What Sparked This?

Boston Public Health Commission creates Anti-Racism Advisory Committee

In 2005 the Boston Public Health Commission (BPHC) hosted an “Undoing Racism” training by the People’s Institute for Survival and Beyond and Visions, Inc. A large number of employees attended the training, which led to the formation of BPHC’s first anti-racism working group. The former Mayor and BPHC’s Executive Director were strong proponents of this work, and that support continues through the current Mayor and BPHC Executive Director.

In 2008, BPHC formally established the Anti-Racism Advisory Committee to build on the growing interest among staff to address racism through their work. The Committee has representation from across different programs and is intended to review, assess, and develop recommendations on internal policies, practices, structures, and systems using a racial justice and health equity framework.

Participation in the Anti-Racism Advisory Committee is voluntary, which ensures that members are motivated to participate and helps draw diverse staff from all levels of the organization. There is also targeted recruitment to ensure equitable participation. Committee members review membership expectations and obtain supervisor approval to allocate a certain number of hours to their participation on the committee.

Anti-Racism Advisory Committee builds shared language and organizational identity statement

The Advisory Committee was instrumental in incorporating concepts of racial justice and health equity into the Health Department’s vision and statements about how the Commission intends to carry out its mission. One of the Committee’s early tasks involved creating a glossary to support conversations about racism and systems of oppression. The glossary is used regularly in staff trainings and was adopted by BPHC to inform how staff understand health equity within a racial justice framework.

The glossary also impacted revisions to the Commission’s organizational identity statement, which includes its mission, vision, and guiding principles and a preface explaining the racial justice framework and the link between racism and health inequities. The Commission revised the statement to: 1) reflect its understanding that racism is a significant root cause of health inequities, and 2) illustrate its commitment to addressing the impact of racism.

Through in-person listening sessions held over 2 years, the Anti-Racism Advisory Committee received extensive feedback from 300 stakeholders to produce a meaningful identity statement that represented Commission employees and Boston residents. In November 2013, the Commission’s Senior Leadership Team and the Board of Health approved the revised statement.

All staff required to attend mandatory racial justice and health equity trainings

In 2008, Commission leadership conducted 27 all-staff meetings with over 800 employees. At these meetings, leadership surveyed over 400 employees and found that staff wanted more language and better skills to align their work with BPHC’s health equity priority. This led to the creation of the Professional Development Series, the current model for organizational change led by the Racial Justice and Health Equity Initiative (RJHEI) described below. The goal is for all 1,100+ BPHC employees to apply the principles and practices of health equity and racial justice in their work across the Commission.

Coordinated by a Senior Trainer for Racial Justice and Health Equity, Professional Development Series workshops have been designed and implemented collaboratively with staff from across the Commission. The facilitation team is composed of Commission staff who are selected, trained as facilitators, and assigned by their supervisors at 15%–25% FTE for at least 2 years.

Developed over 18 months with support from consultants and launched in 2011, the mandatory 2-day Core Workshop introduces concepts of racial justice and health equity, explores data about health inequities and what shapes health in Boston, and identifies what all staff members can do — as employees and as city residents — to achieve health equity.

Commission leadership worked with unions to build this professional development opportunity into collective bargaining agreements to ensure compliance, and worked with staff supervisors to ensure staff were allocated time to participate. To meet the unique needs of staff, a customized workshop was designed for Emergency Medical Services that highlights examples relevant to their roles as first responders. By June 2017, 93% of all Commission staff had completed the Core Workshop.

Staff are also required to complete at least 8 hours of follow-up Practice Workshops on topics such as community engagement, policy advocacy, evaluation of health equity efforts, quality improvement and accreditation, and promotion of equity in internal operations. Practice Workshops are supported with coaching/technical assistance, and can be customized to respond to specific programs or challenges that staff encounter in applying a racial justice and health equity lens to their work.

More details about the comprehensive Professional Development Series model for building internal capacity to achieve equity are available online.

