Every year, over 11,000 deaths in English hospitals are linked to poor care, and hospital staff recorded more than 2.1 million patient safety incidents between November 2020 and October 2021. The NHS runs thousands of quality improvement (QI) projects to address this, but these efforts rarely consider whether the benefits reach disadvantaged groups—and can sometimes widen inequalities. This research aims to change that by developing an equity-focused QI support and training package for frontline hospital staff. The team will first review existing evidence and interview staff to understand how QI projects can either reduce or worsen inequalities. They will then study completed QI projects in four hospitals to see their real-world impact. Finally, they will co-design a training package with patients and staff, pilot it, and evaluate its effectiveness. If successful, this work could help hospitals routinely design QI projects that actively reduce, rather than inadvertently increase, health inequalities for groups such as lower socio-economic or minority ethnic communities and people who are homeless.
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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.
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