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Facing Down Denial and Data Challenges When Addressing Equity

Why It Matters

“Ultimately, we work in service of improving lives, and we want to know if we’re effective in that service.”


The comment caught him off guard. At the time, Tosan O. Boyo, MPH, FACHE, was leading the Ambulatory Care Network across San Mateo County in California. It was his first executive role.

Boyo had been doing his rounds, talking to the staff and patients he encountered. He saw a Black family with their young son. Boyo greeted them as he did all the patients he saw: “How are you? How is your care going? Is there anything you need? What can I do to support you?”

“What is your role here?” the father asked.

“I’m the administrator,” Boyo responded. “I’m the person who oversees primary care and specialty care for the clinics. I just wanted to see how your day is going.”

The family was clearly surprised — and pleased. The child appeared awestruck. “You see that?” the father said to his young son. “You could be him one day.”

For Boyo, a Black man born in Nigeria and raised in New Jersey, the interaction was a formative one. “I will never forget it until the day I die,” he said in a recent interview. “I don’t take those moments for granted. Those moments are what fuel me.”

The incident was personally meaningful, but it also confirmed Boyo’s belief that representation at the highest levels in health care is essential. “When decisions are made and resources are allocated, there is power in having people at the table who are from the communities most likely to die, be hospitalized, and have their life expectancy be reduced by disparities,” he asserted.

In the following interview, Boyo — Senior Vice President of Hospital Operations at John Muir Health and a new Institute for Healthcare Improvement (IHI) board member — explains how he uses his love of problem-solving and dedication to equity to challenge the status quo.

On the importance of addressing workforce equity

If we only look at equity in a community, and not in our own organizations, we’re only looking at one part of the equation. If there’s an opportunity to have a bigger impact in the work and the mission and the journey, let’s push ourselves to look at the whole equation. You need to understand what your workforce is going through. Research shows that staff engagement and patient experience are connected. Let’s look at the people doing the work and the people who are being impacted by the outcome of the work.

On how he responds to those who say their organization has no problems with equity

One of the reasons I was very honored and humbled to join IHI is because I love solving problems, and IHI is the bastion of scientific problem-solving and continuously improving. When I hear a health system say, “We don’t have those problems here,” I ask how they know. What have you done to validate and verify that you are providing equitable care for patients and equitable support for staff?

I would say, “Let us validate that all-encompassing statement that you’ve made. I would love to see your hospital-acquired pressure injuries data. I would love to see your data on hemoglobin A1C under control. Show me your pain medication adherence and administration data. Then, let’s stratify the data by race, ethnicity, and language (REaL). And let’s validate that across the board when you look at [patients who identify as] Hispanic, Native American, Black, Asian, and Caucasian.”

I would then want to look at staff engagement scores and stratify those by race. How likely are your employees to recommend your organization as a place to work to their family members or friends? Let’s look at turnover rates. How likely are people to stay after X amount of years? Let’s stratify those numbers.

Our data might be telling us we are doing a phenomenal job on bringing babies into the world, for example, but it’s important to stratify the data by race because we know that Black women are 243 percent more likely to die from pregnancy- or childbirth-related causes than White women. If we aspire to great quality outcomes, shouldn’t we want to know if we’re [getting those outcomes] for all our patients?

Data helps us tell a more comprehensive story, but more importantly, it’s why we are doing the work. Ultimately, we work in service of improving lives, and we want to know if we’re effective in that service. This is why I have a fundamental belief that equity work is quality work.

Simply saying you don’t have a problem [with equity] is not even a hypothesis. Without stratified data, it’s just a statement one believes without evidence.

On the challenge of using data to address equity

In addition to people questioning whether they really have a problem with equity, data is another area where I often hear, “How in the world are we going to do this? Where do we start?” Those questions are valid. But you can’t measure the impact you’re having without data.

My response to people who are concerned about how hard it is to put the data together is simple: Would you rather not know? There’s validity to how challenging the data can be. I’m never going to debate that. But if you say that getting the data is too hard, you’re also saying you would rather not know what challenges you have.

On the difference between addressing equity and becoming an anti-racist organization

I’m not going to pretend to be an expert here. I’m still on my learning journey as well. I think of equity as an overarching journey that is focused on how we make sure that no patient or community is left behind when we’re providing care. We need to dive into REaL and SOGI (sexual orientation and gender identity) data to make sure that those who have the least access and the least support get the most attention.

I believe being an anti-racist organization means asking what we’re doing to ensure that our workforce is not contributing to or being passive in the maintenance or the perpetuation of systemic racism. It’s one thing to focus on trying not to do anything to make things worse. That’s being passive. If you’re focused on not trying to offend anyone or doing things by the book, that’s a passive way of maintaining [the status quo].

Perpetuation of racism means we don’t want to talk about racism. We don’t want to emphasize that racism is a public health issue. We don’t want to talk about anything that is going to make leaders or donors uncomfortable.

The pivot between being passive and perpetuating to becoming anti-racist is being clear about what you’re doing to dismantle historical, institutional, or systemic racism. How are we educating our team members on the different types of racism? Are we talking about personally mediated racism, internalized racism, and institutional/systemic racism? What are we doing to make sure that underrepresented staff and vulnerable patients feel seen and valued? Being anti-racist means being very intentional about making sure that your environment and your organization are not perpetuating or passively maintaining racism.

Many health care organizations are in different places on their equity journey. [In 2017], there were some health care organizations and individuals in health care who took a stand against the travel ban. The American College of Physicians called hate crimes a public health issue after the deadly rally in Charlottesville. More organizations took a stand after George Floyd was murdered.

My hope is that these organizations maintain the momentum because one of the things that makes equity and anti-racism work hard is that — especially for the majority of White people in leadership roles — equity work is “opt-in.” It’s optional. For people of color and people from vulnerable populations and communities, it’s not opt-in.

I’m hoping [organizations will understand] that helping your employees feel like you want them to thrive is not additive. I would hope that wanting to make sure your Black patients who are pregnant don’t become maternal mortality statistics is not additive. I don’t believe health care can opt out. We don’t opt out of being there for people when they need us for other reasons, so why should we opt out of dealing with the other factors that contribute to patients needing us?

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