Insights

The make up of the leadership team plays a significant role in the development and execution of strategies to achieve equity for the patients and communities that their heare care organizations service.

A commitment to diversity in health care leadership must go beyond placing certain people in certain positions. Proportions and percentages matter, but supporting and empowering diverse members of the team is essential to ensure that they are set to succeed and to thrive. Patients, clinicians, and staff need to see women doctors and doctors from racially underrepresented groups leading other doctors. Organizations must start early in grooming, guiding, and providing growth opportunities to individuals from these groups so that they are positioned for successful high-level leadership positions. Mentorship and sponsorship opportunities must be implemented in health care organizations as part of a global strategic effort to achieve diversity and inclusion at high levels of leadership.

“Just because you’re invited to or have a seat at the table does not mean your voice is heard at the table. There also has to be a desire of the group to listen to our perspectives.” This insight is shared with me by Folasade May, MD, PhD, MPhil, the Director of the Melvin and Bren Simon Gastroenterology Quality Improvement Program at University of California Los Angeles Health. She expresses of her experience as a rising leader in her field of medicine, where she focuses on quality improvement and cancer prevention. “There are massive biases and incredible assumptions made about your abilities based on the way you look or on past experiences with others of the same racial and ethnic background.” A Harvard-, Cambridge-, and Yale-educated physician and researcher, May shares a story of when she moved to the West Coast for her fellowship to a hospital where a senior physician made it clear that because the persons of color they had encountered in the past did not do so well clinically, they were not sure she could be successful in her role. “If the perception is that we are challenging to work with, leadership teams are less likely to take a chance and invite us to the table. This is unlikely to be the case when a white person does not perform well; that person does not reflect poorly on the entire race. It’s a heavy burden that we are often responsible for challenging the future perception of our entire race.”

The Numbers

The current discourse on inequities in health care cannot be fully examined without a thorough evaluation of the lack of racial and gender diversity in executive and senior health care leadership. Although underrepresented groups make up roughly 29% of the population, just 9% are physicians, and only 7% are faculty in our medical schools.1A survey put out by the Institute for Diversity in Health Management2 showed that, in 2015, only 9% of CEOs and 14% of Chief Medical Officers in our hospitals were from minority groups. A 2014 survey conducted by The American College of Health Executives (ACHE),3 showed racial minorities were more likely to have taken a less desirable position when compared to whites for two reasons: (1) financial need and (2) lack of opportunity; 29% of Black health care executives compared to only 15% of white ones took a less desirable position because of financial need, and 38% of Blacks compared to 24% of whites said they took a less desirable position because of lack of opportunity.This ACHE survey was administered to Black, white, Asian, and Hispanic executives currently employed in health care. The 2014 version represents the fifth cross-sectional study, dating to 1992, aimed at determining if the racial/ethnic disparities in health care management careers have narrowed.Survey results also show variation in career aspirations by gender and race/ethnicity: 42% of white men stated they planned to be a CEO in 5 years, compared to 32% of Black, 31% of Hispanic, and 11% of Asian men. No more than 22% of women, regardless of race/ethnicity, aspire to be CEOs in 5 years. Notable, too, is variation among respondents who reported that they had witnessed a fellow worker’s health care management career affected by racial/ethnic discrimination: 64% of Blacks, 35% of Hispanics, 32% of Asians, and just 16% of whites.
In my experience as a health care leader of color, I have found an undoubtable trend can form early in the professional careers of racially and gender-underrepresented groups. In order to advance in their careers, they may feel compelled to stay quiet on issues pertaining to racial and gender diversity for fear of being branded as angry, difficult, and not a team player.

The Impact

In my experience as a health care leader of color, I have found an undoubtable trend can form early in the professional careers of racially and gender-underrepresented groups. In order to advance in their careers, they may feel compelled to stay quiet on issues pertaining to racial and gender diversity for fear of being branded as angry, difficult, and not a team player. Many times they are stepped over for projects or opportunities that would expose their talents and set them up for that next promotion. Mentorship and sponsorship opportunities are sparse if there are not active initiatives in place to support them. And once they do make it to a senior executive leadership or a board position, the lack of diversity among the current members in these roles creates an environment where, in order to hold on to that position, they may feel compelled to “not rock the boat” on matters pertaining to racial and gender diversity and inequities. We have made some strides in improving access to medical school entrance with a little over half of medical school entrants being women.4 However, the same progress is not seen in access to senior/executive health care leadership positions.To make a true mark on improving health equity, this must change.