Creation of the Racial Justice and Health Equity Initiative  

Started in 2011, the Commission’s Racial Justice and Health Equity Initiative (RJHEI) is “a broad organizational transformation process to adapt, improve or develop innovative public health practice to measurably reduce inequities in Boston. At its core, the Initiative is about engaging the entire organization in building a movement towards health equity and fulfilling the organization’s mission and vision.”

Since its inception, hundreds of staff have engaged in RJHEI, from brown-bag learning sessions on racism to the shared responsibility of tracking and reducing racial health inequities in Boston. Staff drive the work and are accountable to the broader community of Boston residents. RJHEI works closely with the Commission’s Senior Leadership Team (a leadership body of bureau directors and directors of cross-cutting departments or public health service centers), the Office of Health Equity, the Research and Evaluation Office, the Consortium for Professional Development, the Office of Accreditation and Quality Improvement, and others toward an inclusive organizational change process to advance health equity.

Program Description

Through the Anti-Racism Advisory Committee, the Professional Development Series, and other activities, staff and leadership developed a common language, collective vision, and clear strategies for how to advance racial justice and health equity within the organization and in partnership with community. One strategy is to improve workforce diversity so that the Commission’s workforce reflects the population of the city of Boston.

All-staff survey informs development of hiring, promotion, and retention workgroup

In 2013, the Anti-Racism Advisory Committee developed an all-staff survey to understand how the Commission could further align itself with racial justice and equity principles. Findings demonstrated that recruitment, hiring, promotion, retention, and professional development overwhelmingly rose to the top of staff issues and concerns.

In response, the Committee and the Senior Leadership Team identified 2 priorities:

• Equal opportunities for advancement to leadership positions
• Professional development and retention for lower wage staff

In January 2014, the Senior Leadership Team released 10 strategies to advance these priorities. To achieve these strategies, the Commission developed cross-commission workgroups — one of which was focused on hiring, promotion, and retention — and did extensive outreach to ensure participation from across the organization, particularly from teams responsible for implementing recommendations.

Prioritizing workforce development and hiring practices to advance equity

The Anti-Racism Advisory Committee’s work was subsequently incorporated into the 2015–2018 BPHC Strategic Plan. Workforce development goals include: 1) BPHC’s workforce is trained to effectively monitor and respond to the current and future public health needs of Boston’s residents, and 2) BPHC’s policies and procedures support the recruitment, retention, and advancement of a qualified and prepared workforce that is reflective of the community it serves.

Similar to other health departments, the Commission has a decentralized hiring structure where hiring managers are responsible for ensuring that applicants are appropriately screened. Without a clear workforce plan or standardized instruments to ensure consistency across screening, there has historically been wide variation in how applicants are screened and whether they are invited for interviews.

The main goal in creating the Hiring, Promotion, and Retention Workgroup was to advance racial justice and health equity in the organization’s hiring, promotion, and retention practices. This would ensure a more equitable and standardized process throughout screening, interviewing, and hiring with the end goal that the Commission recruits, hires, promotes, and retains Boston residents of color to be representative of the people BPHC serves.

Hiring, Promotion, and Retention Workgroup formed

Prior to establishing the Hiring, Promotion, and Retention Workgroup, Anti-Racism Advisory Committee members met with lead staff for hiring and retention practices to jointly develop a scope of work and identify who else should participate to ensure integration from the start of the collaboration.

In 2015, the Committee and the Human Resources Office formed the Hiring, Promotion, and Retention Workgroup. Membership included staff across bureaus, the Accreditation and Quality Improvement Team, and staff in the Consortium for Professional Development. It started with 12 members, though membership has ebbed and flowed over time.

At their first formal meeting, Office of Health Equity staff facilitating the process realized they needed to first address racial imbalance within the Workgroup. They specifically stated that they were not asking any participants to leave the group, but rather inviting participants to step back and encourage others on their staff to also participate if they could. As a result of this conversation, the Workgroup became more diverse and more clearly aligned with the Workgroup’s priorities and goals.

