Framework for Inequality in Quality Improvement (QI)

Say you are in clinic, and you have noticed that there is an increase in patients struggling to control their blood pressure. You, astute clinician that you are, decide that the way to fix this is to promote close follow up. What if, one week after their visit, you had your patients return for a nursing visit to recheck their blood pressure? You pat yourself on the back for a job well done.


Several months later, you realize an odd trend. Some of your patients are not coming to their nursing visits to follow up on their blood pressure. You notice that many of the patients failing to show up are the patients who need it the most. You’re frustrated. You created this wonderful quality improvement initiative. Why isn’t it working?


No matter how noble your intentions, quality improvement projects can unintentionally perpetuate the health inequality that contributes to the problems you are trying to solve. Take, for example, your nursing visits. By requesting patients return to the clinic, are you unintentionally alienating your patients who work during the day, who cannot take off twice for a doctor’s visit? What about those who struggle with transportation to and from clinic, or those with mobility issues?


By creating a health equity framework through which to view quality improvement initiatives, it can be easier to avoid common pitfalls with quality improvement projects. Questions, such as the ones below, can act as a checklist to ensure that no one is overlooked in an attempt to improve health outcomes. Questions are adapted from Health Equity Curricular Toolkit from Starfield II Health Equity Summit:


1. What are you or your team trying to improve?

2. Who does this intend to serve?

3. What data or evidence guides this intervention/practice/policy/etc. (Consider all demographic data; maps; qualitative experience, etc.)?

4. What is the data telling you about inequities experienced in the community?

5. Does the data take into account community priorities and culturally-specific feedback?

6. Whose voice is missing from this discussion


While these questions do not cover every aspect of health inequality, they can help open up a conversation about how to truly reach everyone that you want to reach. By making questions like these a standard part of the QI process, you can help avoid common pitfalls before they happen.


For more tools to address socio-economic determinants of health inequality, check out the Health Equity Curricular Toolkit from the American Academy of Family Physicians.


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