Why It Matters
"If you don’t think you have a workforce equality problem, you may not be looking closely enough."
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Use QI to Address Workforce Equality

By Navina.evans@nhs.net | Tuesday, September 10, 2019

Use QI to Address Workforce Equality

Workforce diversity is a worthy goal, but it is insufficient unless all staff members are treated with respect and dignity and have equitable access to employment opportunities. In the following interview, East London NHS Foundation Trust (ELFT) Chief Executive Navina Evans, MD, explains how ELFT pursues workforce equality as an integral part of their improvement journey. ELFT is a member of IHI’s Health Improvement Alliance Europe.

On East London NHS Foundation Trust

We provide mental health, community health, and some primary care services through [England’s] National Health Service (NHS). We have more than 150 sites extending across inner city London through to some rural areas. We have a diverse workforce of about 5,500 staff members. We serve a diverse population in terms of ethnicity, race, and culture, but also in terms of employment, unemployment, and poverty. It’s a vibrant mix of hip and trendy in parts, and in other parts quite rural and quiet.

On why ELFT is addressing workforce race equality

We started to realize that we had to pay attention [to this issue] based on what staff were telling us in our annual survey. We also have Workforce Race Equality Standard (WRES) survey data. The WRES requires NHS England health care providers to ensure employees from black and minority ethnic (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. All [staff of] NHS England complete an anonymous WRES survey about race equality.

Also, when we embarked on our quality improvement (QI) work with the IHI [about five years ago], we started to focus on the culture of our organization. As we looked at our organization’s behaviors and values, and our ability to deliver quality and safety improvements, we started to make connections between equity, race equality, and productivity, and then value and cost. We realized that if we improve the experience for black and minority ethnic staff, then this benefits white staff as well.

On the importance of difficult conversations

I had to look at all the things we tried to do [to improve equality] that hadn’t worked. We had some difficult conversations about being judged nationally. You’re judged against other organizations, so you run the risk of chasing the rating as opposed to making actual change to people’s experiences.

For example, more BME staff [than white staff] are subject to [disciplinary action]. More of them get suspended. More black male patients are detained [and involuntarily committed to a psychiatric facility]. There are also inequalities in terms of health and well-being.

We also have data on who gets promoted. We have very high numbers of BME staff at the lower [salary] bands. There are fewer in the [higher salary bands] in the NHS. This is less of a problem at ELFT, but in the wider NHS you hear people say things like, “We’d love to [hire] someone who’s not white, but black people just don’t apply for these jobs.”

Hearing things like that offers an opportunity to start conversations and say things like, “It’s not good enough to say black people don’t apply. They don’t apply because there isn’t a level playing field.” For example, BME staff are less likely to have mentors who encourage them to apply for higher-level positions. This leads to a discussion about what equity means.

These can be quite difficult conversations to have. It’s important to have them when we’re not angry, accusatory, or blaming. It’s also important to have white allies so we can talk openly about power dynamics and white privilege. Many of these conversations focus on [racial equality], but they’re also part of other work we do related to gender, disability, LGBTQ, age, and other protected characteristics.

On leadership accountability

If you look at the proportion of time our board spends on quality, safety, performance, finance, and [staff and patients], I’d say we’re beginning to spend a proportionately significant amount of our effort, energy, and time on [staff and patients] that’s equal to, if not more, than finance. The board chair, non-executives, and all our executives have inclusion in all our objectives.

The leadership and the staff selected targets for our interventions. We’ve chosen reducing the number of [disciplinary proceedings] that black and minority ethnic staff go through. We’re also working to increase the number of people who have access to career development and opportunities for progression into higher [salary] bands. We want to decrease the number of people who report experiencing bullying and harassment and increase those reporting that they’re treated with respect and dignity.

Some organizations have a lead for inclusion. In our organization, that lead for inclusion is me as the chief executive. I am assessed on this objective by my chair in my [annual review]. I do the same with my executive team. They all have inclusion objectives.

After my first year as chief executive, I had my [review] with my chair and she told me, “This isn’t good enough.” When we talked about it, I realized I hadn’t been giving enough emotional energy to [workplace equality]. That’s changed. Other people do the work, but I am accountable. This is my responsibility.

On what didn’t work

Some of the senior people would point to the annual survey data we wanted to improve, and we’d say to everybody across the organization, “You must have an action plan.” Then, six months later, we’d run around asking, “Have you implemented your action plans?” Some people did and some people didn’t.

As an organization that has been using QI for many years, you’d think we’d have applied QI, but we didn’t. But then, we changed to properly use improvement methodology to inform how we do this work. One of the biggest successes for us has been flipping from top down to bottom up and working as a collective to identify change ideas and test them. Things started to change when we sat down to do this work in a proper systematic way. We’re beginning to see some of the fruits of that.

Lessons learned

  • If you’re not struggling, then you’re not doing it right.
  • If you don’t think you have a workforce equality problem, you may not be looking closely enough.
  • Leadership ownership is essential. This work must be owned by the person at the very top of your organization. It must be a personal goal of the chief executive. It has to take up a good proportion of your emotional, psychological, cognitive effort, and energy. This [level of commitment] sends a strong message to the organization.
  • Policies, processes, and protocols don’t need to be perfect before you start. These are important, but you don’t need to wait for all of it to be in place before you start the work.
  • Understand that data is only the beginning. Look at your data, but also talk to people about their experiences. Work on building trusting relationships and emotional buy-in.

On linking workforce equality to joy in work

How will we know if these changes are leading to improvement? All the survey data and what people tell us is important, but I would also like to link improved staff experience to improvement in joy at work and then also to improved outcomes for patients. I’m expecting that when we see staff experience start to improve, we should start to see clinical outcomes also improving.

Editor’s note: This interview was conducted by IHI New Business Manager Chesley Rappleye and has been edited for length and clarity.

You may also be interested in:

Equity sessions are part of IHI’s National Forum this December.

NHS England Workforce Race Equality Standard 2018 report

When Talking about Race and Racism, Don’t Wait to Feel Comfortable

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