People who visit emergency departments (EDs) but leave without their care completed are often assumed not to have been ill enough to require that care. However, the high rates of people who leave without completed care is a symptom of the mismatch between the Canadian promise of health care for all and the current capacity of the health-care system. The most profound effects of this mismatch fall on people who are structurally disadvantaged. Our research shows that the people who rely the most on EDs report the poorest care experiences, and often leave without their care completed. This creates a cycle of worsening health and increasing costs. Studying the care experiences of nearly 1,700 patients across three British Columbia EDs, our research team found that people facing the greatest social and economic disadvantages were more likely to report discrimination in the ED, lack access to primary care, depend on EDs for ongoing health problems and rate their care poorly. They were also the most frequent users of EDs. In a different analysis, our research also showed that EDs can significantly interrupt this cycle.Promoting equityOur team at EQUIP Health Care has been researching how to increase effectiveness by supporting health-care organizations to focus on people least well-served by the health-care system. In other words, researching ways to promote equity.Studying primary care clinics that serve people marginalized by poverty, racism and other forms of stigma and discrimination, we identified three key dimensions to doing so: trauma- and violence-informed care, cultural safety/antiracism and substance-use health. We also identified 10 implementation strategies. Our findings showed that patients who received care that promoted equity were more comfortable and confident in their care, leading to increased confidence in preventing and managing their health problems. This, in turn, improved their health outcomes, including depression and trauma symptoms, chronic pain and quality of life. We learned that although education and addressing biases were useful for many providers, inter-professional conversations were needed to develop policy and practices to address racism, stigma and discrimination. We learned that disruption was inevitable and necessary, and that policy change was as important as changes to health-care providers’ practice.More effective careBased on these lessons, we partnered with three B.C. EDs to design an intervention to support leaders and staff to deliver care more effectively. EDs are under immense and increasing pressure, evident in long waits for care and high levels of staff turnover and burnout, fostering a focus on optimizing short-term efficiency. However, the intervention was designed to align with the quintuple aim of health-care improvement, which optimizes effectiveness by enhancing:Patient experiences and outcomes Health-care provider well-being Health equity Service efficiencyHealth system efficiency Despite significant challenges related to COVID-19 and the worsening epidemic of overdoses and deaths related to the toxic drug supply, staff at two of the EDs mounted intervention strategies. Results showed encouraging trends in patients’ perceptions of the quality of their care and discrimination in the ED, but there were no significant changes in staff sick time. However, most importantly, there was a significant decrease in the percentage of patients who left without their care being completed at the site with the most robust intervention activities. This is crucial because patients who leave the ED before their care is complete often return when their health concerns are more urgent, resulting in significant harms to patients and costs to the health-care system. It’s also demoralizing for staff.We examined how to build on and strengthen these results. Staff and leaders were committed to focusing on those with greatest needs. However, other priorities — such as recruiting and orienting new staff, and responding to escalating crises such as violence against staff, the toxic unregulated drug supply, and COVID-19 — overshadowed their efforts and curtailed the staff and resources needed.Resources and recommendationsWe identified 10 recommendations for systematically improving care for those who need it most:Initiate interventions within care delivery organizationsConceptualize equity as foundational to health-care quality, not as an “add-on”“Hook” participation by linking equity to the organization’s most pressing “pain points”Seek commitment to effectiveness from leaders across all employment groupsCommit sufficient resources to ensure representation from service-users and all employment groups and sufficient leadership and expertiseCompose implementation teams of people from all levels and roles, including service-usersAssign leadership responsibility to those with leadership roles at executive and clinical levels in alignment with their skills and responsibilitiesTailor the intervention to align with the realities of the contextProvide some level of education and opportunities for interprofessional dialogue for allReconsider how time is used to support effectiveness and other elements of the quintuple aim, not efficiency aloneTo support these recommendations, we created The EQUIP Equity Action Kit, which includes step-by-step directions, assessment and evaluation tools, discussion tools, action tools, videos, animations. We have free on-line courses to support the Action Kit and tools to support the well-being of health-care providers as they face challenging workloads, high stress levels and violence daily. Some resources are available in both English and French. In addition to EDs, many resources have been tailored to other health-care settings such as primary care and cancer care.Colleen Varcoe works for the University of British Columbia, and PreVAIL (Preventing Violence and Inequity Across the Lifespan) a non-profit organization. I have received funding for the research reported in this article from the Canadian Institutes for Health Research and the Public Health Agency of Canada.