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BMC Health Services Research. 2019 Oct 10;19(1):687
University of British Columbia. Critical Research in Health and Healthcare Inequities
The Author(s).
Varcoe, Colleen, 1952-
Bungay, Vicky
Browne, Annette J.
Wilson, Erin
Wathen, C. N
Kolar, Kat
Perrin, Nancy
Comber, Scott
Blanchet Garneau, Amélie
Byres, David
Black, Agnes
Price, Elder Roberta
Background: Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. Methods: EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. Discussion: This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. Trial registration: Clinical Trials.gov # NCT03369678 (registration date November 18, 2017).
STUDY PROTOCOL Open AccessEQUIP Emergency: study protocol for anorganizational intervention to promoteequity in health careColleen Varcoe1* , Vicky Bungay1, Annette J. Browne1, Erin Wilson2, C. Nadine Wathen3, Kat Kolar1, Nancy Perrin4,Scott Comber5, Amélie Blanchet Garneau6, David Byres7, Agnes Black8 and Elder Roberta Price1AbstractBackground: Social inequities are widening globally, contributing to growing health and health care inequities.Health inequities are unjust differences in health and well-being between and within groups of people caused bysocially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada,such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health andsubstance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health careto contribute to improving population health, few studies examine how to achieve equity at the point of care, andthe impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitabletreatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting inreliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasinghuman and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditionsand barriers to care linked to health inequities.Methods: EQUIP is an organizational intervention to promote equity. Building on promising research in primaryhealth care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically anddemographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes inkey outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patientsand staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without carebeing completed), c) a process evaluation to assess how the intervention was implemented and the contextual featuresof the environment and process that are influential for successful implementation, and d) a cost-benefit analysis.Discussion: This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencingthe negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework,including implementable, measurable interventions, tested, refined and relevant to diverse EDs.Trial registration: Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).Keywords: Health inequities, Health disparities, Stigma, Discrimination, Racism, Emergency, Intervention research© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.* Correspondence: colleen.varcoe@nursing.ubc.ca1Critical Research in Health and Healthcare Inequities Research Unit, Schoolof Nursing, The University of British Columbia, Vancouver, BC, CanadaFull list of author information is available at the end of the articleVarcoe et al. BMC Health Services Research (2019) 19:687 https://doi.org/10.1186/s12913-019-4494-2BackgroundSocial and health inequities are widening globally. Healthinequities are unjust differences in health and well-beingbetween and within groups of people caused by socially-structured, and thus avoidable, marginalizing conditions[1, 2]. In Canada, marginalizing conditions include aneroded social safety net, rising income inequality, deeplydamaging impacts of historical and ongoing colonialismand racism, and enduring stigma and discriminationagainst people who experience issues such as disability,mental health or substance use [3]. Marginalizing con-ditions disproportionately position Indigenous persons,racialized newcomers, those experiencing poor mentalhealth, substance use issues or interpersonal violence asvulnerable to a wide range of acute and chronic healthproblems, and create barriers to accessing care [4–11].This results in inverse care, where those who experi-ence social inequities and poorer health often have theleast access to appropriate care, and are more likely toexperience lower quality, under-resourced care. Inversecare may exacerbate harms, particularly for populationsexperiencing the negative impacts of structural inequi-ties [10, 12–14]. As is the case globally, Indigenouspeople in Canada experience significant health inequi-ties that are directly related to race-based colonial pol-icies and racism, and exacerbated by discriminationacross social institutions, including health care broadlyand in emergency departments (EDs) specifically [15–20].Research shows that discrimination towards Indigenouspeople in health care settings leads to misdiagnoses,under-treatment and medical errors, deters timely careand increases conflict, and increases costs and worsensoutcomes [15, 17, 21–24].Enhancing equity in health care is an important strat-egy to improve population health. While calls for equityin health care abound (e.g., [2, 25]), few studies examinehow to achieve equity at the point of care, and the im-pact of doing so. Having identified the key dimensionsof equity-oriented health care (EOHC) [7, 20, 26], we de-veloped and tested an organizational-level interventionto promote equity at the point of care in primary healthcare (PHC) settings [6]. Study of this intervention, enti-tled “Equipping PHC for Equity (EQUIP PHC)” foundthat for patients, EOHC predicted greater comfort withand confidence in care, which in turn predicted greaterconfidence in managing their own health, and conse-quently better health outcomes, including fewer depres-sive and trauma symptoms, less disabling chronic painand better quality of life [5]. We also showed that staffinvolved in EQUIP PHC had greater confidence andskills in providing EOHC [4]. Lessons from the primarycare study indicated that supporting direct care pro-viders to have greater ownership in implementing theintervention in their settings, delivering it more intenselyover a shorter time frame, and preparing staff and lead-ership for inevitable disruptions in knowledge, attitudesand practices would strengthen intervention uptake and,ideally, impact [4]. We also learned that care providerswanted “tools” to help them translate the abstract ideasbehind equity-oriented health care into action. Import-antly, throughout our PHC study, numerous patientsand most providers expressed concerns about patient’snegative experiences and difficulties accessing care inEDs. Negative experiences included stigma and discrim-ination based on racism, mental