The Workgroup began by looking at the list of strategies developed by the Senior Leadership Team in 2014. The strategies included specific items such as developing a training for hiring managers about screening and interviewing techniques, creating a “do’s and don’ts” list of information to ask during an interview, and creating a checklist for the interview process, so that every hiring manager would be shown or reshown the same set of information and process they should be following.

Some of the strategies had already been implemented, and others were still in progress. The Workgroup evaluated whether already implemented strategies — like the training of hiring managers — were having the impact they wanted them to have. As noted by one staff member, “Looking back at what’s already been done doesn’t always feel that exciting or new, but it was critically important for us to understand what’s working or not and what to do differently and why.”

The Workgroup’s discussions to date have focused on how to create accountability mechanisms throughout the hiring process. Preliminary work findings have been presented to leadership to get additional buy-in for the Workgroup’s process, and have also been shared with other organizations. As noted by the Director of Human Resources, “This is a constant growth process.”

Hiring managers’ survey identifies opportunities for hiring process improvement

In June 2016, BPHC conducted a survey of the 120 managers who had participated in the hiring manager trainings between 2015 and 2016. Fifty-seven percent of hiring managers participated in the survey, and results showed that most were implementing the practices suggested in the training — e.g., using a standard set of questions for the position, allowing candidates to speak the majority of the time, and not using yes or no questions.

One of the required checklist questions was about health equity: “Given that the mission of the Boston Public Health Commission is to protect, preserve and promote the health and well-being of all Boston residents, particularly the most vulnerable, please answer the following question: ‘What experience have you had at work, in school or in your community with health equity?’” One lesson learned from the survey was that this question caused confusion among candidates. Hiring managers reported that the question was not working well, and the Workgroup realized that they needed to replace it with something else. Part of their ongoing work is to figure out how to get the concept of health equity into the screening and interview process as well as holding hiring managers accountable for recruiting a diverse pool of candidates.

Data collection used to help target diversification efforts

The City of Boston created a workforce dashboard showing the race, gender, salary, and tenure of city workers to illustrate how departments are moving toward the vision of becoming a city government reflective of the city.

BPHC operates as a city department but is also its own legal entity with separate payroll, human resources, and other departments that are structured and collect data differently than the City of Boston. BPHC collects more extensive data and has in-house data analysis and evaluation staff. Using their data, BPHC can analyze who applied for positions, who was hired, length of BPHC employment, and promotion opportunities. Still, ongoing data analysis of BPHC’s workforce is under-resourced.

In early 2017, BPHC used employee data to compare 2013 and 2016 staffing to inform their assessment of whether they met their 10 strategies. As of June 2017, they had accomplished a number of the strategies, but recognized there was still much more to do. The Hiring, Promotion, and Retention Workgroup is meeting with the Senior Leadership Team and incorporating quality improvement tools to determine their next steps, and developing a report illustrating the impacts made so far.

Outcomes and Impacts

“The fight to include the word racism is not as prevalent anymore — now it is more about building accountability structures to ensure racial and health equity practices are standard.”

• Deeper engagement with anti-racism work 

  Over the past decade, BPHC’s anti-racism work has evolved and grown across the whole organization. Today it is embedded throughout BPHC practice and is being cultivated across departments and other government agencies. However, there is still much to be done.

• Walking the talk of equity

  Today, the Hiring, Promotion, and Retention Workgroup is comprised of a racially and ethnically diverse group of staff with expertise in human resources, racial justice, professional development, management, quality improvement, and programmatic functions. Work group members support each other to “walk the talk” and incorporate equity in all of their work.

• New culture of quality improvement builds momentum

  In the past 2 years, BPHC has created an Office of Accreditation and Quality Improvement to prepare the organization to apply for public health accreditation. Staff observe that having the office and framework of quality improvement, which identifies small and measureable changes, has created a new culture for learning and continuous quality improvement. The Director of Human Resources notes, “I’ve participated in many different group processes, and this [Hiring, Promotion, and Retention Workgroup] is the first group that has had as many small accomplishments in its first 2 years.” The Office of Health Equity Program Manager agreed and stated, “We’ve integrated all that we can from our learning into this process to be very intentional moving forward. Often quality improvement is an equity issue, so framing it as such is important for organizational growth. We are continuously undergoing quality improvement and building on the expertise of staff at all levels.”

