Linking Quality and Equity

Roadmap Step 1: Linking Quality and EquityEquity and Quality are connected. Equity is a cross-cutting component of quality. As such, it also needs to be a cross-cutting component of quality improvement.

Some people think that equity is only an issue of access. In other words, that disparities are caused by the fact that many minority patients can't easily access affordable healthcare.

It is true that many patients from minority backgrounds have poor access to care. However, research has demonstrated that that even when access to care is equal, racial and ethnic minority patients tend to receive lower quality care than do white patients.

So, even equal access can result in unequal care. Likewise, quality improvement that only focuses on the overall population, and fails to address racial and ethnic differences, can result in unequal quality.

We know that even when quality improvement efforts improve outcomes across the entire patient population, disparities between racial/ethnic groups can remain or even worsen.

What is quality care? Equitable care?

What is quality care?

The Agency for Healthcare Research and Quality defines quality care as "doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results."

Quality health care is:

  • Safe
  • Effective
  • Patient/family-centered
  • Timely
  • Efficient

What is equitable care?

Equitable care is care that does not vary in quality because of someone's race, gender, income or location. However, it may vary in practice, because quality care – the right thing at the right time—is different for different people.

Equitable care does not mean treating every patient exactly the same. Instead, equitable care ensures optimal outcomes for all patients regardless of their background or circumstances.

How do quality care and equitable care relate to one another?

In its Future Directions Report, the Institute of Medicine moved Equity from being a single component of quality care to a cross-cutting dimension.

In practice, this means each component of quality (effectiveness, safety, timeliness, etc.) may mean different things to different patients. And we need to consider those differences as we address each component.

Quality improvement affects different populations differently

Quality improvement is intended to improve outcomes for all patients over time.

You may have heard the phrase, "a rising tide lifts all boats." When it comes to reducing disparities, however, this is often not true. Quality improvement efforts aimed at a general or non-specific population may fail to improve, or even worsen disparities.

It's counter-intuitive to think that quality-improvement initiatives can improve health overall, but make disparities worse. That's why it's important to focus on not just overall health, but also on the gap in quality between white and minority patients.    Health outcomes may improve overall—but does the difference in outcome remain?

When planning quality improvement initiatives, remember that there are multiple possible outcomes:

Differential impact of quality improvement

  •  The gap could remain the same over time.
  • Or it could narrow over time, with minority patients' outcomes coming closer to those of whites.
  • Or the gap could widen.

An example of quality improvement that worsened disparities

This is a graph showing the rate of breast cancer mortality in 1990 and 2005 in Chicago, adapted from information published in the American Journal of Public Health. On the Y axis you have rate of death from breast cancer and on the X axis you have time. On this graph lower is better – it means that fewer people died. The black line represents Non-Hispanic Blacks and the blue line, Non-Hispanic Whites.

Although it’s difficult to discern in the graph, mortality related to breast cancer decreased for both white and black patients. However, the gap between white and black patients grew significantly, from 20% to 99%.

Adapted from:
(Jennifer M. Orsi, Helen Margellos-Anast, and Steven Whitman.  Black–White Health Disparities in the United States and Chicago: A 15-Year Progress Analysis. American Journal of Public Health: February 2010, Vol. 100, No. 2, pp. 349-356.)


These findings demonstrate that you can improve outcomes for all patients but the disparities between racial and ethnic groups can still widen. These gaps remain invisible unless they are specifically examined. In the previous example, if we just measured breast cancer mortality across the entire patient population, we would be thrilled to see an overall decrease. But that would tell a very incomplete story.