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Don't Wait for an Expert Before Working on Equity

Why It Matters

“We have to reconnect to the work that health care has been doing for the last 20 years. [So many] tools and frameworks can be used for equity.”
Don't Wait for an Expert Before Working on Equity

Photo by Denys Argyriou | Unsplash

When new members join the Diversity, Equity, and Inclusion team at Albert Einstein Hospital (São Paulo, Brazil), they engage in a period of mentoring. One day, one of Health Equality Specialist Santiago Nariño’s mentees said, “Santi, I want to be an expert in this work. What do I need to learn? What do I need to read?”

Some may find Nariño’s response surprising: “You don’t have to be an equity expert to do equity work.”

First at the Institute for Healthcare Improvement (IHI) and now at IHI Strategic Partner Sociedade Beneficente Israelita Brasileira Albert Einstein since 2021, Nariño has worked on a range of health equity efforts with teams around the world. While noting the necessity of understanding an organization’s historical and cultural context and the benefits of good training, he worries that health care organizations often think they need new frameworks or specific education before they can start equity and anti-racism efforts.

“At Einstein, we truly believe that [working on equity] is less about training and more about changing systems,” Nariño says. “We focus on consciously identifying inequities and addressing them with concrete changes and protocols for those most vulnerable in the system.” He adds, “This means recognizing inequities as unwanted variations in care, as [IHI President and CEO] Kedar Mate says, and ensuring that our processes avoid that variation.”

Nariño also emphasizes the need to build equity efforts on foundational work in patient safety, person- and family-centered care, joy in work, asking “What matters to you?” and the psychology of change. “We have to reconnect to the work that health care has been doing for the last 20 years,” he urges. “All these tools and frameworks can be used for equity.” Equity work at Einstein, for example, emerged from a three-piece (quantitative, qualitative, and stories and feedback) data review that staff in some units used in combination with the IHI Framework for Improving Joy in Work. Nariño describes the joy framework as “a tool for equity because it begins with listening and empathy.”

Starting Inside to Make an Impact Outside

As is often the case in the US, recognizing racism’s current (and not just historic) impact both internally and externally has been a gradual and sometimes complicated process. “It’s been hard acknowledging that racism exists in a Brazilian society that likes to think of itself as colorblind,” Nariño says. Consequently, it is not surprising that this challenge extends to work within his organization. “At the very beginning, between around 2017 to 2019, we weren’t really [comfortable] saying the word racism,” he recounts. Over time, he adds, there have been “more opportunities to reconcile with the words and wisdom of Black and Indigenous movements in Brazil that have been telling everybody in society that this is a problem.”

After many discussions with leadership and staff, the Einstein Diversity, Equity, and Inclusion work officially started in 2019. “Our strategy focuses on supporting people with disabilities and LGBTQ individuals and addressing gender equity, ethnicities and anti-racism, and generational equity,” explains Nariño. His team’s work is sponsored by Einstein's chief executive officer and its chief medical officer and chief of human resources serve as ambassadors. Leadership support has helped them “focus on changing policies at the organizational level to bring equity, diversity, and inclusion to the forefront,” says Nariño. This means eliminating variation in protocols and processes and ensuring quality improvement is centered at the core of all they do.

Pointing out that the size of their staff (20,000) rivals that of some entire communities, Nariño notes that Einstein has an opportunity to make an impact beyond the walls of their health system. “We have a movement within the hospital to change policies and create consciousness, but our goal is to deeply connect to the wider community,” he says.

The Diversity, Equity, and Inclusion team has been supporting the organization’s internal hiring practices and employability programs to help improve employee retention and engagement. They also work with community partners to earn the trust and increase the diversity of the people applying to work at Einstein. These programs include efforts to hire refugees, immigrants, people formally incarcerated, trans people, and others from socially vulnerable populations. Einstein has also created training opportunities for people from Paraisópolis, one of the biggest favelas (working-class neighborhoods) in São Paulo.

There is a 52 percent employability rate among the more than 150 people who graduated from these programs. By working closely with community organizations to develop their talent pipeline, “all of these opportunities are deeply connected and rooted in community trust,” says Nariño. Opportunities are available in many areas of the organization, including Einstein’s data and innovation departments.

Once people are hired, Einstein uses their internal and external resources (including Einstein's medical school and master’s and technical programs) to offer employees ways to further their education and skill development. “Someone’s first job at Einstein may be as a janitor,” Nariño explains, “but, if they want, we have the educational opportunities for them to eventually become a nurse technician and then a registered nurse. They can also earn a graduate degree.” The point, he says, is to “use all these systems we have to allow people to learn and thrive.”

As a major employer, Einstein is aware of the influence they can have on making health and health care better for the communities they serve and for those who work in their organization. “We have a motto for expanding the opportunities that allow all people to flourish: How do we bring a drop of Einstein to the rest of Brazil?”

The key, Nariño asserts, will be respectfully understanding the narratives and historical context of how oppression takes root throughout everyday life. “We need to listen better to families, patients, and communities,” Nariño advises. “We need to build empathy to do this work, and you don’t need to be an [equity] expert to do that.” It does, however, take what he calls a “mindset shift” to “center and design everything for those most vulnerable in the system [as a way] to improve care for everyone.”

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