health issues, and sub-stance use.Emergency departments in Canada often operate atover-capacity [10, 11, 15, 27], in part because of the lackof primary health care services responsive to the needsof populations experiencing marginalization. While EDsare not designed to rectify shortfalls in primary healthcare, they nevertheless present a key arena for mitigatingthe impacts of structural conditions and barriers linkedto health inequities at the point of care [5, 7, 15, 27].However, despite intentions within health care systemsto uphold principles of fairness, many people facingmarginalizing conditions continue to experience inad-equate and inequitable treatment in EDs, which makespeople less likely to access care, paradoxically resultingin reliance on EDs through delays to care and repeatvisits, interfering with effective care delivery and increas-ing human and financial costs [15–17, 21, 22, 28]. Im-proving care quality in EDs for people at greatest riskfor health and social inequities is essential to reducingreadmission rates, reducing admissions for ambulatorycare-sensitive and family practice-sensitive conditions (e.g., COPD, respiratory infections, post-surgery care), im-proving continuity of care and cutting overall costs tothe system [27]. Building on the lessons learned in ourPHC study, we are adapting EQUIP to ED contexts andtesting its impact at three geographically and demo-graphically diverse EDs in one Canadian province. Thispaper outlines the study protocol for the EQUIPEmergency (EQUIP ED) Study and briefly describes theintervention framework.Approach and settingsEQUIP Emergency is a study of an organizational-levelintervention to improve care quality at the point of carefor those who face health inequities. This study is athree-way collaboration among health researchers, healthcare staff and Indigenous/community leaders aimed at de-veloping an evidence-based intervention framework to pro-mote equity for Indigenous and non-Indigenous people indiverse EDs. The study is part of a broader program of re-search entitled EQUIP Health Care that aims to reducehealth inequities at the point of care in pursuit of the quad-ruple aims of health system optimization: improving theVarcoe et al. BMC Health Services Research (2019) 19:687 Page 2 of 14health of populations, enhancing patient experiences andoutcomes, reducing per capita cost of care, and improvingthe work life of staff [29, 30]. A key goal is to createintervention processes that are, if evaluated to be effect-ive, scalable and “ready to implement.” As such, our ap-proach to knowledge mobilization, broadly defined as“a wide range of activities relating to the productionand use of research results, including knowledge synthesis,dissemination, transfer, exchange, and co-creation or co-production by researchers and knowledge users,” [31] isboth integrated and grounded in key principles of imple-mentation science [32, 33].Approaching EDs as complex adaptive systems [34],this mixed-methods multisite study will:1) engage ED staff and leaders in participatoryimplementation processes to enhance organizationalcapacity for EOHC;2) examine impacts of EQUIP on processes of care,patient experiences of care and short-term outcomes,organizational policies, and on staff attitudes,confidence, behaviours and job satisfaction;3) analyze the cost-benefit and feasibility of EQUIPactivities and scale-up potential in other contexts.A tripartite model of Indigenous/community, practiceand research team members is used throughout. The re-search leadership team is comprised of an IndigenousElder with extensive research experience (author RP), ahealth care leader with wide-ranging expertise in practiceleadership and research (author DB), and four academic re-searchers (authors CV, VB, AJB, EW) as co-Principal Inves-tigators. Additional co-investigators are diverse Indigenous,practice and research leaders. The project is guided by anadvisory panel, comprised of Indigenous community, prac-tice and research leaders. For all intervention activities, theresearch team is supporting the engagement of Indigenousand community leaders, health care leaders and all staff ineach ED.We are working with 3 EDs in one Canadian province,purposely selected to capitalize on our extant researchrelationships and maximize diversity of settings: aninner-city, a suburban area, and a northern region serv-ing rural, remote and small urban communities. We aredeveloping, implementing, testing and refining theframework to optimize care for Indigenous people and awider range of people who commonly face stigma anddiscrimination. We have designed an overall process thatwill be tailored to the unique characteristics, context andstrengths of each ED. For example, one ED has extensiveexpertise providing care to patients with substance useproblems, another has expertise caring for diverse groupsof new immigrants, and one is located in a region withrelatively high proportions of Indigenous populations.Collaborating with organizational leadership in thesediverse health authorities promotes understanding of thepotential scale up to other EDs. Table 1 provides somedetails regarding each.Theoretical approaches and evidence baseOur understanding of equity and EOHC is informed bycritical theoretical understandings of social justice, andthe structures that perpetuate health and social inequi-ties. The overall study is guided by complexity theoryusing an integrated approach to implementing and mo-bilizing interventions. These approaches and our tripar-tite leadership model are complemented by a changeleadership approach known as Front Line Ownership(FLO), all of which align with understanding health caresystems and EDs as complex adaptive systems.Complexity theoryIntervention research to bring about change withinhealth care settings has historically had low successrates. Lack of success has been associated with failingto attend to the complexity of environments in whichinterventions are carried out, or factors associated withcapacity and readiness for change [37–39]. Conse-quently, the intervention detailed in this protocol wasinfluenced by central tenets of complexity theory. Asnoted, EDs are complex adaptive systems with manycomponent parts that interact and influence oneanother [39]. These interactions include and extendbeyond the patient level to the provider, organization,and policy levels of health care [40]. Complexity theorydirects us to analyze the diverse and complex inter-actions among these components.Front line ownershipIn addition to attending to the complexity of the ED set-tings, our intervention design utilizes the evidence-basedand theoretically-informed change management approachof Front Line Ownership. With its roots in complexitytheory, FLO is an intentional