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[ Home ](https://mdster.com) 2. [ Blog ](https://mdster.com/blog) 3. [ Medical Education ](https://mdster.com/blog?category=medical-education) 4. Equity in QI: Prevent Better Care From Widening Clinical Gaps [ Medical Education ](https://mdster.com/blog?category=medical-education) Equity in QI: Prevent Better Care From Widening Clinical Gaps =============================================================== Use stratified measures, community partnership, and smarter intervention design to make improvement work for every patient. [ MDster Editorial Team ](https://mdster.com/about) · Oct 23, 2026 · 5 min read · 43 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) \| [Corrections Policy](https://mdster.com/corrections) [ Quality Improvement ](https://mdster.com/blog?tag=quality-improvement) [ Patient Safety ](https://mdster.com/blog?tag=patient-safety) [ Internal Medicine ](https://mdster.com/blog?tag=internal-medicine) [ Health Equity ](https://mdster.com/blog?tag=health-equity) ![Equity in QI: Prevent Better Care From Widening Clinical Gaps](https://mdster.com/storage/blog/images/equity-in-qi-prevent-better-care-from-widening-clinical-gaps.png) Share this article Share this post On this page 1. [ The failure mode: improvement for some, exclusion for others ](#the-failure-mode-improvement-for-some-exclusion-for-others) 2. [ Anticipate the access barrier before launch ](#anticipate-the-access-barrier-before-launch) 3. [ Make the equity question measurable ](#make-the-equity-question-measurable) 4. [ Stratify outcomes—not merely participation ](#stratify-outcomes-not-merely-participation) 5. [ Let patients help design the change ](#let-patients-help-design-the-change) 6. [ Partnership means influence, not just feedback ](#partnership-means-influence-not-just-feedback) 7. [ Test, learn, and decide whether to scale ](#test-learn-and-decide-whether-to-scale) 8. [ Put equity into each PDSA cycle ](#put-equity-into-each-pdsa-cycle) 9. [ Key Takeaways ](#key-takeaways) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) On this page 1. [ The failure mode: improvement for some, exclusion for others ](#the-failure-mode-improvement-for-some-exclusion-for-others) 2. [ Anticipate the access barrier before launch ](#anticipate-the-access-barrier-before-launch) 3. [ Make the equity question measurable ](#make-the-equity-question-measurable) 4. [ Stratify outcomes—not merely participation ](#stratify-outcomes-not-merely-participation) 5. [ Let patients help design the change ](#let-patients-help-design-the-change) 6. [ Partnership means influence, not just feedback ](#partnership-means-influence-not-just-feedback) 7. [ Test, learn, and decide whether to scale ](#test-learn-and-decide-whether-to-scale) 8. [ Put equity into each PDSA cycle ](#put-equity-into-each-pdsa-cycle) 9. [ Key Takeaways ](#key-takeaways) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) Your clinic’s new portal-based hypertension program raises follow-up rates. At the celebration meeting, someone asks whether patients who need an interpreter improved too. Nobody knows. **Equity in QI** starts with that question: not just whether the average moved, but who benefited—and who could not use the intervention. The failure mode: improvement for some, exclusion for others ------------------------------------------------------------ ### Anticipate the access barrier before launch An intervention can generate inequity when its benefits depend on resources patients do not share. Portal-only outreach, for example, assumes portal access, reliable connectivity, digital confidence, and an understandable message. If those assumptions differ across patients, an improved clinic-wide average may coexist with a wider gap. Research on patient portals has documented disparities in access associated with socioeconomic and healthcare factors. [\[1\]](#cite-1 "Reference [1]") Map the intervention from invitation through clinical benefit. At each step, ask who can receive it, act on it, and complete follow-up. For a BP program, those steps include obtaining a usable cuff, reporting readings, getting medication adjustments, and affording or collecting prescriptions. Do not mistake enrollment for blood-pressure control. - Offer routes besides the portal, such as telephone or in-person follow-up. - Arrange qualified interpretation and accessible materials rather than asking patients to bridge communication gaps themselves. - Check whether cuff access, appointment times, or transportation make the proposed workflow unrealistic. > **Clinical Pearl:** If your QI dashboard shows only the overall rate, it cannot tell you whether improvement reached the patients most likely to be missed. Make the equity question measurable ----------------------------------- ### Stratify outcomes—not merely participation Define an eligible denominator before examining subgroup results. For example, count all clinic patients eligible for hypertension follow-up, not just those who activated the portal. Otherwise, the very barrier under investigation disappears from the analysis. Keep numerator, denominator, observation period, and exclusions consistent across groups. Stratify measures by relevant, appropriately collected variables: race, ethnicity, preferred language or interpreter need, disability, insurance or other measures of financial constraint, and geography when useful. Use patients’ self-reported demographic data when feasible; inspect missingness rather than silently placing unknown records outside the analysis. CMS provides technical guidance on demographic data definitions, while IHI recommends selecting meaningful stratifiers, reference points, and disparity measures before interpreting gaps. [\[2\]](#cite-2 "Reference [2]") For the BP project, display three measures over time: - **Outcome:** proportion of eligible patients whose BP meets the project’s clinically appropriate target, by subgroup. - **Process:** proportion who receive and complete a usable follow-up pathway, by subgroup. - **Balancing:** missed work, unwanted