Journal article
A realist review of how, why, for whom and in which contexts quality improvement in healthcare impacts inequalities
- Abstract:
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Introduction: Quality improvement (QI) is aimed at improving care. Equity is one of the six domains of healthcare quality, as defined by the Institute of Medicine. If this domain is ignored, QI projects have the potential to maintain or even worsen inequalities.
Aims and objectives: We aimed to understand why, how, for whom and in which contexts QI approaches increase, or do not change health inequalities in healthcare organisations.
Methods: We conducted a realist review by first developing an initial programme theory, then searching MEDLINE, Embase, CINAHL, PsychINFO, Web of Science and Scopus for QI projects that considered health inequalities. Included studies were analysed to generate context-mechanism-outcome configurations (CMOCs) and develop an overall programme theory.
Results: We screened 6259 records. Thirty-six records met our inclusion criteria, the majority of which were from the USA. We developed CMOCs covering four clusters: values and understanding, resources, data, and design. Five of these described circumstances in which QI may increase inequalities and 15 where it may reduce inequalities. We found that QI projects that are values-led and incorporate diverse, patient-led data into design are more likely to address health inequalities. However, when staff and patients cannot engage fully with equity-focused projects, due to practical or technological barriers, QI projects are more likely to worsen inequalities.
Conclusions: The potential for QI projects to positively impact inequalities depends on embedding equity-focused values across organisations, ensuring sufficient and appropriate resources are provided to staff delivering QI, and using diverse disaggregated data alongside considered user involvement to inform and assess the success of QI projects. Policymakers and practitioners should ensure that QI projects are used to address inequalities.
- Publication status:
- Published
- Peer review status:
- Peer reviewed
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(Preview, Version of record, pdf, 942.5KB, Terms of use)
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- Publisher copy:
- 10.1136/bmjqs-2024-017386
Authors
- Publisher:
- BMJ Publishing Group
- Journal:
- BMJ Quality & Safety More from this journal
- Volume:
- 34
- Issue:
- 8
- Pages:
- 537-546
- Publication date:
- 2025-01-19
- Acceptance date:
- 2024-11-25
- DOI:
- EISSN:
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2044-5423
- ISSN:
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2044-5415
- Language:
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English
- Pubs id:
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2079335
- Local pid:
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pubs:2079335
- Deposit date:
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2025-01-20
- ARK identifier:
Terms of use
- Copyright holder:
- Johnson et al
- Copyright date:
- 2025
- Rights statement:
- © Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
- Licence:
- CC Attribution (CC BY)
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