How to cultivate equity-oriented health care at an organizational level: lessons from a process evaluation of EQUIP emergency

Background

Widening social, economic, and health inequities intensify the need for equity strategies in health care if population health is to be improved. EQUIP Health Care, a program of research and knowledge mobilization aimed at supporting health care organizations to promote equity, has been developing and testing organizational-level interventions. This process evaluation of the implementation of EQUIP Emergency, a collaboration among staff and leaders at three diverse Emergency Departments, community and Indigenous leaders, and researchers, provides direction to organizations wishing to promote health and health care equity.

Methods

This process evaluation, grounded in the Active Implementation Frameworks, is based on analysis of qualitative comments from a staff survey (n = 313 comments), qualitative interviews with staff, leaders, and researchers (n = 43), and observational data captured as fieldnotes (n = 784 entries). A thematic analysis identified four themes pertaining to the process and implications of engaging with EQUIP Emergency.

Results

Despite a rhetorical and practical commitment to equity at all levels, other priorities, including ensuring staffing adequate to provide care, orienting new staff, and responding to escalating crises such as the unregulated drug poisoning emergency, violence in Emergency Departments, and later in the study, COVID-19, overshadowed efforts toward equity. The material (e.g. staffing) and non-material (e.g. skills) resources available to support and aligned with equity goals shaped the capacity of staff, leaders, and the organizations to enact equity goals. Our analysis led to 10 suggestions for leaders at all levels of health care, including clinical, executive, and policy leaders, for systematically cultivating equity in health care service settings.

Conclusions

To promote equity, health care organizations must approach equity as foundational, not as an “add-on,” link equity to key organizational issues, engage leaders from all relevant employment groups at the outset and throughout, engage and compensate staff at all levels and from all roles, and counter siloed bureaucracies (systemic structural misalignments) within their systems. Time for leaders to comprehensively plan should be augmented with analysis of local patient and staff data that can be shared with direct care providers to set the stage for implementing equity strategies and evaluating progress as an embedded way of doing business.

Trial registration

Clinical Trials.gov #NCT03369678 (registration date November 18, 2017)