departure from prevalenthierarchical health care change management practiceswhereby leaders promote ideas to staff and try to get buy-in. Instead, FLO involves those most actively engaged indirect patient care developing the ideas, making the deci-sions and designing and acting on the plans they create[41, 42]. FLO includes change processes that support par-ticipatory, peer-based learning and recognizes that learn-ing and change are most effective and sustainable whenthe solutions (in this case, to the problem of inequities inhealth and health care) are generated by the health carestaff themselves [42]. FLO does not infer absence of for-mal change leadership; it requires that leaders support thedevelopment of staff capacity to both identify and leadchange initiatives. Supportive strategies, often referred toVarcoe et al. BMC Health Services Research (2019) 19:687 Page 3 of 14as “liberating structures,” [43] include quick-to-learn toolsfor the staff to enhance their capacity for facilitationamong their peers including active listening, engage-ment and inclusion of ideas and strategies amongthe diversity of staff working in the setting (e.g.,nurses, physicians, security personnel, housekeeping,unit coordinators or admitting clerks). FLO supportsstaff to both identify and think about problems dif-ferently and to take a leadership role to generate so-lutions to problems that occur in their settings [43].FLO achieves increased change sustainability by:identifying local solutions that reflect the uniquecontext in which issues arise; increasing organizationalinterconnectivity and the development of new actionpathways via a process of point of care, worker-directed collaboration; and building the capacity ofthese workers for real-time problem-solving overtime [42]. FLO is a contextual and non-linearapproach to change management and change leader-ship ideally suited to interventions occurring incomplex settings.Equity-oriented health careAt the definitional core of health equity is the criticalanalysis of power and the workings of discriminationdynamics in the pursuit of social justice [4, 44, 45]. Ourconceptualization of EOHC is grounded in understand-ing discrimination as a socially structured and often im-plicitly sanctioned phenomenon, justified by ideologyand expressed in interactions among and between indi-viduals and institutions in ways that maintain privilegesfor members of dominant groups, and contribute to in-equities for others [13, 46], with profound impacts [47].Experiences of discrimination are often amplified whenissues of poverty, substance use, or stigmatizing condi-tions such as HIV or chronic pain syndromes intersectwith people's sense of being treated differentially on thebasis of their ethno-cultural and other identities [48].From this vantage point, interventions aimed at improvingorganizational cultural competencies or providing diversityeducation for service providers to reduce discriminationand increase access to services are often good startingpoints, but are insufficient to achieving equity-orientedTable 1 Overview of Study Sites: Key equity-relevant featuresStudy Site Health Authority Key Equity-Related CharacteristicsSt. Paul’s HospitalVancouver, British Columbia (BC)Providence Health; affiliated withVancouver Coastal Health• Located on un-ceded traditional lands of thexʷməθkʷəyə̓m (Musqueam), Skwxwú7mesh(Squamish), and Səlí̓lwətaʔ/Selilwitulh(Tsleil-Waututh) Nations• Primary hospital serving people living in theinner-city neighborhood known as the DowntownEastside (DTES) of Vancouver• DTES residents experience some of the highestlevels of health and social inequities in Canada(e.g., no fixed address, malnutrition, complexmedical problems such as HIV)• Part of a Catholic health care community with astrong history of social justice• Located in the epicentre of the opioid overdose crisisin Canada; high proportions ofpatients experience significant substance use issues• Percentage of people identifying as Indigenousvaries, with fewer than 2% in the gentrifiedareas, and up to 30% in others [35]Surrey Memorial HospitalSurrey, British ColumbiaFraser Health • Located on the lands of the Semiahmoo, Katzie,Kwantlen, Tsawwassen, QayQayt andKwikwetlem First Nations• The largest ED in Western Canada, withapproximately 140,000 patient visits per year• Serves the highest concentration of newcomersin BC (43%), including people who immigratedfrom India (41%), China (15%) and thePhilippines (13%) [36]University Hospital of Northern British ColumbiaPrince George, British ColumbiaNorthern Health • Located on the traditional territory of theLheidli T’enneh First Nation• Level III trauma centre, providing services topeople dispersed over an area of 600,000 km2 innorthern BC• Advanced referral ED for over 300,000 residentsof diverse rural, remote and isolated communities• 20.1% of population served identifies asIndigenous (Indigenous people comprise 4.9%of the Canadian population overall) [36]Varcoe et al. BMC Health Services Research (2019) 19:687 Page 4 of 14practices. For example, such interventions often lack afocus on how social systems produce and sustain health in-equities, thus allowing the fundamental causes of inequitiesto remain unidentified and unchallenged. In comparison,equity-oriented approaches seek to address the continuitiesbetween structural and interpersonal discrimination. Suchapproaches go beyond providing education to fill know-ledge gaps, and aim to support critical reflection and actionby providers and other staff on the interconnected barriersto health care across personal (e.g., stereotypes and as-sumptions about patients), interpersonal (e.g., interactionswith patients that may be discriminatory), organizational (e.g., security protocols that create access barriers for patientswho experience poverty, mental health or substance use is-sues) and structural levels (e.g., inadequate access to hous-ing and social welfare supports).EQUIP PHC, the precursor to the current study,showed that in PHC settings EOHC was associated withpositive health outcomes [5], and that intervening at theorganizational level improved staff confidence and com-fort with providing such care [4]. We do not, however,know whether such an intervention can improve healthoutcomes, or how emergency department staff can besupported to provide EOHC. This project pursues threekey dimensions for enacting equity-oriented health carederived from our prior research [6, 7, 20]: Culturally-SafeCare; Trauma- and Violence-Informed Care (TVIC); andHarm Reduction, each of which must be Contextually Tai-lored. These key dimensions, described in greater detail inprevious publications [4], are briefly summarized below.Culturally-Safe Care locates the culture of health careas the site for