Equitable Rulemaking

Ensuring Everyone is Given a Voice


Health Systems Quality Assurance recognizes the difficulties all communities may face when attempting to participate in our rulemaking processes. It is important to center diversity, equity, inclusion, and belonging into our engagement processes, rulemaking, and oversight systems. We want to eliminate inequitable practices and promote health equity throughout the state. We hope that the regulatory system has successful changes in the engagement process, including using listening sessions and collaborative rule workshops, using storytelling to implement new rules. 

Barriers in Regulation

In 2020, Washington State Governor Jay Inslee issued executive order 22-04, declaring Washington State as a pro-equity anti-racist state. Moving towards a pro-equity/anti-racism government organization with health regulatory functions is complex. Many policy decisions and rulemaking processes focus on equal access and participation opportunities and functions under the assumption that everyone has the same understanding of regulatory functions and access to meetings that are responsible for guiding policy. In addition, regulatory systems must follow Washington laws. These laws guide our work, and we recognize that they may be contributing to oppressive systems. These systems have been functioning for hundreds of years and will take time to change.

  • Our laws create equal systems, not equitable systems. We need to find ways to remove barriers that prevent everyone from participating at the table, having their ideas included, and feeling as if they belong.
  • We must follow regulatory systems and laws that guide our work. Laws limit us in many ways. We are part of the executive branch and are responsible for making sure our systems follow those laws.
  • Oppressive systems that have been functioning for years will take time to change. We are still responsible for changing these systems. We must bring innovative ideas forward to create meaningful change.
  • While we don’t create the laws, we are responsible for fulfilling them, and our community is not always aware of this. We must communicate clearly about our roles and responsibilities and where we are bound by law.
  • There is a lack of diversity among our workforce, with technical requirements that limit our hiring ability. Lack of diversity can give the impression that we are unwilling to listen, or we have the same inequitable thinking patterns.

Steps to Equitable Rulemaking

In 2021, the Washington State Legislature passed a law requiring all health care professionals to take health equity continuing education every four years. Through the implementation of the law, the department used a new and innovative approach to engage stakeholders with lived experiences in health inequities to elevate voices frequently forgotten during the rulemaking process; what we learned and now use as a guide in current and future implementations is three steps.

1. Collaborative Engagement – We used existing partnerships to create new partnerships and meet with affected communities. We were able to provide documents that ensured that all individuals could understand. We worked with partners to identify missing communities and use new outreach strategies that were co-created with communities. 

  • Use culturally and linguistically appropriate documents
  • Use unique outreach strategies; one size does not fit all
  • Engagement planning creates transparency and direction
  • Create non-negotiables for the process so everyone knows of what can be done

2. Listening Sessions – Create an environment where the community can participate and show their experiences with a topic, share ideas to overcome challenges, and make everyone aware of what they hope to be an outcome.

  • Create a safe space for all to be included and belong with the addition of agreements
  • Be Transparent on how stories will be used and times we might not be able to 
  • Elevate Voices that are not often heard; give those voices space, time, and attention
  • Use stories to create data. There is a wealth of qualitative data that can uncover themes 
  • Real-time Interpretation increases accessibility. Making our meetings accessible increases engagement

3. Collaborative Rules – Encourage robust discussions and formulate drafts in collaboration with the community in rulemaking sessions. Share drafts prior to meetings, go through drafts during the session and make visible notes, and provide data and questions that provoke discussion.

  • Provide all data in plain talk; it is important to work with all in the room, regardless of their credentials
  • Remind participants of data gathered from listening sessions and ensure that data guide the process
  • Connect listening sessions to rulemaking and continue those conversations
  • Ensure that discussion includes all voices and there is opportunity to provide input in varying ways
  • Involve the community and remind them that they are just as welcome to come and participate in the process as those who are paid to attend.

Advancing Health and Racial Equity

Historically, the way public health agencies regulate and develop policy did not represent all communities. There are many ways the system can adapt while staying within the required legal structures. We know public health is improved when all individuals are closer to achieving health equity. Our public health systems fail at addressing public health issues if they do not ensure equitable practices are rooted in oversight and regulation policies. 

Improving engagement and focusing on equity provides an avenue for individuals to overcome barriers that prevent them from participating in processes that have a direct impact on health. Innovations within our rulemaking and policy processes can lead to equitable decision-making. By improving engagement with all communities that our work impacts, we receive a diverse viewpoint that may better reflect better practices for all individuals. Listening sessions build upon engagement activities and show a commitment to inclusion to the public and aim to mobilize voices in ways that strengthen equitable policies. Facilitating collaborative rulemaking gives space for voices to come together and create stronger policies. Health organizations must build partnerships with diverse community members and change engagement practices. 

Better policies that promote equitable health system oversight, ensure appropriate training among health care professionals, and create healthier spaces to provide health care, and lead to improved health outcomes. Although this is just a small piece of work, this innovative work goes to addressing systemic and systematic issues.

To learn more about this process and other equity centered work, contact the health systems quality assurance equity and social justice team.