Photo by Brett Jordan | Unsplash
Many of us can recite by heart the Crossing the Quality Chasm report’s six Aims for Improvement that 20 years ago redefined what quality in health care should be:
It is worth noting that in the report itself, and almost whenever the six aims are listed, we often name equity last.
We need to name equity first and make it synonymous with what quality means in our systems. There is simply no route to quality in health care that doesn’t travel the vital road of improving equity. There is no quality without equity. Those who suffer the consequences of inequities have waited too long for relief. We need to take action today. Not 10 years from now. Not 100 years from now. Today.
At IHI, we are examining how we design our projects and programs to do everything we can to reduce inequities that we detect in health care. Because we’re now actively looking for inequities, we find them everywhere — in every project, in every program, in every system. Those inequities were always there. Looking for them didn’t create them. We just see them more clearly now. And we work, with our health system partners, to ensure that much of our shared work is as focused on equity as it is on the other dimensions of quality.
But we know it is not enough to focus on equity only in our external work. It is difficult to meaningfully work on health equity without committing to ensuring equity internally. Until we do some critical self-reflection, self-examination, and self-improvement within our own organizations, we will struggle to understand the conditions and environments in which our partners and patients are living and working every day. We will not fully appreciate the true root causes of the harms we see in many facets of the world today, including how the legacy of slavery and other forms of oppression continue to etch themselves onto the bodies of our staff, and the bodies of our patients, families, and communities. If we don’t consider those root causes deeply enough, we may not design improvement initiatives that truly and meaningfully address them.
IHI is deeply committed to our internal equity journey. Like many organizations, we have had both successes and opportunities for improvement. For example, we once assumed that having a more diverse staff would make us more equitable. It took time, but we became more diverse by thoughtfully and deliberately improving our hiring processes. But we learned that diversity on its own will not make an organization equitable.
We used to think that building capacity and capabilities would be the key. So, we offered multiple trainings on unconscious bias and dismantling racism. Many of those trainings were helpful, but we learned that we can’t train our way to equity. Over time, it has become clear that building internal equity requires investing in building a culture to support anti-racist actions and behaviors. It means creating an environment in which all staff have equitable opportunities to reach their full potential. To support this, IHI is committed to ensuring that all staff have equity capacity and capabilities, and that we create spaces for staff that we call racial justice affinity groups where people can come together to learn, build community, and support one another to thrive at work and in our lives. Pursuing internal equity also requires organizations to actively dismantle policies, behaviors, norms, and group practices that fail to support diversity, inclusion, and equity.
I often think about improvement as being an exercise in commitment and perseverance, and internal equity is exactly that. Becoming equitable is a long process, not a destination. IHI’s commitment to equity, diversity, and inclusion requires continual community self-reflection on who we've been, who we aspire to be, and where we're planning to go. This is part of why we’ve committed to being transparent about our progress around diversity, inclusion, and equity by sharing our internal equity data publicly. I hope other health care organizations will join us and do more of the same.
IHI, like many organizations and US states, officially celebrated Juneteenth for the first time in 2020 in the wake of the murder of George Floyd. Just as it is not sufficient to do anti-racism and equity work outside our organizations, it is not enough to consider the legacy of slavery and oppression only on June 19. What matters most is what we do to dismantle that legacy and avoid its replication on Juneteenth and on all the days in between Juneteenths.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, equity, social justice, leadership, and improving health and health care worldwide.
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