transformation and seeks to challenge dis-criminatory values and assumptions held within healthcare across interpersonal, historical, and structural levels(e.g., legacy of colonization and racism that shapes dis-crimination as a barrier to health care) [4, 7, 20]. It shiftsthe focus away from attempting to identify the uniquecultural characteristics of individuals or groups as thepotential barriers to care, towards critiquing structuralconditions and inequitable power relations, requiringchanges to dominant norms to enhance care for everyone.Trauma- and Violence- Informed Care (TVIC) involvesunderstanding past and ongoing interpersonal and struc-tural violence as causes of trauma, and developing policiesand practices to minimize harm, prevent re-traumatizingpeople during care, and promote healing. The primary goalof TVIC is to create safe and trusting environments [49].Harm Reduction involves practices that mitigate harms,not only of substance use but also harms associatedwith the historical, socio-cultural and political determi-nants of substance use and related social and healthpolicy [50].Contextually-Tailored Care explicitly and continuallyadapts services, practices, organizational policies andclinical guidelines to optimally address the populationsserved and to local social and community contexts, thusexpanding beyond the individually-focused concept ofpatient-centred care [4].Methods/designBased on the above theoretical and empirical innova-tions, EQUIP Emergency is an organizational interven-tion tailored to hospital emergency department settings.Drawing on the concept of FLO, all categories of staffinvolved in providing patient care in each ED (e.g., se-curity, nurses, clerks, cleaning staff, physicians, aides)will be invited to participate in self-led working groupsover a 6-month catalyst period. Working groups will as-sume a leadership role in facilitating change within theirlocales, identifying and prioritizing areas of improvementto foster equity among patient populations dependingon the context. With the goal of recruiting direct-carestaff to participate in working groups, we will begin withinformation sessions, flyers, emails and meetings to pro-vide orientation to the project. In line with contextualtailoring, these communication methods will build onpreferred site-specific practices. For example, one sitetypically holds 10-min staff huddles to share information,and these will be used to share information and recruitworking group members at that site. Administrative lead-ership at all sites has committed to paid staff time formeetings and intervention-related activities. Workinggroups will be provided with: an orientation to EOHC, envisioned as a 2–3 hworkshop; access to the online Equipping Health Care for EquityModules and tools (https://equiphealthcare.ca/modules); a context profile of the communities servedincluding demographics and history, with anemphasis on those most likely to experience socialand economic marginalization; data snap shots from patient and staff survey datacollected as part of the research; access to two types of coaches to supportparticipants to apply the three key dimensions ofEOHC and tailor such application to their contexts:a. A change coach at each site will encourageparticipants to identify social, political, andeconomic forces that restrict possibilities forchange, to reflect on the interpersonal andemotional impacts of organizational change, andto develop creative solutions in light of restrictionsand potential disruptions. Having learned in ourPHC research that efforts to promote EOHC werenecessarily disruptive, change coaches will helpteams to anticipate such disruption toward havingthe most positive impact possible [4].Varcoe et al. BMC Health Services Research (2019) 19:687 Page 5 of 14b. Content coaches will encourage participantsto reflect on how systemic inequities impactthe health and wellbeing of people at thepopulation level, the barriers to health carethat people experience, and interpersonalinteractions. They will also support theworking groups to think creatively aboutstrategies that might mitigate such inequities.Given the diverse expertise required,there may be several content coaches; forexample, one with expertise in harmreduction, another in Indigenous-specificcultural safety.Ultimately, the coaches will work to render themselvesunnecessary to the working groups. a work book to guide the working group activitiesoverall. The work book is based on principlesderived from the theory and evidence underpinningEQUIP, and will lead working groups through 5steps: 1) orienting themselves to EOHC, 2) planninghow to work together, 3) assessing their department,4) planning change initiatives, and 5) evaluating andmonitoring. Assessment of the department isorganized around a SWOT (Strengths, Weaknesses,Opportunities, and Threats) heuristic. To facilitatethe SWOT analysis, working groups will be able todraw summaries of patient and staff data from ourbaseline data collection, and the context profile.Patient demographics, compared to populationdemographics, and patients’ experiences ofdiscrimination and ratings of care will be analyzedaccording to pertinent subgroups (e.g., thoseidentifying as Indigenous or those with unstablehousing) to help staff identify groups who may bebest and least well served. Having learned in ourPHC study that staff found explicit analysis of theimpact of their population demographics invaluable[51], we see such analysis as foundational to equity-promoting change.The change process will be facilitated with 1) paidstaff time for working group members to attend meet-ings for 6 months (anticipated to be monthly or semi-monthly two-hour meetings), 2) a site-specific research as-sistant (2 hours/week), 3) access to change and contentcoaches for up to 20 h total over 6months and 4) a $10,000 catalyst grant to be used for change initiatives. Theemployers have committed to paying staff time, and theremaining resources are provided by the research funding.The working group members will decide the focus andduration of coaching with a minimum of an introductorysession with a change coach.Research designA mixed methods multisite design will examine changesin key outcomes specified in the intervention theory(Fig. 1) including: a) a longitudinal analysis of changeover time based on structured assessments of patientsand staff, b) an interrupted time series design (ITS) ofadministrative data (i.e., staff sick leave, patients wholeave without care being completed, including those whoregister but leave before being seen by a care provider,before being assessed, before being treated, or againstcare provider advice), c) a process evaluation to assesshow the intervention was implemented and the context-ual