Array of portraits of a diverse group of doctors, photo by JohnnyGreig/Getty Images

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(The RAND Blog)

When It Comes to U.S. Health Systems—Diversity Matters

Photo by JohnnyGreig/Getty Images

by Ryan E. Tsuchida, Sydney Fouche, John Burkhardt, Ted Corbin, Harrison Alter, Mahshid Abir

September 25, 2020

Health systems could go beyond mission and non-discrimination statements to disavow discrimination and show that diversity matters. As health care providers, public health researchers, and patients we believe research and policy prioritization around diversity, equity, and inclusion could result in a health care workforce that mirrors the community it serves and, ultimately, lead to better health outcomes.

Past policy initiatives (PDF) have aimed to measure and eliminate disparities in health outcomes for historically marginalized communities—such as people of color and those with limited English proficiency. At the same time, similar groups are under-represented in medicine. As an influential California study showed, black men were more likely (PDF) to take preventive health measures recommended by black physicians compared to white physicians. This study showed the importance of health care provider diversity and its implications for patient care and treatment adherence. Further, the importance of increasing diversity among care providers is recognized by governmental agencies such as the National Institutes of Health, the National Academy of Medicine (PDF) and by specialty organizations such as the American College of Emergency Physicians and the American Academy of Family Physicians.

Creating a culture of inclusion interwoven with workforce diversity could help to overcome the practical limitations of patient-provider background congruence. For example, unplanned visits to emergency departments may not afford patients the ability to pre-select their provider—and emergency departments cannot realistically staff with a fully representative diverse workforce at all times.

Opening the Door to More Diverse Health Professionals—and Keeping Them

One of the first steps toward attaining a diverse health care workforce could be intentional recruitment—considering candidates' diverse attributes as “value-added” just like educational attainment, standardized test scores, and professional experience. Intentional recruitment can sometimes meet with resistance because of fears about legal retaliation and negative associations with affirmative action. However, intentional recruitment is a distinct process. Unlike affirmative action, intentional recruitment does not use quotas and thereby can help avoid claims of “reverse discrimination” that some opponents of affirmative action make. Intentional recruitment could be supported by growing evidence of significant limitations that “objective” metrics such as test scores may have on predicting job performance and the cultural bias (PDF) these metrics can impose on minority test takers.

One of the first steps toward attaining a diverse health care workforce could be intentional recruitment

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Building a diverse health care system may not be the work of a single institution, human resources philosophy, or checkpoint on the way to becoming a health care provider. A collective effort across multiple stakeholders and organization types could help enhance diversity. For example, the number of diverse physicians is limited by the number of diverse medical students which, in turn, is limited by the number of diverse undergraduate students. Pipeline programs fund early mentorship and select recognition of underrepresented minorities in health care. Health systems could sponsor these pipeline programs in order to be able to recruit from a diverse group of mentees. Described as “the diversity snowball effect,” pipeline programs' intentional and positive feedback loop might result in long-term benefits far outweighing the initial investment.

Health systems also could engage in intentional retention and intentional promotion. For example, retention and promotion disparities are well documented for women in medicine. Pay disparities for women (PDF) persist despite controlling for all other conceivable factors like specialty, full- versus part-time status, and geographic location, among other things. For physicians, these disparities can start with their first job out of residency and have lasting influence on career-long earnings. Ensuring pay equity for women along with efforts ranging from furnishing lactation spaces to promoting female leaders as mentors could have a positive impact on retaining women in the workforce.

To better meet the needs of all groups, health system leaders could solicit feedback from employees of underrepresented backgrounds to find ways to make them feel valued and included in the health systems they work for. Further, as a demonstration of institutional priorities, programs that result from such a process could incentivize participation—funding mentorship, for example, or considering Saturday academic enrichment activities in promotion assessments.

Health systems could be better off viewing themselves as integral to the pipeline process, part of a larger continuum of recruitment, retention, and promotion of a diverse workforce. These intentions could be combined with a continuous auditing process to ensure that their initiatives are producing the desired outcomes. The responses might best be carried out without penalty to those who uncover the opportunities for improvement as well.

Implementing a Data-Driven Approach to Closing Gaps

A common problem plagues both the health care system's homogeneity and community health disparities: a lack of measurement. In a data-driven society with outcomes-based reimbursement models, health systems have robust systems for measuring quality of care. When scientific inquiry stratifies health outcomes among historically marginalized and underserved populations, health disparities may become apparent. Hospitals, however, have largely lagged in measuring these disparities within their own institutions and patient populations, leaving unused a powerful tool for informing policies and practices aimed at closing those gaps.

