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“Racism impacts health, and health improvement is our work.”
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What Does Quality Improvement Have to Offer #blacklivesmatter?

By Kimberly Mitchell | Friday, May 15, 2015
In this blog post, Amy Reid, MPH, Senior Research Associate at IHI and co-chair of IHI’s Diversity and Inclusion Council, and Ron Wyatt, MD, MHA, DMS(Hon), Medical Director in the Division of Healthcare Improvement at The Joint Commission, discuss three ways the field of quality improvement can contribute to current national conversations on racism and #blacklivesmatter. 

AmyReid  RonWyatt
Amy Reid (left) and Ron Wyatt (right)

What is quality improvement?
Quality improvement (QI) is an approach to getting better outcomes in systems by creating more reliable processes. What started in production lines with Toyota has been brought to health care, education, and other social sectors. QI is a way of thinking and organizing the achievement of an aim by starting small, developing and testing changes to the way we work, and using data for decision making to see what changes it will take to bring about improvement in the aim and in factors that contribute to that aim. Quality improvement is a method to improve systems.   

What is #blacklivesmatter?
The #blacklivesmatter movement began following the killings of unarmed black teens including Trayvon Martin and Michael Brown. These killings have been the catalyst to a movement that includes national protests, increased community organizing, proposals for policy change, and national discussion on race and racism in America, specifically, police brutality and mass incarceration of black Americans. The movement is about demanding change, knowing we can be better. But the intolerable pattern continues. The system we have built is producing unacceptable outcomes. 

How do QI and #blacklivesmatter relate to each other?
In two New England Journal of Medicine Perspective articles published in March 2015 [one by Bassett, the other by Ansell and McDonald], the authors urge medical and public health practitioners “let’s not sit on the sidelines” when it comes to racism, its impact on health, and the need for increased racial diversity in our fields. In this post, we look specifically at the field of quality improvement in health and health care and consider what we have to offer the aim of improved police systems and the #blacklivesmatter movement. 

Racism impacts health, and health improvement is our work. Race has an impact on health above and beyond income and education. As we conceptualize equity-focused population health, considering race as a primary driver of inequity is essential. Over a decade ago, Camara Phyllis Jones, president of the American Public Health Association, developed a framework for understanding racism. First, there is institutional racism that promotes differential access to goods and services. This includes historical insult, structural barriers, inaction, and the practice of unearned privilege. Next comes personally mediated racism that is manifested as prejudice and discrimination, which become expressed through “every day” actions such as poor service, purse clutching, surprise at competencies, scapegoating, and dehumanization. The result is pathogenesis that is manifested by increased systemic inflammation leading to heart disease, stroke, cancer, poor birth outcomes, and diabetes. Finally, and a direct result of years of racism, people developed an acceptance of the negative messages about their own worth that leads to poor adherence, self-devaluation, resignation, helplessness, and hopelessness. The field of quality improvement has an opportunity to acknowledge racism and commit to being part of the national discussion and the solution. 

As quality improvers, we have a unique lens and set of tools to bring to achieving aims and bettering the systems linked to those aims. We could bring quality improvement to police departments and communities to set measurable aims, test new ways of working, and track data to determine whether the new way is bringing about the desired improvement. The aim is to reduce the percentage of police encounters that result in killings of men, women, and transgender people of color by police. The drivers, or key system elements, to outline in partnership with police, community members, and other stakeholders might include police training, community-police trust, racism, and policies. Next, we would break down further each of those key system elements to their parts and outline actionable changes to test. Key to a QI approach is the identification of reliable measures that will tell us at regular monthly intervals what impact the changes we are testing are having on our key drivers and on the overall aim. 

What the QI field can bring is a systematic way of generating change ideas from local knowledge and bright spots, a regular rhythm of testing changes, and rigorous use of data to inform next steps. The #blacklivesmatter movement is reacting to unwanted and avoidable outcomes in our police and justice systems, and we have tools and coaching skills to support improvement. As we faithfully do in our work to improve health care, we would ask three questions [the Model for Improvement]: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? And as experts in change management, we also know that this will require more than an aim and a driver diagram because change is social and complex. We will have to develop strategies to engage leaders in this work, to tap into motivation of a broad group of stakeholders, and keep this top of mind as many other items compete for our attention.

While we have an opportunity to join the conversation, and have skills that can aid this movement, what is tough is getting started by having discussions about race, privilege, violence, and mass incarceration. These conversations, however, will be essential in order to productively engage in supporting community solutions in this critical work. We will need to get comfortable talking about race in our own organizations to be able to work on solutions together and mobilize our colleagues. Do you talk about racism and health in your workplace? Do you engage in the national discussions on racism? How included do blacks and other minorities feel in your workplace? How diverse is leadership? Does your work serve minority communities? Why or why not? 

Sometimes the challenge that a legacy of racism poses can make us feel hopeless, but in fact we can be part of the solution by acknowledging that we in QI have a role, using our skills to support improvement in this area, and beginning to discuss this in our workplaces.

How do you think QI can be part of the solution? Tweet to us @TheIHI #blacklivesmatter

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