features of the environment and the process that areinfluential for successful implementation, and d) a cost-benefit analysis. Table 2 provides a summary of ourhypotheses and research questions and the related datasources and analytic approaches.Longitudinal analysis of changeChanges in patients’ overall ratings of care (primary out-come), and self-reported experiences of discrimination inthe emergency department (secondary outcome) will beexamined using survey data collected at 5 points in time: 2times pre-intervention, immediately post-intervention,and at 6months and 12months post-intervention. Staffperceptions of patient care (primary outcome) and staffsatisfaction and engagement with their job and workplace(secondary outcome) will be examined using survey datacollected at 4 points in time: pre-intervention, immedi-ately post-intervention and 6 and 12months later. Table 3provides a summary of the patient and staff survey itemsand their sources.Interrupted time series (ITS)Data will be collected at equally spaced intervals (monthly)on selected variables hypothesized to be sensitive to EOHC,and which have sufficient stability over time. Variables in-clude the number of people who leave the ED prior to thecompletion of care (primary outcome) as a percentage ofthe total number of people seen, and the rate of staff sicktime taken as a proportion of productive hours (primaryoutcome). Using retrospective data, we will collect monthlydata from hospital administrative sources for 24monthsprior to the start of the intervention, 12months during theimplementation of the intervention and 12months post-intervention for each variable.Process evaluationFrom a complex systems perspective, a research interven-tion is seen as an event that unfolds within and occurs ininteraction with a system [38, 39, 61]. In order to accuratelydocument and assess the implementation of an interventionand the relevance of the implementation processes forintervention outcomes, it is necessary to monitor theVarcoe et al. BMC Health Services Research (2019) 19:687 Page 6 of 14contextual influences shaping intervention activities. Aprocess evaluation will be conducted to examine how con-textual influences shape EQUIP Emergency implementa-tion and ultimately, outcomes, including the readiness ofthe EDs to engage in activities to foster EOHC. Table 4provides a summary of the proposed process evaluationphases mapped across EQUIP intervention activities andkey data sources.Cost-benefit analysisThe costs of the intervention will be calculated frombudget monitoring data for the research budget and forFig. 1 Intervention TheoryTable 2 Research questions & data sourcesHypothesis/Question Data Sources AnalysisPatient overall ratings of care will improve from pre-interventionto post-intervention and be sustained at 6 & 12 monthsPatient self-reported experiences of discrimination will decreasefrom pre-intervention to post-intervention and be sustained at6 & 12monthsPatient Survey Generalized Estimating Equationsto test change over timeStaff perceptions of care and team effectiveness will improvepre-intervention to post-intervention and be sustained at6 & 12monthsStaff Survey Generalized Estimating Equationsto test change over timeThe number of patients leaving without care being completedwill decrease pre-intervention to post-intervention and besustained at 6 & 12monthsAdministrative Data Interrupted Time Series withsegmented regressionStaff sick time will decrease pre-intervention to post-interventionand be sustained at 6 & 12 monthsAdministrative Data Interrupted Time Series withsegmented regressionWhat is the impact of EQUIP ED on organizational policies andpractices?ObservationsQualitative interviewsPoliciesEthnographic analysisWhat influences the uptake of EQUIP ED? ObservationsQualitative interviewsDocumentsPoliciesProcess EvaluationVarcoe et al. BMC Health Services Research (2019) 19:687 Page 7 of 14the costs of staff time. The cost-benefit ratio will becomputed for each of the primary outcomes. These cost-benefit ratios will reflect the cost to improve patient andstaff ratings of care by 1 unit, cost to have one lesspatient leave without care being completed, and cost toreduce each hour of staff sick time.Power analysisThe power analysis is based on the within-site analyses.For the longitudinal patient survey data, we estimatedthe number of patients needed per site to detect a smallto moderate effect size of 0.25. Means and standard devia-tions from the EQUIP PHC study for patients’ experienceswith care informed the power analysis. With power of0.80 and alpha of 0.05, we can detect significant changeswith an effect size of 0.25 with a sample size of 250patients. We used methods suggested by Zhang et al. [62],to estimate the power for the ITS design. Based on thetrend over time in the primary ITS outcomes extractedfrom the administrative data for the past 24months, weestimate that the time series will have an autocorrelationof − 0.20 and will require an autoregressive model with 1lag (AR1). Power is 0.85 to detect a moderate effect sizewith alpha of 0.05, AR1 model, and an autocorrelation of− 0.20 with 24 time points prior and 12 time points postthe intervention.Data collectionPatient survey dataAt each time point, at least 250 patients entering the EDwill be recruited and consented. To simultaneously miti-gate the risk of staff deviating from usual practice ondata collection days and to recruit diverse patients in-cluding those without phones, over approximately 2weeks (depending on patient flow), all adult patientswho are able to give consent will be invited to partici-pate as they present for care. Triage staff will hand pa-tients an invitational flyer with study information. Ifpatients are unable to give consent when first presentingfor care (e.g., unconscious, in pain) but become able sub-sequently, they will be approached to participate when itappears they may be able to consent. Contact informa-tion will be collected from interested patients, whoeither will be interviewed immediately following dis-charge in a private interview room close to the ED, intheir hospital room if admitted, or interviewed by phonewithin 5 days of their visit. Following processes we pre-viously have used, we will collect data directly on tablets.We will select recruitment periods across all shifts anddays of the week. Anticipating a 50% refusal rate [63]and 15–30min per interview we will select the numberof shifts required at each site.Staff survey and interview dataWe will conduct quantitative surveys focused on staffEOHC confidence, work experiences, and team effective-ness. Surveys will be open to all staff at four time points(baseline, at the end intervention and 6 and 12monthslater). The number of staff varies greatly with