Johnson Lucy Lara, Wong Geoff, Kuhn Isla, Martin Graham P, Kapilashrami Anuj, Lennox Laura, Black Georgia Bell, Hill Matthew, Swiers Ryan, Mahmood Hashum, Jones Linda, Beng Jude, Ford John
Queen Mary University of London Wolfson Institute of Population Health, London, UK.
Primary Care Health Sciences, University of Oxford, Oxford, UK.
BMJ Qual Saf. 2025 Jul 18;34(8):537-546. doi: 10.1136/bmjqs-2024-017386.
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.
We aimed to understand why, how, for whom and in which contexts QI approaches increase, or do not change health inequalities in healthcare organisations.
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.
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.
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.
质量改进（QI）旨在改善医疗服务。公平是医学研究所定义的医疗质量六个领域之一。如果忽视这一领域，质量改进项目有可能维持甚至加剧不平等现象。
我们旨在了解质量改进方法在医疗组织中为何、如何、针对谁以及在何种背景下会增加或不改变健康不平等现象。
我们进行了一项现实主义综述，首先制定初始项目理论，然后在MEDLINE、Embase、CINAHL、PsychINFO、科学引文索引和Scopus中搜索考虑健康不平等问题的质量改进项目。对纳入的研究进行分析，以生成背景-机制-结果配置（CMOCs）并制定总体项目理论。
我们筛选了6259条记录。36条记录符合我们的纳入标准，其中大部分来自美国。我们制定了涵盖四个集群的CMOCs：价值观与理解、资源、数据和设计。其中五个描述了质量改进可能增加不平等的情况，15个描述了质量改进可能减少不平等的情况。我们发现，以价值观为导向并将多样化、患者主导的数据纳入设计的质量改进项目更有可能解决健康不平等问题。然而，当工作人员和患者由于实际或技术障碍无法充分参与以公平为重点的项目时，质量改进项目更有可能加剧不平等现象。
质量改进项目对不平等现象产生积极影响的潜力取决于在整个组织中融入以公平为重点的价值观，确保为实施质量改进的工作人员提供足够和适当的资源，并使用多样化的分类数据以及考虑用户参与情况来为质量改进项目提供信息并评估其成功与否。政策制定者和从业者应确保利用质量改进项目来解决不平等问题。