• Scaling up hiring practice work

  The City of Boston Health and Human Services Cabinet, which houses BPHC and 6 other commissions, initiatives, and offices, is in the process of developing a hiring toolkit, and BPHC’s Director of Human Resources is working with them on cabinet-wide toolkit development and training. BPHC’s Director of Human Resources is working with the leadership and human resources directors from other city departments to train them on the toolkit and expand BPHC’s work.

• Supporting staff on the ground 

  BPHC staff realize they need to better support staff on the ground doing the hiring for BPHC positions. They are working with hiring managers to identify ways to eliminate existing barriers and to promote equity in hiring retention practices. At the same time, they are trying to foster peer-to-peer learning among hiring managers on successful strategies and practices for increasing diversity, particularly in leadership positions.

• Lessons learned about how to engage staff 

  Over the past decade, participation in the Anti-Racism Advisory Committee has fluctuated, sometimes involving more people from a certain BPHC area depending on the type of organizational change prioritized at the time. As noted by the Office of Health Equity Program Manager, “Different bureaus have different abilities to release staff for participating on the committee. For example, it is often a challenge to get direct service staff to participate. However, we work to offer project-based opportunities with shorter timelines, so participation can extend beyond regular meetings.” The Committee has learned to adapt to staff needs to increase participation: they now seek participation by directly recruiting staff and by targeting across race, ethnicity, and organizational placement, especially in groups that may be inadequately represented. Participation expectations are clear and supervisor approval is still expected, though without a written document.

Future Steps

BPHC’s work to address racism has grown tremendously, impacting their own employees as well as staff in other agencies and community residents. There is an ongoing effort to institutionalize the work and have clear mechanisms for accountability to stated goals and objectives.

The Hiring, Promotion, and Retention Workgroup is currently assessing its next steps. The Workgroup recognizes that racial justice and health equity work is not a linear process, and requires learning from past efforts and integrating that learning into new efforts, not being attached to any particular process/practice/procedure, and being honest about impact and whether goals are being achieved.

The BPHC Executive Director stated, “I am extremely proud of the tremendous effort and accomplishment of training so many of our staff. However, in order to build on the momentum of these efforts, we need to build on these trainings to ensure that staff are actually using the tools that they have learned in their day-to-day public health practice.”

Advice for Local Health Departments

• Without being vigilant, equity can be lost

  You must ensure that that you are always doing everything you can to avoid perpetuating inequitable systems. Continuous quality improvement, evaluation, and focus and reflection are integral to advancing equity.

• Aim for the big wins and celebrate the small wins

  True transformation takes time. If there are specific items that can be done in the short term, do them. Small and “free” wins are especially worth doing. You need short-term wins to gain momentum for the long haul. Celebrate all wins, but keep a clear sense of where you are and what you are working toward.

• Be transparent about the process

  Many people don’t have equity written into their job descriptions to make it clear when and how they are supposed to do this work. Large organizations are hierarchical in nature, so it is important to be very clear and explicit with workgroup participants about the process and the ultimate decision makers. Be clear that you will lift up their recommendations but avoid overpromising. Being transparent about the process helps ensure people are not surprised if their ideas do not prevail, and it helps people stay engaged.

• Take the time to evaluate what’s currently happening

  The Hiring, Promotion, and Retention Workgroup learned from what had been done before. Although it can feel tedious, and seem as though you are not moving forward, it is important to understand what was implemented in the past and examine whether or not it was having an impact, whether it should be scaled up or discontinued, etc. Doing this will allow you to build on the foundation created by earlier efforts.

Strategic practices leveraged in this case study

Build a Health Equity Movement

Change Internal Practices and Processes

Develop Leadership and Support Innovation

Change the Conversation

Build Organizational Capacity

Confront the Root Causes

Additional Resources

• People’s Institute for Survival and Beyond
• Institute for Healthcare Improvement
• Seattle Race and Social Justice Initiative