Shifting power: co-developing a framework for equity in healthcare

BACKGROUND: Efforts to advance equity, diversity, and inclusion (EDI) in healthcare have grown quickly in recent years, spurred by the broader calls to confront systematic racism and address structural inequities exposed during the COVID-19 pandemic. While EDI initiatives have gained visibility across various healthcare domains, such as patient safety, quality improvement, and social innovation, there are questions about how deeply they engage with the systemic roots of inequity. The objective of this paper is to describe the development of a framework designed to guide healthcare organizations in advancing EDI through a process focused on disrupting systems of oppression and present the resulting framework for building EDI into health care practices, processes, and policies. METHODS: Our large team used a collaborative co-development approach involving a diverse advisory group of people with lived/living experiences of structural inequities, as well as healthcare providers, academics, and leaders. A rapid evidence scan was conducted to synthesize key definitions and existing frameworks. Through a series of virtual and in-person meetings, the advisory group refined a framework iteratively to embed an intersectional, anti-oppressive lens into healthcare improvement. RESULTS: The co-development process generated a health equity framework that emphasized the need to recognize systems of oppression and the creation of EDI initiatives that prioritize the disruption of these systems. The framework came about through multiple iterations based on advisory group feedback, eventually leading to a set of commitments that guide how it is used. These commitments include acknowledging intersectionality, embracing anti-oppression, fostering good relationships, building trauma literacy, and a commitment to learning and unlearning. The framework focuses on improving care for patients, caregivers, and communities, and is meant to guide work within organizations and across healthcare systems. CONCLUSION: This paper highlights the importance of grounding EDI initiatives in a critical understanding of systems of power and oppression. An equity-oriented approach to healthcare improvement needs more than just inclusion efforts; it demands ongoing critical reflexivity and deliberate disruption of the structures that produce inequity. This co-developed framework provides a foundation for health organizations to advance EDI in a meaningful way, while recognizing the need for constant evaluation, learning, and adaptation over time.