Why It Matters
While it’s been heartening in recent months to see more willingness to address equity in health care — especially given the disproportionate impact of COVID-19 — some people fail to see the need to explicitly address race and racism. Some see science, including improvement science, as inherently free from bias. I can sympathize because I had similar assumptions of my own not so long ago.
But it has become increasingly clear to me that we can’t improve equity — one of the six aims identified by the IOM — without taking on racism. Isn’t the failure to deal with these issues the reason equity has too often been the “forgotten” aim for 20 years?
Taking on systemic racism requires a reexamination of the foundations not just of health care, but of who we are as a people. It is to acknowledge something we may not be ready to admit about our history, about the fabric of our social systems, and the way we were built as a country.
Yes, improving safety, effectiveness, patient-centeredness, timeliness, and efficiency (the other areas for improvement defined by the IOM) is difficult, but equity is the most challenging because we never intentionally designed systems to harm patients. We never legislated long waiting times. We never imposed rules, regulations, customs, and norms for ineffective care.
We did, however, legislate inequity. It’s in the founding documents of our country. It’s how we built this nation. It’s in our language. It’s in the way that we read and write. It’s in the way that we build our cities. It’s in what we see online.
It’s in everything and, yet, the racism and systemic oppression in our work are so baked in some of us don’t see it. If you don’t agree, you need to look harder, as IHI board member Mark Smith, former CEO of the California Health Care Foundation, has counseled us to do. Inequities exist within IHI. They are present in your organization, too, if you’re willing to see them.
The reason it was necessary to identify six aims for improvement is because you have to make the invisible visible by naming it. You can’t fix what you can’t see.
With safety, for example, we made the invisible visible by admitting we were harming patients, and then we moved to quantify it. How many falls? How many infections? How many pressure ulcers? This was not easy. It’s still not. It’s painful to admit that our care sometimes hurts the people entrusted to our care.
It is also painful to admit racism exists, but we must, or we’ll never see an end to it. Who is getting early cancer screenings? Whose diabetes care is improving? Who is attending smoking cessation groups? Which policies regarding uninsured patients and those on Medicaid leave some people behind? Does it matter if the inequities are not intentional if the results are the same?
Talking about racism is not the problem, just as talking about medical errors was not the problem — it was a step toward the solution. With safety, we named the problem and measured it. Once you name and measure a problem, you can start to change it.
It’s our thesis at IHI that these are the prerequisites for taking disciplined action to bring these inequities to resolution. We will also need to approach this work with openness, honesty, and a willingness to fail. We will need to pitch very broad tents and invite people in who have expertise and knowledge that we often simply do not have. We must be humble and ready for these difficult discussions.
And, yes, they are difficult. They’ve been hard for me, as I’ve gone through my own personal understanding of racism and how it affects me, as a person of color, but also, in some cases, how I perpetrate it, continue it, and stabilize it, as someone with considerable privilege. It has required openness, honesty, and humility, and no small amount of discomfort at times.
When it has been hard, I’ve taken refuge in the fact that I am 100 percent confident that we are on the right side of this issue. As health care leaders, it is our responsibility to move away from deep inequities built into the fabric of our systems and to move toward creating equitable outcomes for all. We can no longer tolerate the idea that a high-quality health care system can leave out significant segments of the population. Any organization that is ready to have this conversation will find IHI ready to join you.
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.
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