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Abstract
The last decade has opened many eyes and awakened many hearts to prevailing societal and global inequities. Major sociopolitical events of the past decade as well as the COVID-19 pandemic have highlighted demographic, racial, socioeconomical, geographical and other inequities with negative impact on health and wellbeing. Healthcare leaders, in the privileged position of influence, would benefit from an enhanced capabilities framework that articulates the specific actions and behaviours needed to embed equity, diversity and inclusivity (EDI) into their regular activities and ultimately into the healthcare system as a whole. The LEADS in a Caring Environment Capabilities Framework has been widely adopted in Canada and is similar to other national health leadership frameworks. Enhancements through an EDI lens are highly generalisable and can be contextually adapted to improve health, well-being and social justice worldwide.
- medical leadership
- capability
- behaviour
- competencies
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
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Introduction
Achieving culturally competent healthcare requires a system that reflects the population it serves and is equitable and inclusive. Events of the past decade including the Black Lives Matter and MeToo movements, Canada’s Truth and Reconciliation Commission report and COVID-19 have laid bare inequities across the healthcare system, including in its physician medical staff and leadership.1 There is ample evidence that minority and marginalised individuals experience inequities when accessing the healthcare system and that healthcare practitioners from their own community can mitigate some of these systemic effects.2–5
Despite changes in the gender, racial and ethnicity demographics of medical students6–8 and medical residents,9 recent data demonstrate little improvement in the diversity of academic faculty in medical schools 10 and clinical leadership.11 12 With many organisations more focused on aligning their policies to reflect equity, diversity and inclusion (EDI) principles, the practice of leadership in health systems has not changed commensurately. While there is no comprehensive playbook that articulates the requisite actions and behaviours needed for EDI-enlightened leadership, enhancement of existing health leadership frameworks through an EDI lens can provide a roadmap to achieve this goal. The LEADS framework, used in Canada, Belgium and India and similar to the Health LEADS Australia, the UK’s National Health System Healthcare Leadership Model, and the UK’s Faculty of Medical Leadership and Management’s Standards is an ideal scaffold in this regard.13 Below we expand the rationale for and highlight evidence-based EDI enhancements to the LEADS framework that can serve to inform other frameworks used to develop inclusive leaders for the current times.
Diversity, equity and inclusion
The following are the foundational definitions of EDI14 used to explore the requisite health leadership actions and behaviours in these areas.
‘Equity’: Refers to fairness and justice and is distinguished from equality. While equality means providing the same to all, equity requires recognising that we do not all start from the same place because power is unevenly distributed.
‘Diversity’: Refers to the identities we carry. There are many kinds of diversity, based on race, gender, sexual orientation, class, age, country of origin, education, religion, geography, physical or cognitive abilities, or other characteristics. Valuing diversity means recognising differences between people, acknowledging that these differences are a valued asset, and striving for diverse representation as a critical step towards equity.
‘Inclusion’: Refers to how our defining identities are accepted in the circles that we navigate. Belonging evolves from inclusion; it refers to the extent to which individuals feel they can be authentic selves and can fully participate in all aspects of their lives. Inclusion is a state of being valued, respected and supported. At the same time, inclusion is the process of creating a working culture and environment that recognises, appreciates and effectively uses the talents, skills and perspectives of every employee; uses employee skills to achieve the agency’s objectives and mission; connects each employee to the organisation; and encourages collaboration, flexibility and fairness. In total, inclusion is a set of behaviours (culture) that encourages employees to feel valued for their unique qualities and experience a sense of belonging.
The LEADS in a Caring Environment Capabilities Framework
The LEADS in a Caring Environment Framework13 (LEADS) was developed in 2006 by the Health Care Leaders Association of British Columbia in a collaboration to improve health leadership. In 2012, the initiative was transferred to the Canadian College of Health Leaders. This framework, which is the most commonly used healthcare leadership framework used in Canada, is underpinned by the concept of lifelong learning and that becoming a fully developed leader is a continuous contextually dependent process. While EDI principles are often articulated, a comprehensive set of EDI focused leadership actions and behaviours is not explicitly embedded within the framework. The LEADS framework has five domains: lead self, engage others, achieve results, develop coalitions and systems transformation. Applying an EDI lens to the LEADS domains and capabilities offers another focus for continuous learning, honouring diversity in all aspects of organisational life.14 The following recommendations were derived from individual suggestions which were then subjected to multiple rounds of revision until consensus by the group was achieved.
Domain 1: Lead self
A leader needs to be aware of how their own values, principles, biases and life experiences, affect their beliefs and behaviours. Leaders need to reflect on what they think they know and don’t know, expand their skillsets and redefine their values in the context of power, privilege and cultural safety.
Sisk15 has recently challenged us to be aware of how power and privilege can impact the health of communities and thereby the health of the individuals within them. They define power as ‘the ability to direct laws, policies and investment that shape people’s lives’, and privilege as the accumulation of benefits of special rights. Their recommendations:
1. Create and/or seek out ‘Brave Spaces’ to explore the role of power in (our) work
2. Understand the role that power plays in (our)current work
3. Analyse and challenge privilege.
are aligned with the lead self capabilities. As they authors note: ‘professional silence in the face of social injustice is wrong’.