each site(from ~ 80 to ~ 500), and we will aim for a survey responserate of 50%. In addition, we will conduct qualitative inter-views with a range of staff pre- and post-intervention ateach site, including staff who take leadership roles andthose who express interest, but do not participate.Leadership interview dataSemi-structured interviews will be conducted with re-search team leads, and with health authority leadershipto assess the broader contextual influences affecting theacceptability and implementation of the intervention.Table 3 Overview of Patient and Staff SurveysMeasure Number of items Source & ReferencesPatient survey data Discrimination in Everyday Life 8 Everyday Discrimination Scale [52]Discrimination during ED Visit 7 Discrimination in Medical Settings Scale [53]Experiences of Care 32 ED Patient Experience of Care survey [54] and BC EDPEC [55]7 items developed for EQUIP ED StudyDemographics 4 Rainbow Health Ontario’s Sexual Orientation Measures [56]Canadian Community Health Survey [57]Financial Strain Index [58]Staff survey data Your Work Experiences 25 Accreditation Canada’s Worklife Pulse Tool [59]1 item developed for EQUIP ED StudyTeam Effectiveness 11 Canadian Institute for Health Information’s PHC TeamEffectiveness Scale [60]Perceptions of patient care 1 Developed for EQUIP ED StudyCultural Safety 5 All items developed for EQUIP ResearchTrauma- and Violence- Informed Care 5 All items developed for EQUIP ResearchCare related to Drug and Alcohol use 7 All items developed for EQUIP ED StudyVarcoe et al. BMC Health Services Research (2019) 19:687 Page 8 of 14Table 4 Process Evaluation MatrixEnablers Component/Activity How or why are we doing this? Key PerformanceIndicatorsData SourcesPre-InterventionAssessingReadiness andEngagementChange Readiness,Leadership & Policy,EngagementEngage hospitalleadership in projectSecure leadership buy-in & supportfor grant; Assess change readinessof site; Build leaders’ knowledge ofcore principles (EOHC, FLO)• Commitment fromhospital leadership toparticipate in project• Agreement fromleadership to sign onto grant application• Qualitative interviews• Meeting minutesLeadership & Policy,Funding,EngagementSecure fiscalcommitment fromsitesFund working group staff time;Support FLO in intervention• Stated commitmentto fund Workinggroup at each site• Qualitative interviews• Meeting minutesLeadership & Policy,EngagementBuild rapport withunit leadersAssess change readiness of unit;Foster participation & support forproject• Stated commitmentto participate inproject• Qualitative interviews• Meeting minutesInterventionPHASE IWorking GroupEngagementEngagementKnowledge &TrainingSpread awareness ofEQUIP project at unitlevelFoster awareness of EQUIPresearch activities; Begin togenerate interest in workinggroup; Lay groundwork forworking group activities• Diverse categories ofstaff attendorientation sessions• Communicationsreceived by researchteam about the studyby ED staff• Field notes• Qualitative interviewsChange Readiness,EngagementEnrollment, FrontLine Ownership,StewardshipFacilitate staff interestin working groupFacilitate development of workinggroup; Foster FLO processes;Prepare for intervention activities• Working group formsat each site• Field notes• Qualitative interviewsInterventionPHASE II AEstablishing aSustainableWorking GroupKnowledge &Training, Front LineOwnership,StewardshipIdentification ofchange coaches andequity coaches tosupport workinggroup activitiesSupport the working group’schange process: translatingassessments to action,anticipating and managingdisruption• Identification ofequity coach andchange coach foreach site• Finalized jobdescription forchange coaches• Qualitative interviewsFunding,Engagement,Human ResourcesEnrollment,Knowledge &Training, Data &Information, FrontLine Ownership,StewardshipDeliver orientationworkshop during firstworking groupmeetingOrient working group to coreprinciples of EOHC & FLO; FosterFLO & project ownership;Facilitate working group teambuilding; Provide roadmap forproject activities (e.g. assessment)• Staff knowledge ofcore principles• Staff commitment tocore principles• Staff commitment tocontinue workinggroup• Field notes• Meeting minutes• Qualitative interviewsFunding,EngagementEnrollment, FrontLine Ownership,Data & InformationStewardshipWorking group meetsa second time toprepare for actionFoster FLO & project ownership;Provide opportunity to reflect onfirst meeting; Facilitate workinggroup preparing for action• Working group setsfuture meeting date(s)• Working groupdevelops plan forfurther EDassessment• Field notes• Meeting minutes• Qualitative interviews(working groupmembers, coaches)InterventionPHASE II BWorking GroupBegins ActionFunding,Engagement,Human ResourcesKnowledge &Training, Front LineOwnership,StewardshipWorking groupdevelops internalmechanisms forsupporting team(terms of reference,mandate)Fostering FLO throughoutintervention; Supporting successof working group interventionactivities by building afunctioning team• Working groupdevelops documentsto guide teamworkthroughoutintervention• Field notes• Meeting minutes• Qualitative interviewsChange Readiness,Funding, HumanResourcesKnowledge &Training, Front LineOwnership,StewardshipWorking groupidentifies problem(s)and begins action toaddress this problemWorking group begins locallytailored intervention activitiesgrounded in FLO principles• Working groupconducts equitywalk-through(s)• Working groupcompletes EDassessments, throughexisting data analysisand furtherassessment• Field notes• Meeting minutes• Qualitative interviewsVarcoe et al. BMC Health Services Research (2019) 19:687 Page 9 of 14Table 4 Process Evaluation Matrix (Continued)Enablers Component/Activity How or why are we doing this? Key PerformanceIndicatorsData Sources• Working groupidentifies keychallenges to equitywithin each siteEngagement,Human ResourcesFront LineOwnership,StewardshipResearch team phasesout leadershipEnsure FLO is operationalizedthroughout intervention activities• Working grouporganizing andfacilitating their ownmeetings• Research team innote-taking role• Working groupmembers directingresearch teaminvolvement• Working groupidentifies ownknowledge andresources needs• Field notes• Meeting minutes• Qualitative interviewsData & Information Research teamdecides when tocollect first post-intervention dataEnsure data collection is timelyand according to study design,while also best capturingoutcomes from progress towardstated goals at each site• Dates finalized forpost-interventiondata collection ateach site• Meeting minutesInterventionPHASE IIIWorking GroupImplementationFunding, Leadership& Policy, HumanResourcesKnowledge &Training, Data &Information, FrontLine Ownership,StewardshipWorking groupdevelops project planand budget forhospital/unit