contact, clinician workload, or delayed care introduced by the new process. Compare each subgroup’s baseline with its own subsequent results **and** examine the gap between groups. Absolute percentage-point differences are often easier for a clinical team to act on than an overall percentage alone. Annotate run charts when changes are tested; treat small denominators and missing data cautiously, and protect confidentiality when reporting small groups. IHI identifies outcome, process, and balancing measures as complementary tools and recommends disaggregation to detect inequities. [\[3\]](#cite-3 "Reference [3]") Let patients help design the change ----------------------------------- ### Partnership means influence, not just feedback A focus group held after the workflow is built may uncover problems too late. Invite patients and trusted community organizations into problem selection, measure choice, workflow design, and interpretation of findings. Make participation feasible through accessible meeting formats, interpretation, and compensation where appropriate; be clear about which decisions partners can change. For example, a community partner might reveal that telephone outreach is welcome, but calls during work hours are not. Patients might prioritize obtaining medications over uploading BP readings. Neither insight is visible in a portal-activation dashboard. IHI’s health-equity framework includes community partnerships, and federal community-engagement guidance emphasizes sustained, reciprocal relationships and shared decision-making. [\[4\]](#cite-4 "Reference [4]") Close the loop: share stratified findings with partners, explain what changed because of their input, and revisit the design when results disappoint. Do not ask one patient representative to speak for an entire demographic group. Community partnership improves the questions your team asks; it does not replace careful measurement. Test, learn, and decide whether to scale ---------------------------------------- ### Put equity into each PDSA cycle State an aim that protects both overall performance and subgroup outcomes: improve hypertension follow-up without widening the gap for patients who need language assistance. In a small Plan-Do-Study-Act test, compare portal outreach with a supported telephone option. Predict who each route will reach, record what actually happens, and ask partners why patients decline or drop out. IHI’s Model for Improvement calls for small tests that are adapted using observed results. [\[5\]](#cite-5 "Reference [5]") A rise in average follow-up is not sufficient evidence to scale if one group’s completion rate stalls. Adapt the channel, staffing, timing, or practical support; then retest. If subgroup numbers are too small to interpret reliably in one cycle, accumulate observations over appropriate periods and pair the data with patient accounts rather than declaring that no disparity exists. Key Takeaways ------------- - Define eligibility so patients excluded by an intervention remain visible in the denominator. - Stratify **outcomes, processes, and balancing measures** by relevant demographic variables. - Look for widening gaps even when the overall measure improves. - Give community partners meaningful influence over design and interpretation. - Test alternative access routes before spreading a promising workflow. Equitable QI is not a separate project added after the clinical work. It is the discipline of checking whether the patients you intend to help can actually reach—and benefit from—the change. Frequently Asked Questions ---------------------------- ### Can a QI project worsen inequity even if its overall outcome improves? Yes. Patients able to use the new workflow may improve faster while others cannot access it. Review subgroup outcomes and gaps alongside the overall result. ### Why should the denominator include patients who never enroll in the intervention? Excluding them hides access barriers. Define the denominator using clinical eligibility, then measure enrollment and outcomes separately. ### Which demographic variables should a clinical QI team use? Choose variables relevant to the local care pathway and collected appropriately, such as race, ethnicity, language, disability, or geography. Examine missing data and protect privacy. ### What makes community input a partnership rather than a consultation? Partners have a defined opportunity to shape decisions, help interpret results, and hear how their input changed the project—not merely comment on a finished plan. References (7) ------------------ 1. 1. [ academic.oup.com/jamiaopen/article/5/4/ooac104/6887151?searchresult=1 ](https://academic.oup.com/jamiaopen/article/5/4/ooac104/6887151?searchresult=1) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ Centers for Medicare & Medicaid Services. Resource of Health Equity-Related Data Definitions, Standards, and Stratification Practices. 2024. ](https://www.cms.gov/files/document/cms-2024-omh-data-definitions.pdf-0) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ Institute for Healthcare Improvement. Model for Improvement: Establishing Measures. ](https://www.ihi.org/library/model-for-improvement/establishing-measures) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ www.ihi.org/library/white-papers/achieving-health-equity-guide-health-care-organizations ](https://www.ihi.org/library/white-papers/achieving-health-equity-guide-health-care-organizations) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ www.ihi.org/library/model-for-improvement?trk=article-ssr-frontend-pulse\_little-text-block ](https://www.ihi.org/library/model-for-improvement?trk=article-ssr-frontend-pulse_little-text-block) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ IHI Health Equity Metrics Advisory Group. Advancing Health Equity: An Approach to Systematically Identify and Evaluate Health Disparities. 2025. ](https://www.ihi.org/library/white-papers/advancing-health-equity-approach-systematically-identify-and-evaluate-health) 7. 7. 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