The Solutions

A review of studies related to diversity in health care showed positive associations between diversity, quality, and financial performance. For example, patients generally fare better when cared for by more diverse teams, and improvements to innovation, team communications, risk assessment, and financial performance are associated with increased diversity.5Organizations that do not have significant racial and ethnic minority representation in senior leadership are less likely to make racial health inequities a priority.6 We need to prioritize the creation of racially and gender-diverse executive leadership teams in order to curb health inequities in our systems.7,8 Such diverse teams can establish priorities to replicate their makeup and encourage diversity throughout the rest of the organization. Senior leadership must lead by example in making leadership diversity a strategic priority.9 A diverse hospital leadership team, in and of itself, reveals to our health care units and patients that we all matter equally. This unspoken but powerful message will help break down implicit biases that fuel the health inequities in our health care systems. Additionally, a diverse upper leadership structure is more likely to recognize and address the institutional racism that cripples health care delivery and lays the foundation for health disparities and inequities. They will be more likely to develop and support structures and processes that promote health equity. How do we do this? By nurturing, coaching, mentoring, and sponsoring young women doctors and physicians of color to aim for senior executive positions. And then, once attained, by creating and fostering a supportive environment with structures in place for continued formal mentorship and training to set them up to succeed and thrive.This focus on diversity by the leaders at the Robert Wood Johnson University Hospital has yielded results in this area. As part of implementation of diversity initiatives, the hospital included initiatives to support and foster diversity in health care leadership. They set up a mentoring program for employees who wanted to develop their leadership skills as part of a commitment to develop junior employees into future leaders who would better reflect the hospital’s multicultural patients. They collected data through the annual leadership review process to learn what ethnicities and genders were underrepresented across its management and to pinpoint opportunities to promote them. They also studied the organization’s succession planning program and linked executive compensation to meeting diversity goals.10 These strategies, among others, helped increase the percentage of minorities on the hospital's leadership team to more than 30% in 2015 from just 4% in 2012. Minority representation on its board grew to 22% in 2015 from 17% in 2011. In addition, the organization has adopted a REAL (race, ethnicity, and language) Data Integrity LEAN Six Sigma Project to address health inequities affecting patients.11,12 These efforts resulted in an increased use of interpreter services; an associated decrease in hospital readmissions, specifically for heart failure, by 30%; and a decrease in its overall 30-day readmission rate from 13% in 2013 to 5% in 2014.

The Support Structure

Patients and health care providers need to see women doctors and doctors of color leading other doctors. To minimize imposter syndrome and feelings of inadequacy experienced by young health care professionals of color and women,13,14 organizations should start early in grooming, supporting, guiding, and helping to set them up for positions of leadership. Mentorship and sponsorship opportunities should be actively implemented in our health care organizations as part of global strategic efforts at diversity and inclusion. Promotions or special project opportunities should be established in a way that acknowledges the unique attributes and experiences each candidate brings to the position as it aligns with the advancement of the organization and health care as a whole.May expresses agreement in this area as it pertains to academic medicine. “What is needed is an overhaul of the promotion practices and policies in academic medicine. Papers and grants are important, but more value needs to be placed on community work, mentorship, and advocacy. These are areas that persons of color tend to be more involved and are drawn into because they affect our day-to-day experiences as persons of color,” she says. “It is important for our institutions to recognize this work and these contributions to the institution as much as they recognize papers and grants because they are just as important for health outcomes and the productivity of the organization.”Once these doctors reach senior leadership positions, there should be support structures in place for continued formal mentorship and training. When a Black woman physician leader rises to a new leadership position, those assisting with the transition process should be carefully selected as ones who will help set her up for success in the same manner they would for a white man. To achieve health equity, a hospital system needs to celebrate the accomplishments of a new Hispanic female CEO instead of celebrating only the fact she is Hispanic. Racially and gender-underrepresented health care leaders should be considered for a variety of senior and executive leadership positions and not just be limited to positions related to improving racial diversity in the organization. White men and women should also be encouraged to play an active role in implementing diversity initiatives within our organizations. This will send the message to our teams and patients that we place an equal value and importance on every human life in our institution by fostering an environment of diversity and equitable provision of care.
Racially and gender-underrepresented health care leaders should be considered for a variety of senior and executive leadership positions and not just be limited to positions related to improving racial diversity in the organization.

The Commitment

As our communities struggle with tackling racial injustice and disparities, those of us in health care should commit to hold ourselves to a higher bar. It should be our collective goal as health care professionals that even if racial inequality permeates our society, any person may seek refuge from this reality in any health care institution across the globe. To achieve the goal of health equity we have to actively develop long-term strategic initiatives with the specific goal of breaking glass ceilings and increasing the number of gender- and racially underrepresented tenured professors/researchers, C-suite/executive leaders, and board members in our health care institutions.15 By dedicating time and resources to these diversity initiatives we will also accelerate and enhance our efforts to achieve health care equity for our patients. Our ability as a health care community to narrow this gap reminds me of the Latin phrase per aspera ad astra: Through adversity to the stars. Our health care system, together, has the stamina and resilience to navigate through the adversity of racial and gender disparities in health care leadership with the goal of improving health equity.