Better demographic data could help to improve patient outcomes.

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Better demographic data could help to improve patient outcomes. For example, the Centers for Disease Control and Prevention has determined that “collecting SO/GI [sexual orientation and gender identity] data is essential to providing high-quality, patient-centered care.” Still, data collection varies widely among health systems—and it is unclear if and to what extent these data are used to address disparities. Some states have enacted legislation requiring health systems to collect SO/GI demographic information, exemplified by California's Lesbian, Gay, Bisexual, and Transgender Disparities Reduction Act. While state policy can provide the necessary impetus for change, it may be prudent for all health systems to track demographic data to inform health system improvement. For example, in the setting of the ongoing COVID-19 pandemic, systematic collection of race and ethnicity data could help to address the needs of disproportionately impacted African-American and Latinx communities.

Health systems could measure inequities among all job families within their workforce. For example, while pay inequity for women is well documented, rarely are these data collected routinely and systematically by individual health systems as part of a self-audit process. Salaries and pay scales could be scrutinized to detect the presence of bias. Barriers to investigating pay equity may include concerns about employee privacy, limitations on direct comparison when employees have unique job titles/responsibilities, and the role unconscious bias plays in the analysis. Health systems could approach the auditing process as an internal quality improvement initiative to temper concerns that the audits serve only to highlight inequities. Such perceptions could be overcome by communicating the importance of the process openly to all employees, frequently performing internal and external audits, swiftly correcting inequities with small, frequent changes, and foregrounding narratives of success.

Using Cultural Humility to Promote Inclusivity in Health Systems

Cultural competency training has long been used by health systems as a tool to eliminate health disparities. These types of trainings have largely been determined to be ineffective, in part, due to the implication that an individual could study information about a different culture and then be deemed “competent” in understanding someone from that culture or background. This presumption is problematic for many reasons, including that it does not emphasize the process of developing rapport and is not sufficiently individualized to specific patient needs. Cultural competency training could be reconfigured to focus on developing a workplace culture that meets the individualized cultural needs of its patients and employees, rather than assuming that individuals within a group necessarily have the same needs. Cultural humility, as opposed to cultural competency, could help in understanding the values that health systems should consider as they develop initiatives around diversity, equity, and inclusion.

Cultural humility was first described by Tervalon and Murray-Garcia as, “[incorporating] a lifelong commitment to self-evaluation and critique, to redressing the power imbalance in the physician-patient dynamic, and to developing culturally beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.” This process could go beyond the check-box approach of simply meeting cultural competence.

Approaching the workplace and patient care with cultural humility might naturally lead to a process focused on prioritizing equitable care over equal care. This is important because equal outcomes can only occur if there is equitable care. Cultural humility recognizes that no two individuals have the exact same need—not even among a historically marginalized population. For example, the needs of a wealthy Black trans-man might not be the same as a working-class Black queer woman. To provide more equitable care and better align their actions with their mission statements, health systems and their human resources departments could develop workforce training protocols based on promoting cultural humility and its application to patient care.

A Call To Action

Health care systems are a powerful and relatively well-resourced stakeholder in the effort to eliminate inequities both among the health workforce and among patient populations. The deliberate practice of increasing diversity within the workplace may have the power to create significant, positive impacts on workplace culture and patient care. In some cases, this practice may require neither additional time nor money, but rather a shift in organizational priorities, culture, and effective leadership. And while measurement of workplace and patient inequities may require additional funding, it is possible that progress could be achieved by focusing pre-existing health system resources, such as the traditional structure of quality improvement, at goals around diversity, equity, and inclusion.


Ryan Tsuchida is an emergency physician in training at the University of Michigan. Sydney Fouche is a policy analyst at the University of Michigan Acute Care Research Unit. John Burkhardt is an emergency physician at the University of Michigan. Ted Corbin is an emergency physician at Drexel University College of Medicine & Dornsife School of Public Health, Department of Health Management and Policy. Harrison Alter is the interim director at the Alameda County Health Care for the Homeless and an emergency physician at Highland Hospital - Alameda Health System, in Oakland, CA. Mahshid Abir is a senior policy researcher at the nonprofit, nonpartisan RAND Corporation and an emergency physician and director of the Acute Care Research Unit at the University of Michigan.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.