21st June 2019

The Structuration of Institutional Racism in Australia’s Governance of Safety & Quality in Health

By DrMJLock


This 16 part blog series shows how institutional racism is embedded into the governance of Australia’s Safety and Quality Health Service Standards. I reveal how the cultural voice of Australia’s First Peoples is routinely excluded from the governance of safety and quality. It emphasises a methodology that focusses on the construct of the ‘institution’ as deeply embedded patterns of organisational behaviour that individuals are unaware of. That is, we can be active participants in creating and recreating racism but we are unaware of it. This requires new policy trajectory methodology based on Anthony Giddens’s structuration theory, Foucauldian discourse analysis, and corporate document analysis. The results, interpreted through the lens of Australian cultural safety, show that:

  • Routine knowledge production processes for safety and quality only in a limited way address cultural diversity.
  • Particular kinds of information or ‘evidence’ is favoured that excludes human relational factors.
  • Different cultural conceptions of health, safety and quality, and governance are ignored.
  • There is no specific reference to Australia’s First Peoples in Acts, organisation governance, committee charters, & evidence-gathering criteria.

As a result, I argue that transforming healthcare governance to enable cultural safety with Australia’s First Peoples involves including our cultural voices in and through the points and pathways of corporate governance.


The governance of Australia’s Safety and Quality Health Service Standards is circumscribed by law in the National Health Reform Act 2011, governed by the Australian Commission on Safety and Quality in Health Care, framed by the Australian Safety and Quality Framework for Health Care, and enabled through the National Safety and Quality Health Service Standards (NSQHS Standards).

This policy analysis began when I assessed the developmental trajectory of the NSQHS Standards and realised that the cultural voice of Australia’s First Peoples received only token acknowledgement in them. I wondered, could this be an example of ‘racism by consequence’ (Guess, T.J. 2006)? That is, discriminatory behaviour through ‘social practices that are essentially depersonalized through institutionalization’ in contrast to ‘racism by intent’ that occurs through deliberate individual discriminatory behaviour.

The NSQHS Standards apply to all Australian healthcare organisations (e.g. 1,600 hospitals). In a nutshell, hospitals are assessed against ten standards for safety and quality, receive accreditation, and obtain government funding. The NSQHS Standards have their origin in 1994 and were first implemented 2012 – a developmental trajectory sign posted by 12 policy documents that can be linked into a policy development trajectory (more in the methods section).

As I have found in Australian Open Disclosure Governance, and in the intellectual development of Australian healthcare governance, the cultural voice of Australia’s First Peoples is systematically excluded from the development of the NSQHS Standards from 1994 to 2012.

The Quality in Australian Health Care Study – Ground Zero for Institutional Racism?

The first policy document was the Quality in Australian Health Care Study, published in 1995 (Wilson et al. 1995). The study began in 1994 when it was found that adverse patient events in hospitals resulted in patient disability and lengthier hospital stays, and that these were caused by health care management. This study is “ground zero” for reforms in the Australian healthcare safety and quality and could have been a significant point where Australia’s First Peoples could have influenced the intellectual development of discourse about healthcare safety and quality. However, exclusion instead of inclusion of cultural voice means that I have designated it as a point of origin of institutional racism in Australian healthcare.

Let’s also think about what else was happening in Australia in 1994. It was also the year that the evaluation of the 1989 National Aboriginal Health Strategy found little evidence of its implementation. This finding led to the Australian Government taking over responsibility (in 1995, from the Aboriginal and Torres Strait Islander Commission) for the administration of Aboriginal health and focussed on inter-sectoral strategies, collaboration, and intergovernmental planning, to improve Aboriginal health outcomes (Anderson 2004). That is, at the same time the Australian Government was promoting ‘inter-governmental planning’ in Aboriginal health it failed to include Aboriginal health in the Quality in Australian Health Care study.

It is also instructive to think about the broader social and political context of Aboriginal affairs leading up to the 1994 Quality in Australian Health Care study. In 1991, the final report on Aboriginal Deaths in Custody was released (NAA 2019a); in 1992, the Mabo Case overturned the colonial concept of terra nullius (NAA 2019b), and in 1993, the Native Title Act became law (ALRC 2015). The point is that Australian health care executives knew about police racial discrimination in prisoner deaths, racist beliefs underpinning terra nullius, as well as the need to improve Aboriginal health outcomes – why was this knowledge not reflected in the Quality in Australian Health Care Study?

This ends the introductory blog on this series about the Structuration of Institutional Racism in Australia’s Governance of Safety & Quality in Health Service Standards. In the second blog, I will introduce the methodology of the critique – structuration theory, policy trajectory, Foucault, and corporate document analysis.


  • Guess, T. J. (2006). “The Social Construction of Whiteness: Racism by Intent, Racism by Consequence.” Critical Sociology 32(4): 649-673.)
  • Wilson, R. M., et al. (1995). “The quality in Australian health care study.” Medical Journal of Australia 163(9): 458-471.
  • Anderson, I. P. (2004). “Recent developments in national Aboriginal and Torres Strait Islander health strategy.” Aust New Zealand Health Policy 1(1): 3.
  • National Archives of Australia (NAA 2019a). “Royal Commission into Aboriginal Deaths in Custody – Fact sheet 112”.
  • National Archives of Australia (NAA 2019b). “Eddie Koiki Mabo and the Mabo Case”.
  • Australian Law Reform Commission (ALRC 2015). “Connection to Country: Review of the Native Title Act 1993 (Cth) (ALRC Report 126)”

Lock, M.J. (21 June 2019) “The Structuration of Institutional Racism in Australia’s Governance of Safety & Quality in Health: Blog Post #1”. Newcastle: Committix Pty Ltd. Available at: https://committix.com/2019/06/21/the-structuration-of-institutional-racism-in-australias-governance-of-safety-quality-in-health/