driven.flow checklist to elevate FQHCs' mission-driven equity practices as foundational to their successful community reach and engagement.These tools reflect what is implicit to FQHCs, but had perhaps not been as clearly understood or obvious to others until COVID-19, and were designed to guide decision-making in times of scarcity by making these processes explicit.

FQHC-led Ethics & Equity Framework and Workflow Checklist
We developed the framework (Figure 1) and workflow checklist (Table 1) as the RADx-MA Ethics and Equity Board (EEB).Established to guide the RADx-MA partnership's work through an ethics and equity lens and to accommodate the rapidly changing circumstances that the FQHCs were navigating, the group spotlighted the inherent equity-informed strategies being used.This framework and workflow checklist emerged to facilitate operations when the need for rapid implementation directly competes with sufficient time to consider ethical and equitable engagement strategies.
We engaged the RADx-MA CHCs and LCAGs in three 1-hour collaborative discussions to define ethics and equity and to better understand how each CHC developed and sustained their LCAG and operationalized their equity strategies; resulting thematic analyses were then shared with LCAG membership and CHC participants for feedback and their input was incorporated.
Using the CHC's definitions of ethics and equity and themes that emerged from the community discussions, the FQHC-led ethics and equity framework includes: 1: 1) FQHC as leader; 2) centering of community engage-ment and transparency; 3) partnershipdriven approaches, and 4) race/ethnicity and language data to guide assessment and response informed by FQHC governing policy.Each of these themes is understood within the context of social determinants of health and illustrates an important intersection between the relational public health framework presented by Pacia et al and the insights and expertise of our FQHC-led collaborators in the implementation of equity-driven and community-responsive care.The framework and workflow checklist support the CHC's need for rapid translation of emerging issues, data into action, and equity-driven decision-making within the fast-paced, resource-constrained environment.The complementary workflow checklist emphasizes the operational culture of FQHCs, making it a living process to be adopted widely, applied, shared, and adapted as needed.Prioritizing the FQHC learning community of practice reflects the FQHC culture of sharing and iteratively adapting frameworks/workflows, maximizing the likelihood they will better address community needs.

Conclusion
CHC readiness to translate findings into action offers a unique opportunity to conduct FQHC-engaged and -led research to guide future public health implemen-

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Has a community advisory group (CAG) been engaged?
□ Who is the target population being served?□ Who might be missed?How will they be identified and engaged?□ Which resources and training are essential?□ Is the initiative staffed to mirror the population served?□ How will patients and community access the available services?□ What unintended consequences may arise?How will they be addressed?CHC readiness to translate findings into action offers a unique opportunity to conduct FQHC-engaged and -led research to guide future public health implementation and response strategies that advance the evidence base of ethics and equity-driven innovation, leadership, and results.FQHCs are agile and experienced equity leaders and are uniquely positioned as critical public health and research partners to achieve ethical and equitable reach and maximize the impact of essential resources.

Figure 1 FQHC
Figure 1 FQHC-led Ethics and Equity Framework

Figure legend:
Figure legend:The FQHCs and their LCAGs identified defining terms to guide ethics and equity (box on left).Four domains emerged to guide initiatives that are FQHC-engaged and ethics and equity informed (circle quadrants).In sum, 1)the FQHC needs to be a leader and power dynamics equalized by supporting dynamic leadership across a wide range of team members (entry level through executive); 2) the process should be community engaged and transparent with attention to tailored response and communication reflective of the community served; 3) the initiative should be partnership driven with strategic planning to support inter-institutional resource sharing as needed taking into consideration the need for rapid translation of needs and data into action and weighing the capacity and bandwidth of the staff/resources against the burden of the need; and 4) Race/ethnicity and language data and FQHC policy should be used to guide the approach following FQHC best practice of quality improvement and equity-driven.

Cristina Huebner Torres, Ph.D., M.A., is
and related health inequities every day.
D., hematologist-oncologist, is Professor of Medicine, Harvard Medical School, and Director of the MRCT Center, SMART IRB, and other programs.Karen Emmons, Ph.D., is a Professor of Social and Behavioral Science at Harvard Chan School of Public Health.journal of law, medicine & ethics INDEPENDENT The Journal of Law, Medicine & Ethics, 52 (2024): 41-44.© The Author(s), 2024.Published by Cambridge University Press on behalf of American Society of Law, Medicine & Ethics.