leadersand research teamSupport FLO principlesthroughout intervention whileensuring accountability ofworking group for catalyst grantand project activities• Working groupsubmits project planand budget tohospital/unit leadersand research team• Research teamconfirms release offunds to workinggroup• Hospital/unit leadersprovide feedback onproject plan• Field notes• Meeting minutes• Qualitative interviews• Project plan & budgetdocumentsChange Readiness,Funding, HumanResourcesKnowledge &Training, Front LineOwnershipWorking groupspends $10,000catalyst grant tosupport activities• Working groupspends catalyst grantfunds• Field notes• Meeting minutes• Expensereimbursements• Working group 6-month progress reportChange Readiness,Leadership & Policy,Funding,Engagement,Human ResourcesKnowledge &Training, Front LineOwnershipWorking groupimplements identifiedequity strategiesDrive the intervention, supportedby core principles of EOHC & FLO• Working groupcommunicates equitystrategy plan tohospital/unit leaders• Working groupcommunicates equitystrategy plan to staff• Working groupspends catalyst grantfunds toward equitystrategies• Field notes• Meeting minutes• Qualitative interviews• Working group 6-month progress reportEngagement,Human ResourcesKnowledge &Training, Front LineOwnershipWorking groupconducts peerevaluation tocontribute toassessment of teameffectivenessProvide feedback to workinggroup regarding teameffectiveness to date; Supportadaptation of working group toemergent needs and contributeto success of interventionactivities; Contribute to success ofworking group team beyond 6-month intervention period• Working groupcompletes peerevaluation• Working groupadapts teammechanisms andprocesses based onfeedback from peerevaluation• Field notes• Meeting minutes• Peer evaluationdocuments (researcheruse of documents asdata to be negotiatedwith working group)• Qualitative interviewsVarcoe et al. BMC Health Services Research (2019) 19:687 Page 10 of 14Observational dataObservations of the day-to-day operation of the emer-gency department and of the intervention activities ateach site, including working group meetings and changeinitiatives, will be collected as field notes by thoserecruiting for and/or collecting patient and staff surveydata, and site-specific research coordinators.Administrative dataData will be extracted from existing databases held bythe EDs’ respective health authorities as well as the pri-vate firm contracted to provide security services to thehospitals. In addition to the primary outcome variables(patients who leave without care being completed, andstaff sick time as a proportion of productive hours),variables of interest include equity-relevant incident re-ports (e.g., patient-initiated complaints), equity-relevantadverse event reports (e.g., violence, readmission rates,security incidents including verbal and physical aggres-sion, threat assessments, and code whites), and staffindicators (e.g., staff turnover). These data will beextracted monthly for 24 months prior to the interven-tion, 12 months during implementation, and 12 monthspost-intervention implementation.DocumentsDocuments produced by the research team, such as pre-sentations and reports to the working groups, and docu-ments produced by the working groups, such as meetingminutes and catalyst grant proposals will be collected.Unit and organizational policies and reports will becollected as they become relevant; for example, if aparticular policy is identified as a barrier to equityand considered for revision.CostsCosts of the intervention will be calculated using datafrom research budgets and estimates of paid staff time.Intervention costs will include time and material costsassociated with engaging the staff, staff time for theworking groups and any paid staff time for interventionactivities, coaches’ time, work books, cost of time for theresearch team to generate reports for each ED, and thecatalyst grants.Data analysisLongitudinal analysis will be conducted within site andfor all three sites combined. For each wave of patientand staff survey data, descriptive statistics appropriate tothe level of measurement will be computed. Analysis ofchange across time will use General Estimating Equa-tions (GEE) to account for the repeated measures overtime. Time (5 levels for patient survey data and 4 levelsfor staff survey data) will be the independent variable.We hypothesize increases in patients’ mean ratings ofcare and in staff perceptions of care (primary outcomes),and decreases in patient experiences of discrimination inthe ED and increases in staff engagement and teameffectiveness (secondary outcomes).For the analysis of the ITS data, segmented regressionwith autoregressive models will be used [64]. Interruptedtime series are tested by comparing the level of the out-come of interest and the rate of change over time be-tween the time period prior to the system change andthe time period after the system change [65]. The modelwill yield an estimate of the level and slope across timeof the outcomes prior to the intervention and changes inthe level and slope after the intervention. The change inlevel provides an estimate of the immediate effect of theintervention, and the change in slope provides an esti-mate of the ongoing effect of the intervention acrosstime after implementation. We hypothesize that therewill be a significant change immediately after theintervention with a continued improving trend.A cost per unit of improvement will be calculated foreach of the primary outcomes. Improvement will be thechange in the outcome from the time point immediatelyprior to the start of the intervention implementation tothe 12 months after the intervention. Total cost will bedivided by the change in outcome and scaled to reflectthe cost per 1 unit improvement in patient and staff per-ceptions of care. For the number of patients who leavewithout care being completed, the difference in the totalnumber of patients who left in the 12months prior toand post-intervention will be computed. Total cost todeliver the intervention will be divided by this numberto reflect the cost to achieve one fewer patient per yearleaving without care being completed. This same ap-proach will be used with respect to staff sick time (totalstaff sick time in the 12months prior compared to the12months post-intervention).Process evaluation analysis will be conducted for eachsite and then combined to assess the contextual featuresinfluencing intervention implementation at organizational(e.g., leadership within the health authority and specifichealth care facilities) and unit (e.g., emergency departmentstaff and structures) levels. Each phase detailed in Table 4will be analyzed first at each site to identify the degree towhich the activities have