Have you ever thought about how QI can impact health inequalities? Queen Mary University of London (QMUL) is currently undertaking a 5.5-year £1.3m research project funded by the National Institute of Health Research to explore this issue.
What is Equity Focused-Quality Improvement?
In 2001, the Institute of Medicine (IoM) made an urgent call for specific changes to health systems to improve care quality. Their five-year study looked at the way QI projects can either improve or worsen health care inequalities, and identified six core aspects of good quality care:
- safe
- effective
- patient-centred
- timely
- efficient and
- equitable.
In recent years, there has been a growing acknowledgment that equity is often left out of quality improvement conversations. QI projects have the potential to worsen inequalities if equity is not recognised as being one of the core aspects of quality, as in the case of a heath information technology project in the United States that resulted in a widening of health disparities between black and white patients. In public health, we call instances like this ‘Intervention Generated Inequalities’, or IGIs.
To remedy this, academics have begun to publish work based specifically on the idea of ‘equity focused-quality improvement’ (EF-QI). EF-QI places health equity at the core of improvement efforts.
A recent paper published in the American Association of Paediatrics argued that every QI interview should be treated as a health equity intervention. The paper went on to state that improvement projects as a whole need to be designed with an awareness of existing health disparities.
How does the NHS approach EF-QI?
Currently, there are no specific equity-focused approaches to QI in the NHS. Core QI frameworks such as PDSA, Six Sigma, and Lean do not explicitly mention health care inequalities or provide any guidance on how to include an awareness of health inequalities throughout projects.
However, specific QI efforts, such as that of the East London Foundation Trust have shown that there is a growing understanding of how important health equity approaches are to producing good QI.
CORE20PLUS5 is the new NHS England policy informing action on health inequalities. One of its aims is to improve health care for the most disadvantaged groups through QI.
While EF-QI is crucially important for this next stage of NHS strategy, there is little guidance about how to do it in practice.
At QMUL, we are trying to understand how these aims can be made a reality.
What have we learned so far?
During 2023, QMUL undertook a literature review to explore what has already been published on this topic from an academic perspective. The results of this review will be published in 2024 and shared with the Q community.
Our results suggest that four key aspects can lead QI practitioners towards EF-QI:
- Values and Understanding: how people think about and understand questions of health equity can impact the way EF-QI is done.
- Resources: the right resources, adequate training and a sustainable workload are central to producing EF-QI.
- Data: diverse data types (such as qualitative approaches) and the use of carefully disaggregated quantitative data can help to accurately track and monitor the success of EF-QI projects.
- Design: EF-QI projects need to be co-designed with patients and carers, alongside input from multidisciplinary teams. This helps to ensure that projects are designed to serve those who need them most.
In partnership with the Patient and Public Involvement and Diversity Special Interest Group, we also co-hosted a Q conversation about health equity in December 2023 which has provided us with high quality feedback for our work.
We are now moving into year two of the project which involves building our own body of qualitative data on improvement work to understand how to make equity integral across all QI activity.
Share your views with us
We would like individuals with experience of working in QI in secondary care in England to participate in a one-hour interview with us.
Our goal with these interviews is to test what we have learned from the academic literature with how work is experienced in real-world settings with the people who do QI on a regular basis.
From this evidence base, we aim to develop recommendations and resources to promote EF-QI more widely.
Find out more
Read the Institute of Medicine’s report Crossing the Quality Chasm.
Read more about how a heath information technology project in the United States resulted in a widening of health disparities between black and white patients.
Read a recent paper published in the American Association of Paediatrics on viewing QI interviews as health equity interventions.
I welcome you to share your views on this in the comments section or contact me.
Comments
Alan Gurbutt 15 Jan 2024
I would have thought health care inequalities would have been factored into QI from the very beginning. For example, if you want to improve obesity interventions, social determinants such as austerity and poverty are correlated with hopelessness and depressive illness, which can impact appetites and levels of physical exercise. Psychological distress in deprived and isolated localities is rarely factored into QI interventions because it is influenced by poor political policy choices. It is so much easier to blame the individual than address systemic issues.
Lucy Johnson 16 Jan 2024
Hi Alan, thanks for the comment! It's been really interesting doing this research and seeing how ideas about individual responsibility/agency are weighed up with equity considerations - as you've said often the solution to these things is structural. One of the things we've been thinking about is that QI needs to be as 'low agency' as possible to allow individuals to actually engage with services easily.
Alan Gurbutt 23 Jan 2024
Hi Lucy, you are doing a great job, thank you for your work.
My opinion is framed by my own experience of trying to make a difference in the community in which I live. I’ve promoted health care apprenticeships, children’s learning activities and equal opportunities. These initiatives were to overcome barriers at school, to preserve well-being across the lifespan.
I live in a place, whereby, children are segregated by grammar schools at 10 years old. I see educational inequality all around me, as a catalyst to wasted potential, misguided privilege and psychological distress. Inclusive education sets us free, it enables us to walk in the shoes of others, to see challenges and have empathy, it helps us to improve individual outcomes and build stronger communities.
Conversely, educational apartheid destroys the love of collective learning, it fosters a sense of failure, low self-esteem and loss of hope. It creates a hinterland between the provision of services and dependency upon services. This inequality is implicitly coded into hard to reach, seldom heard and service user disengagement. Selective education reduces opportunities for recruitment from deprived localities, so by default must impact the lens of QI.
I am a mental health nurse who believes that QI should encompass the Equality Act 2010. Low agency for me, would mean the complete redesign of mental health services so that survivor groups are able to truly lead on service provision, free from ableism. Of course this will never happen until the Mental Health Act 1983 is reformed to include the rights of people with disabilities.
In the meantime, we should be able to improve health care if we recognise social determinants as impositions placed upon individuals influence the need for QI to circumvent economic cuts and understaffing.
Best wishes,
Alan
Thomas John Rose 8 Feb 2024
QI seems to me to be a FLS activity. QI and FLS should not be expected to solve all the quality problems in the NHS and certainly not patients either. How about some High-agency QI.
Thomas John Rose 8 Feb 2024
I should have added that I do support your research into EF-QI and see it's value in designing relevant QI projects.
Thomas John Rose 22 Mar 2024
FLS is Front Line Staff. The problem with QI is that it is not supported by a management system. NHS Impact calls for the introduction of management systems in the NHS. These sorts of systems are very difficult to design and implement from scratch, particularly with little previous experience as in the NHS. The new British standard, BS ISO 7101:2023, Quality management in healthcare, could help with this. It is based around the six core aspects of good quality care, including 'equitable', see clause 3.26.