Why It Matters
After two years of embracing the discipline of using QI methods to address racism, a team in the UK has seen a reduction in staff-reported incidences of racism by an impressive 90 percent.
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Using Quality Improvement to Address Racism

By IHI Team | Friday, July 1, 2022
Using Quality Improvement to Address Racism Photo by Liz Falconer | Unsplash

After seeing the video of George Floyd being murdered by a White American police officer in 2020, millions of people took part in racial justice protests all over the world. As Cornelia Kundishora recalls, the news of Floyd’s death was also the apparent catalyst for a sudden spike in racist comments from patients directed at the Black members of her staff at East London NHS Foundation Trust (ELFT), an IHI Strategic Partner.

Kundishora, a modern matron who oversees a team of 20+ staff members in ELFT’s East India forensics ward, was working from home at the time because of COVID-19. During the early months of the pandemic, she called daily to check on ward staff, especially since all were dealing with the risks, consequences, and uncertainties of the virus.

One day, when Kundishora phoned, the staff member who answered was in tears. “I kept asking her what was wrong,” she recalled. “She was so upset she couldn’t talk. She passed the phone to someone else, and she was crying as well.”

Kundishora learned that the staff of color were taking refuge in an office. Multiple patients had been repeatedly hurling racist abuse at them. The name-calling became so ugly and persistent that the only staff member left with the patients was a White senior nurse.

When Kundishora spoke with her, she expected expressions of compassion for her colleagues or to hear that she had spoken to the patients about their behavior. Instead, the nurse indicated she thought the abuse was continuing because the staff had retreated. Kundishora was left speechless. 

In the aftermath of the incident, multiple staff members requested transfers to other units or threatened to quit. “They were traumatized,” she recalled. “They felt that they were not being seen as human beings.” 

When Kundishora asked the team’s senior members how the incident was going to be addressed, she learned that no follow up was forthcoming. When she asked why, she was told that no one knew how to handle it. Kundishora noted that while the verbal abuse was horrible, the inaction of their colleagues — both the bystanders in the room and others later — was what staff found most upsetting.

Racism is undoubtedly one of the hardest challenges to face in the workplace, especially among helping professionals who may find its existence difficult to acknowledge or overwhelming to address. Increasingly, however, health care organizations around the world are recognizing that equity is synonymous with quality and they are finding the courage to tackle racism head on. 

ELFT is one of those organizations. Kundishora is the project lead for an effort to use quality improvement (QI) methods “to understand and dismantle [racism] and develop a strategy to achieve a more respectful, equal workplace.”

For close to a decade, ELFT has been building the QI skills of its staff and offering QI training to their service users to help their entire organization achieve the Triple Aim while promoting joy in work. After two years of embracing the discipline of using QI methods, Kundishora and her team are seeing results within their service: a reduction in staff-reported incidences of racism by an impressive 90 percent (from March 2020 to March 2022).

In the following interview, Kundishora shares what she would like her fellow improvement professionals to know about using QI to address racism.

On the difficulty of openly addressing racism

It’s a difficult subject to tackle. It makes people anxious. It makes people feel uncomfortable. I always say that it is an elephant in the room. People are afraid to talk about it. People can become defensive. They can feel accused that they have been called racists, for example. 

On the value of using QI to address racism

We are a therapeutic community. If there is an incident in our [personality disorder ward] community, we organize a crisis meeting where both staff and patients talk about what happened to encourage thinking and reflecting about the incident. This is part of the group-based psychodynamic approach to treatment. We encourage patients to reflect on the impact of the incident on themselves and the community as a whole.

We realized that we do this kind of open communication with patients all the time, but [we wondered] how would we discuss [an incidence of racism] with our colleagues? How would we do it without seeming like we are accusing them? So, rather than saying, “You're discriminating against me,” we said, “Let’s talk about racism. Let's do [an anonymous electronic survey] and ask staff if they have experienced racism on the ward.”

But we then realized that conversations aren’t enough unless we talk about what we are trying to achieve and have clear objectives. We chose to use QI methodologies to give us a method to drill down and understand staff experiences.

We decided to do a QI project because that’s what we’ve done whenever we’ve identified other things that needed improvement. When we asked about who needs to be involved, we decided we need to involve everybody, including patients. Patients came up with so many ideas to test. I remember one of our patients came up with a brilliant form to record microaggressions. 

On the importance of data

We collected data from the surveys and from what we were getting from the safety cross to help visualize what staff was experiencing. This made it clear we had a problem. Having the data not only confirmed that we need to speak about what’s going on, but it also gave us a way to say, “Let’s think together. What do we do with this problem? It's in our hands now.”

We do our PDSAs and test out ideas. For example, we tested a race relations questionnaire that we tweaked a few times to get the information we wanted about things like the consequences of racism for patients and the role of the Race Relations Representatives [who support staff and patients after an incident]. Every week we review the data. “What happened? Is this working? This is not working. What can we do differently?” Data collection has been quite important for our work.

On tying antiracism efforts to organizational strategy

We tied our work to the strategic outcomes for the Trust, focusing on improved staff experience and improved experience of care. Turnover of staff was quite a problem. People were feeling unsupported and unable to raise these issues of racism. Talking openly about racism made some people feel uncomfortable, and we had to sell what we were trying to achieve [to others], but having clear objectives helped us get buy-in from leadership and that helped us achieve our objectives.

ELFT Anti-Racism Driver Diagram

Source: East London NHS Foundation Trust

On lessons learned

Anyone who wants to tackle racism needs to be resilient and patient. They need to listen to people and understand people’s fears. Try to understand why people sometimes won’t accept that there is a problem of racism within a workplace. 

You have to work as a team. You have to involve patients. One of the reasons we started this work was because patients said they were feeling uncomfortable with how nurses were being abused. And you can’t have people of one race working on their own. I don’t think this project would have been a success without some White allies to be part of it.  Diversity is important. 

Find common ground. We all want to make our workplace better. We all want a better experience of care for our patients. We all want our environment to be somewhere where we go to work with a smile and patients are happy to see us and we’re happy to see them.

On the progress made so far

We are now able to talk honestly and openly about racism. And now, when a racism incident has happened, we are able to share responsibilities. I’m not the only one who will speak to the staff or a patient who has been subjected to racism. Anybody can call for a crisis meeting.  Anyone can follow the agreed process of reporting the incident.

Reviewing racism incidents is now an ongoing agenda at team meetings. We ask if an incident was reported and ask what support was given to the staff or patient. We ask if there is anything more that we can do. We used to have eight or ten incidents in three months, but now we only see maybe one incident in three months.

Our purpose is to look after the patients. The patients suffer if we are not working together. It gives me joy to work and sit with my colleague and a patient and see what we can do to solve a problem together.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

Weaving Equity Into Every Step of Performance Improvement

Improving Health Equity: Guidance for Health Care Organizations

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