Quality improvement and health inequalities

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.

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.

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.

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: 

1. Values and Understanding: how people think about and understand questions of health equity can impact the way EF-QI is done.
2. Resources: the right resources, adequate training and a sustainable workload are central to producing EF-QI.
3. 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.
4. 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.

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.

Read the Institute of Medicine’s report Crossing the Quality Chasm. 

Learn 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.