Why It Matters
Using words like “racism” tends to get people’s attention.
I had an experience nearly two years ago that I will never forget. I was at a meeting in a room full of health care leaders when I suggested we talk about institutional racism. Once I started to speak, the room fell silent.
The Aspen Institute defines institutional racism as “the policies and practices within and across institutions that, intentionally or not, produce outcomes that chronically favor or put a racial group at a disadvantage.”
It’s painful for those of us dedicated to improving health care to consider even the possibility that the institutions we lead reinforce inequities. But just as giving patient safety the attention it deserves means we must admit that health care sometimes unintentionally harms patients, we must accept the reality of institutional racism before we can meaningfully address equity.
This is why I felt compelled to talk about institutional racism at the leadership meeting I attended. Yes, we were talking about multiple ways to address health equity, but we were not discussing our own behaviors or the policies and practices that we create, implement, and enforce. We were talking as if our organizations don’t have a huge role to play in ensuring equity. And, of course, they do.
Never a Comfortable Topic
As a white man, I have never felt comfortable talking about race and racism. It’s difficult to say these words out loud. I believe leaders find addressing issues like unconscious bias and institutional racism especially challenging because we’re compelled to consider our own role in injustice.
This is precisely why I, as a health care leader, must address these issues. If I don’t acknowledge my biases, put aside my discomfort, and persist in putting the spotlight squarely on race and racism, I risk maintaining the status quo rather than being part of the change that is essential to achieve health and workforce equity.
Eye-Opening Data
I speak from experience when I say that it’s easy for leaders to assume their workplace is equitable if they don’t look hard enough. You need to be willing to see it.
For years, our employee satisfaction scores at IHI were typically in the low- to mid-90s. Then, as part of our internal equity improvement efforts, we started to give staff the option on internal surveys to identify, if they chose, as white or as a person of color. For the first time, this gave us the chance to stratify the data. The results have been eye-opening.
For example, in response to the statement, “Overall, IHI is an excellent place to work,” the data from the first stratified survey indicated a 30 percent difference between staff of color and white staff, with around 98 percent of white staff agreeing or strongly agreeing compared to 68 percent of staff of color. The gap has varied over time, but we continue to struggle with how to close it.
Until we stratified our data, I did not understand the depth or the scope of the equity problems we had. I realized that we had to find ways to hear every voice because we had not been listening closely before. It was an important lesson.
I fundamentally believe that it’s my duty as IHI’s chief executive to listen more closely and better understand what everyone needs to thrive. None of us are going to be the best we can be unless all of us are the best we can be.
What Leaders Can Do
As leaders, we can’t eliminate all the contributors to inequities experienced by our patients and staff, but shouldn’t we do all we can to influence the factors that are in our control? Indeed, we can’t fully realize the Triple Aim without equity.
Recently, I have seen more leadership energy devoted to ending racism and achieving equity than I ever have. A number of our IHI Leadership Alliance members have made important steps as they’ve followed the path set out in IHI’s Achieving Health Equity: A Guide for Health Care Organizations white paper. Here are some lessons I’ve learned with help from Alliance members:
- Use your influence to make an impact — As one of the biggest employers in the region, the University of Arkansas for Medical Sciences (UAMS) Medical Center leaders understand they can influence the health of their community by making health equity a strategic priority. UAMS Chief Clinical Officer Stephen Mette, MD, has described the “jaw-dropping” data that led his organization to guarantee a regional living wage to all its hourly workers: of which 10 percent — more than 1,000 people — were making below the living wage for Central Arkansas. An organizational assessment found that the only hot meal some of their food service employees had every day was the free one they ate at work. Such revelations galvanized UAMS to “get their own house in order” as part of their diversity, inclusion, and equity efforts.
- Accept no substitute for open conversation — This means we must develop the willingness and strength to tackle these problems over time through exposure and experience. To develop our understanding, those of us who lack lived experience must listen with humility and respect to what others have to say about their encounters with unconscious bias and institutional racism. Ask open-ended questions with humility: “Will you help me to understand?” “What does this mean from your perspective?” Don’t assume you know the answers. Do more listening than talking. Avoid getting defensive.
- Understand that health care cannot address equity on its own — Partner with the organizations in your community who share an interest in equity and social justice. We have much to learn from them. As Kendra Tinsley, MS, MHCDS, CPPS, Executive Director of the Kansas Healthcare Collaborative has noted, “. . . health professionals are in a unique position to lead efforts to eliminate health disparities and foster health equity by working with communities, patients, providers, payers, legislators, and policymakers.”
- Make equity a guiding principle, not just an outcome — Let’s think about equity as a design feature and not only as a consequence of what we do. In other words, we must work toward equitable outcomes, but let’s also be mindful of equity from the moment we think about providing a service or improving a process. For example, if you see that your diabetes care needs improvement, what should that look like for different communities? Are you co-designing with people from those communities? Let’s make equity a principle that guides our thinking and actions.
While it has gotten somewhat easier for me to address issues around race, racism, and equity over the years, it’s still difficult. No one should expect to ever feel comfortable talking about these issues.
But if you’re avoiding these discussions because of your discomfort, think about all the difficult conversations you persist in having about improving safety and quality. Consider the challenges you take on as part of your organization’s Triple Aim efforts. Understand that equity is essential to improving health and health care worldwide. True transformation will be impossible without it.
Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on the IHI blog.
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