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Changing Views on Equity Bring Risks and Opportunities

Why It Matters

"In the past, many of us have not had the will to link quality and equity. Now we do."


In the spring of 2019, only 25 percent of US-based health care leaders surveyed by the Institute for Healthcare Improvement (IHI) identified health equity as one of their organization’s top three priorities. The results were disappointing, but not surprising.

In a recent IHI survey, the percentage of health care leaders naming health equity as one of their organization’s top priorities more than doubled to 58 percent.

How do we account for this substantial shift?

I believe health care is in a fundamentally different place than we were two years ago. While we still have much work to do, the recognition of racism and systemic oppression and its consequences for health outcomes are at an all-time high. People are seeing these effects play out every day as COVID-19 determines how we live, eat, play, go to school, and go to work. Increasingly, we can see the effects that the combination of a pandemic and racism have on the lives of many.

While health equity is now in the consciousness of health system leaders in a way that we have never seen before, these shifts present us with both risks and opportunities. One big risk is that we engage in more discussion but not enough action. Talking about equity, disparities, and the failures of our systems is important, but we must also make meaningful and consistent changes to advance health equity. We must, for example, stratify data by REAL (race, ethnicity, and language) and SOGI (sexual orientation and gender identity) and take the needed actions to close gaps that we find.

Another risk is missing opportunities for change because they may be hard to face. As we measure disparities, we will almost certainly uncover some difficult truths. Without adequate coaching and support for changing practice and behaviors, clinicians and our health systems are very likely to fall into defensive postures even as they are presented with incontrovertible data showing disparities in how our patients get and experience care and in their health outcomes.

As we move forward, we have the opportunity to learn from the beginnings of the safety movement. Many clinicians and their health systems at that time denied the data that indicated they were harming patients or that harm was happening on their watch. Some became defensive. If you haven’t yet experienced these types of responses when people confront data that demonstrates inequities in their system, please know that you will.

Be prepared for denial. Be prepared for fear. Be prepared for folks saying, “this doesn’t happen here.” Come to the conversation prepared to coach and support. And be ready to come back after the first conversation. You’ll need persistence and perseverance to tackle inequities. Remind your colleagues that improvement science emphasizes using data to learn and improve, not to judge and punish. Present the data in the context of your own organization’s history.

This last suggestion is based on the experience of participants in the second round of IHI’s Pursuing Equity initiative. We invited each participating organization to do some research in their institution’s archives to learn how their hospital or health system might have contributed to the oppression or exclusion of a particular population. No organization to date has come away from this exercise without being profoundly humbled by it.

I urge you to do this in your organization today if you haven’t already. It will bring the work of improving equity home. It will help people see the powerful connection between events that took place 12, 20, or perhaps 100 years ago and what is being experienced today in your system.

Consensus: No Quality Without Equity

The same survey cited above found that 82 percent of respondents somewhat or strongly agreed with the assertion that there can be no progress on health care quality without progress on equity. In the past, many of us have not had the will to link quality and equity in this way. Now we do.

Build your community. Find your allies. Taking on racism inevitably means living through some hard moments in which you’re confronting your colleagues or yourself. No one can do this work alone. We need to rely on one another to challenge the status quo together. Know that IHI is with you. And — as our recent survey shows us — so are many other colleagues and friends.

Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.

You may also be interested in:

On Juneteenth and Always, Equity = Quality

Facing Down Denial and Data Challenges When Addressing Equity