Advancing quality improvement initiatives to address the root causes of health inequity

According to the Lancet Global Health Commission on High Quality Health Systems, poor-quality healthcare contributes to more deaths globally than lack of access to care. While quality improvement initiatives have the potential to help achieve equitable, high-quality care, many prior efforts have maintained or exacerbated existing care quality and health inequalities, as demonstrated by the ongoing COVID-19 pandemic.

A recent Northwestern Medicine editorial published in The BMJ suggests that improving the design and implementation of quality improvement initiatives must go beyond measuring average care quality and change to evaluate existing quality and address the root causes of health inequity.

We need to tailor quality improvement initiatives to make them more responsive to underlying causes of inequity, including making them more culturally competent to ensure that people-centered care as a core domain of quality is defined from the perspective of the person, not necessarily the perspective of the healthcare system. Traditional quality improvement has in the past focused on what healthcare thinks are the gaps and solutions, so bringing in the community to hear their voices, learn what do they think the challenges are and solutions to getting quality care is a very important component."

Lisa Hirschhorn, MD, MPH, professor of Medical Social Sciences, of Psychiatry and Behavioral Sciences and senior author of the editorial

Hirschhorn and colleagues defined three potential outcomes of quality improvement on health equity: equality in improvement (improvement for all but still maintaining the equity gap), decreasing the equity gap and widening the equity gap. According to the authors, effective quality improvement initiatives must be designed with clear health equity aims, measure change among disadvantaged subpopulations and include a strong evaluation process to identify which of these three outcomes are achieved and where more change is needed.

Furthermore, the authors identified five key areas where changes in quality improvement initiatives are needed to address equity: stakeholder engagement, measurement, design, improvement work and learning.

Specifically, stakeholders should be recruited from both within and beyond the quality improvement community, and include individuals with lived experiences of health inequities and policymakers that can facilitate change in the healthcare system. As for measuring and using data, the authors recommend that quality improvement program designers consider using qualitative measurements and plan for data disaggregation from the very beginning.

The authors also recommended moving beyond traditional ways to measure quality improvement and to instead use a multidisciplinary approach, including implementation science, patient-centered outcomes and research to learn about and improve quality improvement. They also encourage the quality improvement community to develop new partnerships with insurers, policy makers, community organizations and different institutions to expand the solution set available.

Hirschhorn noted the U.S. can learn from other countries currently implementing quality improvement initiatives in their healthcare systems designed to improve equity in order to better understand how to sustainably address and resolve health inequity gaps.

"If you want people to get effective care that’s timely and that’s safe and that's equitable, we need to be willing to look outside of our own health system and the solutions which are often being used," Hirschhorn said.