Addressing Institutional Racism in Healthcare Organizations

After George Floyd died while in the custody of the Minneapolis police, Americans (and many others from around the world) marched in protest against this killing that exemplified the historical violence experienced by people of color and the systemic racism that many believe led to this tragedy. For many reasons, including the inequitable toll of the coronavirus pandemic and its economic consequences on people of color, George Floyd’s death is the latest of many similar tragedies that have galvanized millions of Americans to understand the connections between the structural racism of the criminal justice system and systemic racism in other sectors of our society such as housing, education and healthcare.

In solidarity with the movement against the oppression of Black lives, industry leaders, including health system CEOs, made solemn public commitments to address structural racism in their organizations. We cannot lose the momentum of this moment. But how do we begin to address institutional racism in healthcare organizations? 

In 2017 the Institute for Healthcare Improvement used its framework for achieving health equity  Achieving Health Equity: A Guide for Health Care Organizations, which includes a component focused on institutional racism, to guide the work of health systems participating in the Pursuing Equity initiative. Based on learning from the initiative and further IHI research published in 2019, this article presents strategies in five core areas to guide healthcare leaders as they seek to address institutional racism in their organizations. 

Such efforts involve a commitment to change structures, processes and norms to bring about equitable outcomes in healthcare. And they aim to engage the hearts and minds of all who work at the organization to challenge preconceived notions about race and privilege, as well as to learn about the history of racism in the U.S. and the organization’s history in the community. 

Understand History 
An initial step is to learn the history of racism in the U.S. and how it manifested in the city or town in which the institution is located and in the institution itself. Are there examples analogous to the Tuskegee syphilis experiment on Black Americans or to the experience of Henrietta Lacks, whose tissue sample was taken and used for profit without her knowledge? Has the organization participated in gentrification, and did the institution have a reputation of not being a welcoming place for people of all races? Who could practice medicine at the organization? Speak to community members to learn about whether the organization has a racist legacy. These stories are passed on through generations and contribute to mistrust of healthcare to this day. 

Understanding history also includes recognizing the struggles of people of color in the community and coming to terms with the advantages that white people have benefited from because of structural racism. When we see more leaders and others in the organization engaging in their own personal journey, we will gain a better understanding of how the past may impact actions in the present. We each bring our own story and history to our roles in healthcare, and the work we each can do as individuals is critical to advancing racial equity.

Establish a Welcoming Culture 
There are several ways a healthcare organization can create  a welcoming culture. One, it can encourage conversations about race and racism and how racism has influenced current practice. Two, it can change systems and processes that are causing health disparities, be willing to engage in uncomfortable conversations and overcome the disparities caused by institutional and structural racism. Third, we can educate ourselves about implicit bias and evidence-based methods for counteracting it, which is important for clinicians as well as staff at all levels of the organization. Fourth, listening and responding to the needs, norms and preferences of the community is always an important factor when adjusting the culture. Also, the physical environment—what is hung on the walls, the colors used, the general décor—contributes to a welcoming organizational culture when they reflect the rich diversity and cultures of the populations served.

Commit to a Diverse Workforce 
When hiring staff and clinicians at all levels, be mindful that there is a diverse panel of applicants, and that retention strategies include professional development, mentoring and promotional opportunities for staff of color. Also, a commitment to diversity throughout the organization can be demonstrated among executive leaders, board members, the workforce and medical and nursing students and other health professionals in training. When staff, clinicians and organizational leaders reflect the racial and ethnic demographics of the community, decisions can be made with greater sensitivity to the needs of the historically under-represented groups in the community. 

Several other ways to work toward a more diverse workforce include the following: 

• Address employment criteria that exclude low-income community members from being hired (e.g., offer certifications that can be earned during employment). 
• Respond meaningfully to staff-reported experiences of discrimination. 
• Implement fair procedures for assessing staff performance.
• Pay fair wages and ensure pay equity for healthcare workers. 
• Analyze the demographics of disciplinary actions and understand how benefits such as retirement plans and tuition support are used by low-wage staff.  

Assess Business Practices
Beyond the workforce and human resource issues, assessing the impact of business practices on racial equity can guide healthcare leaders as they seek to address institutional racism in their organizations. What insurance plans are accepted by the organization? Where are new healthcare facilities built? Conduct Racial Equity Impact Assessments  to understand how new policies may impact under-represented communities. Consider strategies used by anchor institutions to direct resources to the community: procure services locally and specifically from minority businesses; provide job training for local low-income and minority residents; create pipelines for students to become employees; invest in building community health and wealth through inclusive hiring, investment and purchasing; engage in community partnerships; leverage philanthropy to support under-resourced communities; and allocate a portion of the investment portfolio locally.

Examine Clinical Operations 
Understand where disparities in care exist and close the gaps. Stratify quality data by race, ethnicity, and language, by socioeconomic status/pay, and by sexual orientation and gender identity. Ensure equity is a key part of all quality improvement initiatives; not doing so can result in widening gaps in care. By solving problems for marginalized populations, we often develop solutions that work better for all. Ensure that people of color and those living in poverty have access to care, including services provided by the big profit centers in hospitals (e.g., cardiology, hip and knee, bariatric surgery). It is not enough to identify racial disparities in care for those who have access to the system; we must actively work to provide access to care for people at the margins of society and the economy. Current payment systems and policies make this difficult. Healthcare leaders must advocate for changing these structures, policies and practices at the federal, state and local levels to enable equal access to care and quality care for all. 

Let us keep up the momentum and honor our commitment to address racism in healthcare. Now is the time to identify and dismantle structures, processes and norms that contribute to health inequity and injustice. 

Laura Botwinick is a program director and educator at the University of Chicago (lkbotwinick@gmail.com). Amy Reid is a director at the Institute for Healthcare Improvement (areid@ihi.org). Ron Wyatt, MD, is vice president/patient safety officer at MCIC Vermont and chair of the IHI Equity Advisory Group (ronald.m.wyatt@gmail.com). John Whittington, MD, is a senior fellow at the Institute for Healthcare Improvement (john.w.whittington@gmail.com).