Domain 2: Engage others
The LEADS framework espouses a distributed leadership model where the diversity of strengths and capabilities of many is required for optimal enactment of leadership. Fostering the development of others is one capability in this domain; mentorship is one method to do so. However, mentorship may not always be sufficient to advance the careers of under-represented minorities (URM). Sponsorship, that is, ‘active support by someone appropriately placed in the organisation who has significant influence on decision-making processes or structures and who is advocating for, protecting, and fighting for the career advancement of an individual’, may serve a complementary role and help those of URM be in a position of influence to change the dynamic in a way that further fosters EDI.16
Domain 3: Achieve results
The Achieving Results domain is upheld by its four capabilities: setting direction; aligning decisions with vision, values and evidence; implementing decisions; and regularly assessing and evaluating results, and course-correcting as needed. Diversity in the workforce has been shown to positively impact patient outcomes and access to care, as well as worker satisfaction.17 Deliberate commitment to increase EDI in the workplace demands a commitment to measure the effects of this commitment through baseline and subsequent measures and review disaggregated data on the diversity and satisfaction of faculty, trainees and leadership, with action arising if the results are unsatisfactory. All of this domain’s capabilities are reflected through these actions.
Domain 4: Develop coalitions
Developing coalitions elevates engaging others to a systems level through the lens of strategic leadership, bringing groups together to work as a system. To achieve this, all members of the coalition must have the same mental model of the goal of the partnership. Purposefully building partnerships and networks to achieve results is one of the capabilities in this domain. One application may relate to the fact that patients from ethnic minority groups often receive substandard care, including an increased risk of patient safety incidents. Language proficiency and cultural beliefs are recognised deterrents to medication compliance. these barriers may be surmounted by engaging ethnic consumers in the design of culturally sensitive interventions could improve their effectiveness and improve patient safety.18 Developing partnerships that bring individual and different ethnic consumers together might reveal commonalities and differences stratified by ethnicity and/or disease, and elucidate approaches to providing better care, adherence and outcomes.
Domain 5: Systems transformation
Being oriented strategically to the future is a key capability of the systems transformation domain, and research and innovation are critical contributors to the future of healthcare. Kelly et al posit that while health equity is a goal, we cannot forget the impact of intersectionality on interpretation of results. Intersectionality refers to the fact ‘that individual identities and social locations such as gender, race and class intersect and reflect systems of oppression such as sexism and racism’; the notion of intersectionality broadens the lens on social justice. The authors emphasise that EDI considerations in their entirety are applicable to the makeup of the research team and research environment created, and are all necessary to maximise the quality and output of the research endeavour.19
Conclusion
Inherent in the LEADS framework is the shared goal of achieving the health and wellness of the population we serve—and doing so together. This common constructive purpose is by its very nature inclusive. What we have sought to do in this article is identify actions and behaviours aligned within the domains of the LEADS framework that underpin and represent a healthcare leader’s enactment of their commitment to EDI. Our work is a call to others to expand their existing healthcare leadership frameworks to do the same. The many inequities cited above underscore the moral obligation for all of us in healthcare to move forward with a comprehensive EDI leadership strategy and give it the urgency it so desperately deserves. We are aware that this article focuses on leadership capabilities that are within one’s own sphere of influence but with collective action across many spheres there can be system transformation.
Express checkout
Equity, diversity and inclusion (EDI) must inform the practices of current healthcare leaders to ensure quality healthcare for all. Existing healthcare leadership frameworks do not offer a comprehensive set of EDI-focused guidelines for behaviour and action. Widespread use and adaptation of the LEADS in a Caring Environment Capabilities Framework makes it an ideal framework to begin to address these issues. Five examples aligned with the five domains of LEADS are presented which highlight modifications that can be made to existing leadership frameworks. Modifications to other frameworks to promote EDI are encouraged.
In practice
Healthcare leadership is instrumental to the delivery of value-based, quality healthcare across a defined population. COVID-19 has laid bare the consequences of systems that do not place equity, diversity and inclusion (EDI) at the forefront of their values. While various healthcare leadership frameworks have been developed to advance the leadership capabilities of healthcare providers, a comprehensive set of EDI focused leadership actions and behaviours that can guide action and change the status quo has not been explicitly articulated. The LEADS in a Caring Environment Capabilities Framework has been used or adapted for use widely and when modified to specifically address EDI, can serve as an exemplar of how other leadership frameworks can be modified to achieve the goal of quality healthcare for all. Being aware of power and privilege, sponsoring individuals of underrepresented minorities, incorporating measures that address issues of EDI, developing coalitions that bring both individual and different ethnic consumers to the table and considering EDI in the makeup of the research team and research environment created are examples that align with the five domains of LEADS.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Footnotes
Twitter @AnneMatlow, @NEON8Light
Contributors All authors contributed to the conception, design and writing of the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.