How to undertake equity-focused quality improvement

Equity-focused quality improvement offers a useful strategy for health care organisations to reduce inequalities and improve outcomes. Equity is a central part of quality and all quality improvement (QI) strategies should consider equity. This may involve focusing improvement efforts on reducing the gap between different groups, and/or targeting interventions at specific disadvantaged groups. Simple strategies such as effective resource allocation, using data well, and patient involvement, are key to ensuring QI delivers benefits to everyone.

Quality improvement (QI) is a cornerstone of the NHS. It can be defined as “systematic, data-guided activities designed to bring about an immediate improvement in health care delivery in particular settings” (1). 

Equity, as defined by the World Health Organisation, is the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (2), and is an important part of quality. 

In 2001, the Institute of Medicine published “Crossing the Quality Chasm” which highlighted equity as one of the six core aspects of quality care: (3) 

• Safe
• Effective
• Patient Centered
• Timely
• Efficient
• Equitable
  

In practice, equity is often neglected compared to the other aspects of quality. An effect of this is that QI projects can sometimes increase health inequalities, resulting in Intervention Generated Inequalities (4). There are several notable examples of QI projects that have widened gaps in outcomes or disproportionately benefited privileged groups (5). For example, a Health Information Technology (HIT) QI project undertaken in the USA had the following inequitable outcomes: 

• Quality of care improved for 14 of 17 measures in White patients but only 10 of 17 measures in Black patients. 
• Racial disparities existed at baseline in 7 of 17 measures, but by the end disparities had widened in one measure, and two new disparities had emerged (6). 

Academic literature has called for equity-focused quality improvement approaches to ensure that QI does not widen inequalities, and instead helps to reduce them (7-9). EF-QI can attempt to address inequalities in two ways: 

1. By ensuring equitable distribution of the benefits of QI projects and preventing equity gaps emerging. 
2. By using QI to target specific disadvantaged groups (e.g. homeless populations) or specific conditions intrinsically associated with social disadvantage (e.g. addiction, smoking, obesity). 

NHS England’s new health inequalities programme, Core20PLUS5, states that it will be “driven by QI methodologies to ensure measurable and sustained improvement” for disadvantaged groups (10). However, in practice the UK lags behind other countries in using QI methods to address inequalities. It is important to begin integrating EF-QI principles into everyday QI practice to ensure the aims of Core20PLUS5 are achieved. 

When doing EF-QI, 5 main practical steps can be followed:

Various strategies can be used to help ensure that the steps outlined above are achievable. They include: 

Promoting an organisational commitment to equity 

Doing EF-QI involves fostering a professional and organisational culture that promotes equity. This involves acknowledging that good quality improvement projects will always require a commitment to health equity (9). 

Using resources well 

Adding an inequalities perspective to QI projects is likely to require time and support to be successful. This can be difficult in a health system under increasing strain. One way to resolve this is by providing protected time for staff to do EF-QI. Similarly, building strong QI infrastructure that facilitates easy access to different types of data, and encourages co-production, can help to make sure that time spent on QI is equity-focused. 

Using data well

Monitoring tools, such as Statistical Process Charts, plot average improvement over time, but do not disaggregate the data to explore who benefits most (or least). To be able to assess quality by disadvantaged group, data should be disaggregated before, during and after QI activities. 

Similarly, qualitative data should be used throughout the QI project to understand the perspectives of staff and patients. This could include interviews or focus groups, or could be as simple as leaving dedicated time for staff to give verbal feedback on QI projects. 

Promoting co-production and user involvement throughout projects

Partnering with communities and patients who face disadvantage is important to ensure shared decision-making. By working with those who are most likely to experience the sharp end of health inequalities, QI initiatives are more likely to support those with the greatest needs. 

To do co-production well, it is important to:

• Commit to inclusion from the outset 
• Build a diverse mix of patient groups
• Include multidisciplinary staff members with varied professional backgrounds and experience in project planning

QI practitioners should note that community and patient engagement itself has the potential to increase inequalities. This can occur if health care organisations primarily engage with communities and patients who already experience privilege in the current system. Good co-production is not just about listening to different voices, but is about considering whose voice is magnified through user involvement. 

1. Lynn J. The Ethics of Using Quality Improvement Methods in Health Care. Ann Intern Med. 2007 May 1;146(9):666.
2. Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. 2010 [cited 2023 Nov 20]; Available from: http://drum.lib.umd.edu/handle/1903/23135
3. Institute of Medicine, editor. Crossing the quality chasm: a new health system for the 21st century. 9. print. Washington: National Acad. Press; 2001. 337 p.
4. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health. 2013 Feb 1;67(2):190–3.
5. Weinick RM, Hasnain-Wynia R. Quality Improvement Efforts Under Health Reform: How To Ensure That They Help Reduce Disparities—Not Increase Them. Health Aff (Millwood). 2011 Oct;30(10):1837–43.
6. Jean-Jacques M, Persell SD, Thompson JA, Hasnain-Wynia R, Baker DW. Changes in Disparities Following the Implementation of a Health Information Technology-Supported Quality Improvement Initiative. J Gen Intern Med. 2012 Jan;27(1):71–7.
7. Reichman V, Brachio SS, Madu CR, Montoya-Williams D, Peña MM. Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities. Semin Fetal Neonatal Med. 2021 Feb;26(1):101198.
8. Hirschhorn LR, Magge H, Kiflie A. Aiming beyond equality to reach equity: the promise and challenge of quality improvement. BMJ. 2021 Jul 20;374:n939.
9. Lion KC, Faro EZ, Coker TR. All Quality Improvement Is Health Equity Work: Designing Improvement to Reduce Disparities. Pediatrics. 2022 Mar 1;149(Suppl 3):e2020045948E.
10. NHS. Core20PLUS5 – an approach to reducing healthcare inequalities [Internet]. 2021 [cited 2023 Sep 6]. Available from: https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/

1. Institute for Healthcare Improvement. Getting Started with QI and Health Equity: “Don’t Be Intimidated. Be Inspired”. Available from: https://www.ihi.org/communities/blogs/getting-started-with-qi-and-health-equity-dont-be-intimidated-be-inspired-
2. Centre for the Health Professionals. Bringing Equity into QI: Practical Steps for Undertaking Improvement [Internet]. 2012. Available from: https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/6.2%20Part%202_Equity%20into%20QI.pdf

Johnson L, Dehn Lunn A, Ford J. How-to guide: How to undertake equity-focused quality improvement. Health Equity Evidence Centre; 2024.