achieved the intended purposeusing the predetermined performance indicators for en-ablers assumed to foster successful implementation. The-matic analysis will be conducted using data from meetingminutes, field notes, and qualitative interviews to explainthe outcomes of this analysis. Results from the analyses ateach site will be combined and analyzed to identify simi-larities and differences across sites including potential ra-tionale for any discrepancies. The analysis will be refined,advancing theoretical coding to assess the barriers andVarcoe et al. BMC Health Services Research (2019) 19:687 Page 11 of 14enablers related to the core theoretical tenets underpin-ning the intervention including front-line ownership asa change management approach and equity-orientedhealth care and its related dimensions. This analysiswill identify the processes that facilitated or hinderedthe implementation of EQUIP Emergency and the cir-cumstances under which EQUIP is likely to be success-ful, thereby providing important information aboutscale-up potential.Ethical issuesKey ethical issues are the prioritizing of care processesover research processes, the protection of privacy andensuring informed consent for patients and staff, and en-suring that research processes do not compromise staffemployment relationships. The emergency departmentsserving as study sites are very busy and often operate atover-capacity. In this context, patient care will be thetop priority and no research activities will interfere withcare. Efforts to ensure privacy will include a) using tab-lets for patient surveys and online surveys for staff, b)supporting patients to enter their own data directly, orat least read the questions (without them being read outloud so that others can overhear), c) using private spacesto complete surveys when this is not possible, and con-ducting all qualitative interviews with staff and leaders inprivate spaces. The EDs serve diverse populations, thusefforts to ensure informed consent for patients will in-clude a) reading aloud study information and consentletters unless the patient indicates this is not needed(not assuming literacy), b) offering materials translatedinto the top two languages at each site (for a total of 4languages: English, Hindi, Punjabi and Cantonese). Allstudy processes have been reviewed and approved by theResearch Ethics Boards at the University of BritishColumbia and each Health Authority.DiscussionThis project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particu-larly targeting groups known to be at greatest risk forexperiencing the negative impacts of health and healthcare inequities. The main deliverable is EQUIP’s healthequity-enhancing framework, including implementable,measurable interventions, tested, refined and relevant todiverse EDs. Importantly, the EQUIP framework inte-grates innovative, evidence-based strategies to mitigatediscrimination and racism experienced by Indigenouspeople, and potentially faced by people of all ethnicitiesrelated to substance use, housing instability, sex work,gender, or mental illnesses. In addition to improvingcare delivery, this project contributes new knowledgeabout: how to improve health outcomes for vulnerablegroups (e.g., improved fit of care with need, fewer peopleleaving without care being completed); and how to imple-ment new interventions and mobilize knowledge arisingfrom testing complex health equity-promoting interven-tions. Analyzing the effectiveness of implementing EQUIPin EDs and the associated cost-benefit will generate know-ledge about the potential for scale-up of EQUIP in settingsbeyond the ED.AbbreviationsDTES: Downtown Eastside; ED: Emergency Department; EOHC: Equity-Oriented Health Care; EQUIP ED: EQUIP Emergency Study; EQUIPPHC: Equipping Primary Health Care for Equity Study; FH: Fraser Health;FLO: Front-Line Ownership; GEE: Generalized Estimating Equations;ITS: Interrupted Time Series; PHC: Primary Health Care; SWOT : Strengths,Weaknesses, Opportunities, and Threats; TVIC: Trauma- and Violence-Informed CareAcknowledgementsThe authors gratefully acknowledge the contributions of the researchmanagers, Phoebe Long and Jo Parker, and Cheyanne Stones, ResearchAssistant. They also acknowledge with gratitude, members of the Indigenousadvisory, and the administrative and clinical leaders at the study sites whopartnered in the design and development of funding proposals.Author’s contributionsCV, AJB, VB, DB, RP and NP conceived the study. CV, AJB, VB, DB, RP, EW,ABG, AB and NP were applicants for funding. KK supported initial drafts,CNW led Knowledge Mobilization aspects, SC led portions related to changemanagement within complex systems. All authors were involved in designingthe study and drafting the protocol. All authors read and approved the finalprotocol.FundingThis study is funded by the Canadian Institutes of Health Research (grant#PJT148832). The funding body had no role in study design, collection,analysis, and interpretation of data or in writing this manuscript.Availability of data and materialsNot applicableEthics approval and consent to participateThe study protocol has been approved by the research ethics boards of theUniversity of British Columbia, the University of Northern British Columbia,Fraser Health Authority, Northern Health Authority, and Providence HealthCare (approval #s H16–03397, H17–01548, and H18–01423). Consent will bedocumented on signed consent forms for all participants except for thosecompleting the staff survey. Completion of the staff survey will implyconsent.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1Critical Research in Health and Healthcare Inequities Research Unit, Schoolof Nursing, The University of British Columbia, Vancouver, BC, Canada.2School of Nursing, University of Northern British Columbia, Prince George,BC, Canada. 3Faculty of Information & Media Studies & Arthur Labatt FamilySchool of Nursing, Western University, London, ON, Canada. 4Johns HopkinsUniversity School of Nursing, Baltimore, MD, USA. 5Rowe School of Business,Dalhousie University, Halifax, ON, Canada. 6Faculté des sciences infirmières,Université de Montréal, Montreal, QC, Canada. 7BC Ministry of Health, Victoria,BC, Canada. 8Professional Practice Office, Providence Health Care, Vancouver,BC, Canada.Varcoe et al. BMC Health Services Research (2019) 19:687 Page 12 of 14Received: 12 August 2019 Accepted: 29 August 2019References1. 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Attribution 4.0 International (CC BY 4.0)
Faculty
Health inequities
Health disparities
Stigma
Discrimination
Racism
Emergency
Intervention research
EQUIP Emergency: study protocol for an organizational intervention to promote equity in health care
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