Title: Building an Equitable Healthcare System through Equity-Focused Quality Improvement (EQUAL-QI)
Funder: Department of Health and Social Care

Abstract: Between November 2020 and October 2021, there were over 2.1 million adverse patient safety events recorded by hospital staff. Previous research has estimated over 11,000 deaths are due to poor care in English hospitals annually. Quality improvement (QI) seeks to improve care and safety. It is a fundamental part of the NHS, with thousands of projects undertaken each year, ranging from clinical audits within ward teams to large-scale system redesign.Equity is included in most definitions of quality but is rarely considered in NHS QI projects. QI has considerable potential to address inequalities, for example, through maximising the distribution of benefits to lower socio-economic or minority ethnic groups or targeted projects to improve care for disadvantaged patients. However, there are cautionary examples of QI projects which have inadvertently increased inequalities. These so-called intervention-generated inequalities can arise when, for example, QI projects use targets based on average performances meaning that underserved populations remain underserved.Equity-focused quality improvement (EF-QI) is an approach to considering health inequalities throughout QI. While no single definition exists, this is likely to involve assessing the quality of care, such as socio-economic status or ethnicity, and ensuring improvement initiatives support disadvantaged groups. Alternatively, EF-QI could target specific disadvantaged groups, such as people who are homeless. Co-production with patients and healthcare staff is key to EF-QI. Currently, the UK lags behind other nations, such as the US, in incorporating equity into QI projects. National NHS policymakers recognise the potential of QI to address inequalities, and it is a central part of the flagship NHS health inequalities programme, CORE20Plus5.This research has two aims: first, to explore the types of QI that increase or decrease inequalities, for whom, in what circumstances, how and why, and; second, to develop and evaluate an EF-QI support and training package that incorporates co-production. This research focuses on frontline staff and QI teams in acute hospitals. There are five work packages (WP):- WP1: a realist review of the existing literature to develop a programme theory that explains the contexts and underlying mechanisms by which QI may increase or decrease healthcare inequalities.- WP2: refine and expand the programme theory from WP1 with 20-30 realist interviews with hospital staff involved in QI.- WP3: series of 12-16 in-depth case studies of completed QI projects in four hospitals to understand the impact of existing QI projects on inequalities - WP4: co-produce with patients and healthcare staff an EF-QI support and training package for NHS hospitals drawing upon Ostrom's co-design principles.- WP5: pilot, refine, and evaluate the support and training package using realist approaches.Findings will be shared through a comprehensive dissemination programme targeted at policymakers, hospitals, QI organisations and researchers.For too long, QI has focused on narrowly defined improvement objectives rather than considering how the benefits may be distributed (or not) across disadvantaged groups. This research will help facilitate a step-change in the approach to QI, helping hospitals undertake QI projects designed with equity in mind to support disadvantaged groups.

Lay abstract: Last year there were over 2 million recorded examples of poor-quality care in NHS hospitals. Previous research estimated that over 11,000 hospital deaths are due to poor care each year in England. Every year the NHS undertakes thousands of projects to improve the quality of care, so-called Quality Improvement or QI. These range from large national programmes to small projects led by staff in one hospital ward. While there is not one definition of what quality of care means, most definitions include fairness. For example, good quality hospital care means that everyone should have a fair chance of benefitting from hospital treatment no matter their wealth, gender, age or ethnicity. When care is not provided fairly, it causes health and care inequalities.Healthcare inequalities are differences in healthcare across or between certain groups of patients, for example, those on low incomes or those belonging to a minority ethnic group. Reducing inequalities in health care is a top priority in the NHS. We do not know how QI programmes address or impact these inequalities. QI programmes can improve inequalities, such as those aiming to improve the care of people who are homeless when they visit the emergency department. Sometimes, however, healthcare inequalities may be worsened. For example, NHS initiatives encouraging hospitals or GP surgeries to reach a particular target can mean that staff focus first on easily reached patients rather than disadvantaged groups.This research aims to understand why certain types of QI projects improve or worsen healthcare inequalities and develop, with patients and staff, new training and support to help hospitals consider healthcare inequalities when using QI. It brings together three separate research fields - health inequalities, quality improvement and co-production (e.g. equal working between patients and staff).The research has five different parts: First, I will review previous studies to understand what types of QI projects improve or worsen inequalities, why, for which groups and in what circumstance. Second, I will take this understanding from the review to 2030 hospital staff who already undertake QI projects from across the country to find out what they think and if there are any gaps. The hospital staff members will be invited from an existing QI community. Third, I will work with four hospitals based in Liverpool, Sunderland, Peterborough, and Harlow to identify and examine the impact on inequalities of up to 16 completed QI projects. This will involve looking at the data with an inequalities lens, examining reports and speaking to those involved. Fourth, using the first three parts of the research, I will work in equal partnership with up to ten staff and ten patients to develop training and resources. The process will be jointly led by patients and staff who will decide how to organise the process and spend the budget for this part of the research. Finally, I will roll out the new training and resources in the six hospitals to see the impact. I will ask each hospital to change how they do QI in at least four projects over 12 months, although they may change more. I will collect information to see how much the support and training have changed QI projects to address inequalities and broader hospital changes.I will share the results and resources widely and in different ways to communicate the findings. This research can lead to a step-change in how hospitals use QI projects to address healthcare inequalities and help staff think about inequalities across all parts of their work.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE