Prior to beginning work on this discussion forum, read the attached or watch the following:
Watch the following two videos:
Why Is Healthcare Workforce Diversity Important? (https://www.youtube.com/watch?v=08pCbH629sY)
Inclusion is a Culture of Value and Belonging (https://www.youtube.com/watch?v=UvRWkWZgnRY)
Take on the role of manager of a Federally Qualified Health Center (https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc) that provides primary care services to a multi-ethnic, multi-lingual urban community. Many of the patients live below the poverty line. Health care providers in your center see a high volume of patients with challenging medical and psychosocial issues. Because of the high volume of patients, acutely ill patients often wait for two to three days to see a health care provider. Many patients walk in without appointments.
On the other hand, about 35% of patients fail to show up for appointments on a given day. As you investigate the problem, it is becoming increasingly clear to you that the better-insured and English-speaking patients may receive better access. They are more likely to get a timely appointment, keep the appointment, and show up for their appointments because of better communication. You are interested in promoting more equitable access to health care. You understand the importance of providing culturally sensitive, patient-centered care and a diverse clinic environment to make patients feel more welcome.
In 500 to 600 words, address the following
Effective diversity, equity, and inclusion practices
Gurwinder Kaur Gill1, Mary Jane McNally, MHA1, and Vin Berman, MBA, CHRL1
Abstract Demographics in Canada, and the workplace, are changing. These include population changes due to race, ethnicity, religion/faith, immigration status, gender, sexual identity and orientation, disability, income, educational background, socioeconomic status, and literacy. While this rich diversity can present challenges for patient experiences/outcomes and working environments, it can also present opportunities for positive transformation. For successful transformation to take place, strategies should focus on “Diversity, Equity, and Inclusion” (DEI) versus “diversity” alone and on creating inclusive team environments for positive staff experiences/engagement. There is a growing understanding of the relationship between the providers’ work environments, patient outcomes, and organizational performance. This article leverages the principle of improving the healthcare provider’s experience based on Health Quality Ontario’s Quadruple Aim (“people caring for people”). Based on learnings/experiences, the top three successful practices from the organization’s DEI strategy have been outlined in this article.
Demographics in Canada, and in the workplace, are changing.
This includes trends in immigration, internationally trained
professionals, languages/communication styles, religious/faith
communities, a diverse Indigenous population, single parents,
low-income populations, mental/physical health and lesbian,
gay and transgender populations.1 In healthcare, these trends
can result in health inequities (health differences between
population groups defined in social, economic, demographic,
or geographic terms—that are unfair and avoidable).
From a race perspective alone, racism/cultural oppression have
been realities for many minority groups. Nurses working across
Canada speak of their experiences of discrimination, racism, and
the challenges of working effectively in such environments.2
However, “cultural diversity” goes beyond values, beliefs,
practices, and customs; in addition to racial classification and
national origin, there are many other faces of diversity.3 These
include age, socioeconomic status, religion/faith, immigration
status, gender, sexual identity and orientation, disability, income,
educational background, socioeconomic status, and literacy.
While this rich and broad diversity among population groups
can present challenges for patients, working environments, and
organizations, it can also present opportunities for positive
transformation. For this transformation to take place, the focus of
a successful and effective strategy would need to shift from
“diversity” alone to “Diversity, Equity, and Inclusion (DEI).”
The recognition and embracing of diversity (the range of dif-
ferences among population groups) is essential and foundational.
From a patient’s perspective, going beyond to include equity and
inclusion can result in positively changing a patient’s life, expe-
rience, and outcomes as well as an organization’s outcomes.
Experiences and initial research show that Osler’s DEI initiatives
have the potential to improve equitable access to quality and
safe care, reduce (unnecessary) readmissions or emergency
department visits and length of stay as well as liabilities and
errors. For example, errors can occur when a patient does not
speak the same language as the provider potentially resulting in
miscommunication of diagnosis or prognosis.
From a staff perspective, staff training and education focused
on DEI versus diversity alone within Osler is beginning to
transform the work and team environment and, in turn, positively
impact the patient experience. There is a growing understanding
of the relationship between nurses’ work environments, patient/
client outcomes, and organizational and system performance.2
This is evident from the principles of Health Quality Ontario’s
Quadruple Aim which states that “at its core, healthcare is about
people caring for people.” Evidence also shows that healthy work
environments yield financial benefits to organizations in terms of
reductions in absenteeism, lost productivity, organizational
healthcare costs,2 and costs arising from adverse patient/client
outcomes2 as well as staff experience and engagement.
One key learning for the organization has been that creating
inclusive societies takes time and requires work beyond merely
“not-excluding.”4 Another has been that it is not about
“universalism and treating all the same, i.e. equality; it’s about
equity—the absence of avoidable or remediable differences
among groups of people” (World Health Organization).5 The
difference between equality and equity? “Equality is giving
everyone a shoe. Equity is giving everyone a shoe that fits.”
Key practices from Osler’s DEI strategy have been outlined
in this article with a focus on the healthcare provider/work
1 William Osler Health System, Brampton, Ontario, Canada.
Gurwinder Kaur Gill, William Osler Health System, Brampton, Ontario,
E-mail: [email protected]
Healthcare Management Forum 2018, Vol. 31(5) 196-199 ª 2018 The Canadian College of Health Leaders. All rights reserved. Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0840470418773785 journals.sagepub.com/home/hmf
1. Leadership commitment
2. The DEI training/development for inclusive teams and
the work environment
3. Staff engagement to leverage champions for positive change
Commitment “from the top” has been essential to the success
of Osler’s DEI strategy. Senior leadership understands that
“sensitivity to diversity issues at the senior executive level has
an effect on diversity management practices used by hos-
pitals.”6 Successful leadership practices at Osler include:
� A leadership team that understands the value and
impacts of health equity, inclusion, and social justice.
� Osler’s corporate values—Respect, Excellence, Account-
ability, Diversity, and Innovation—aligned with DEI.
� Senior leadership commitment to a DEI portfolio with
human and financial resources.
� Osler’s DEI plan has been developed in close collabora-
tion with, and monitored by, senior leadership.
� The plan aligns with Osler’s corporate strategic plan/
priorities and has clear goals, objectives, indicators, and
� Accountabilities are defined and shared across the
organization including mechanisms for raising and addres-
sing DEI issues. For example, at Osler, senior leaders from
patient experience, legal, human resources, health equity
and inclusion, and ethics collaborate and provide consulta-
tion on issues related to Performance, Accommodation,
Harassment and Human Rights (PAHHR).
� The DEI is incorporated into Patient and Family Advi-
sory Councils that are diverse in membership. Patients
provide insights and guidance on creating tipping points
for positive change.
Diversity, equity, and inclusion training/ development for inclusive teams and work environments
Similar to other organizations with “diverse” workforces,
Osler’s management is faced with handling requests for which
there is limited precedence. For example:
� Staff requesting time to pray several times daily.
� Being excused from working in areas where religious
items may interfere with imaging equipment.
� Being excused from mask-fit testing as beards cannot be
trimmed on religious grounds.
� Requesting to finish work early because of young children.
� Requesting more time to prepare reports, or having
workspaces modified, to accommodate disability.
� Refraining from working with colleagues who make
derogatory comments/jokes about their community/
� Requesting different assignments because colleagues
converse in a language not understood.
� Patients/families requesting different providers (poten-
tially due to discrimination).
Understanding and meeting diverse needs and creating
inclusive environments stems from being culturally competent.
Campinha-Bacote3 states that to meet the needs of culturally
diverse groups, healthcare providers must engage in the process
of becoming culturally competent—a set of congruent beha-
viours, attitudes, and policies that come together in a system,
agency, or among professionals and enables that system,
agency, or those professionals to work effectively in cross-
How managers respond and address the above kinds of
requests have resulted in either inclusion/alienation. Successful
DEI training/development at Osler includes the following:
Creating safe spaces for employees to have a dialogue and share experiences
This informal, “self-managed” approach invokes understanding
and appreciation. Mandatory diversity training (what does this
look like anyway?) is a requirement at Fortune 500 companies.
But a substantial body of research shows that this training is not
particularly effective at encouraging people to confront their
biases. In fact, it can provoke the opposite effect. “People, not
surprisingly do not like to be told what think.”4,7 Another reason
why self-managed teams may be more successful is when pro-
grams are not actually branded “diversity efforts.”8 Thus, Osler
has a substantial focus on creating safe spaces and opportunities
for employees to voluntarily share experiences.
Stories shared by colleagues have invoked compassion,
empathy, and understanding. For example, struggles of those
who have a disability are new to Canada and/or are low income
or vulnerably housed. Or, after feeling safe to share they were
gay or lesbian, struggles with bias/discrimination.
Creating safe spaces has enabled participants to open up
their hearts and minds to compassion and new learning. Some
admitted that, in their limited understanding of diversity/
diverse groups, they had made incorrect assumptions about
some of their colleagues resulting in negative stereotypes.
Completed pre/post assessments have demonstrated an
upward trend of learning and appreciation/understanding of
differences. Written feedback included heartwarming respon-
ses to “what will I do differently” or “which behaviour will I
Appropriate learning opportunities will yield positive outcomes and a workforce composed of nurses who are open-minded, inclusive, and respectful of all colleagues and recipients of nursing services. Individual members of the workforce identify and are cooperative with one another to address barriers to equity and diversity and build practice environments in which every person’s contribution is valued thus allowing the full potential of all to be maximized. These individuals refuse to participate in discrimination, harass- ment, or bullying and address the issue in a way that will effect change. Registered Nurses Association of Ontario.2
Gill, McNally and Berman 197
change as of today” including being more open and under-
standing of staff and patients’ differing practices/beliefs.
A foundational tenet included in this training is from Dr.
Jean Watson, PhD: “To care for someone, I must know who I
am. To care for someone, I must know who the other is. To care
for someone, I must be able to bridge the gap between myself
and the other.”
Focusing on self-awareness, self-reflection, and reduction of bias, perceptions, and assumptions
Osler’s DEI training/education has a significant focus on self-
awareness, self-reflection, and bias. Significant research
demonstrates that all humans engage in conscious and uncon-
scious processes based on images stored in memory (note 1).
Unconscious bias affects healthcare providers every day; it can
reduce the quality of care and increase errors.9 And that there
are higher levels of racial bias among clinicians directly linked
with biased recommendations (note 2).
The years of subconscious associations affect what we think
we see, how we react, how we feel, and how we behave. “Any effort
to build inclusion . . . has to address our perceptions (and biases).
This takes time . . . but is also more like to endure.”4
A tool used in the training includes one developed by
Dr. Milton Bennett: the Developmental Model of Intercultural
Sensitivity (Figure 1). It has helped staff understand the process
by which they can learn to value and respond respectfully to
people of all cultures. Participants are asked to pause and self-
assess where they are on the scale and then to reflect what they
can do to do better to move from ethnocentrism to being more
Focusing on cross-cultural communication
Communication styles can negatively affect relationships. It is
imperative to be aware of other’s differing communication
styles as well as one’s own. Intercultural communication is
influenced by factors including how power and authority are
shared in the culture, values of individualism and collectivism,
and the role of context in communication. Edward Hall pro-
posed a continuum of low to high context with respect to
contextualizing the messages sent and received. Low-context
cultures (such as Canadian) emphasize the words with less
emphasis on the context such as who says it and how it is said.
In high-context cultures (such as Asian), the context of the
message is just as important as the words used and influences
how the message is understood.10 For example, Communica-
tion becomes a key issue in developing collegial relations in the
team. The literature demonstrates a strong association between
racial diversity and difficulties with communication and con-
flict resolution in teams. Research highlights a significant
association between diversity, group conflict, and communi-
cation difficulties.11 There is a strong business case for initi-
ating communication about culture as a platform for change.11
Leaders who validate different perspectives and demon-
strate a willingness to talk about differences achieve a positive
outcome.2 This involves listening, reflecting, and nonjudge-
mental approaches and focusing on nonverbal communication.
We’ve often “spoken” volumes without saying a word.
Building capacity of employees to understand legal implications
Legal obligations and implications are essential to incorporate
into DEI training. Whether we “agree” with different practices or
not is a moot point in situations superseded by law, for example, the
Ontario’s Human Rights Code. This code recognizes the dignity
and worth of every person in Ontario and provides for equal rights
and opportunities and freedom from discrimination, such as dis-
ability, creed, family status, sex, and gender identity. Employers
have a legal duty to accommodate the code-related needs of people
who are adversely affected by a requirement or standard.
Achieving organizational expectations through living the organization’s core values
Not leaving anything to chance, that respecting each other’s
differences is the “right thing to do,” also include a component
Denial Defensive Minimize Accept Adapt Integrate
1– 3: Ethnocentric Sees own culture as central to reality
4-5: Develops ethno-relative
Experiences culture in the context of others
Figure 1. The Bennett Scale: developmental model of intercultural sensitivity.
All of us, despite the best of all possible intentions, are affected by unconscious processes. -Dr. Michelle van Ryn, PhD, Mayo’s Research Group
198 Healthcare Management Forum
that speaks to the organization’s values and expectations.
Osler’s values—respect, excellence, accountability, diversity,
and innovation—are an integral part of DEI training and per-
Through manager engagement, a “Diverse and Inclusive
Teams” module has been developed and is delivered in
person to groups. The curriculum includes organizational
and individual values, self-assessment/reflection, value-
based exercises, Osler’s code of conduct, anti-harassment
and discrimination, cross-cultural communication, and bias
(implicit and explicit). The results/impacts, through pre/post
assessments and evaluations, are remarkable.
Staff engagement to leverage champions for positive change
Change champions are key to creating tipping points
and cultural shifts to embracing DEI initiatives. In the
Journal of Applied Social Psychology, using a sample of
4,597 healthcare sector employees, research indicated that
diversity practices are associated with a trusting climate that,
in turn, is positively related to employee engagement.12
Key staff engagement mechanisms that have invoked
DEI change at Osler:
� The Diversity Advisory Council: Interdisciplinary staff
learn about, and work on, impacts and issues related
� The Accessibility Advisory Committee: Internal staff/
volunteers and external community members ensure
barriers are reduced for patients, staff, physicians,
volunteers, and visitors with physical and/or mental
� The Women of William Osler Committee: Members
foster a collaborative environment that is gender-
inclusive, respectful, equitable, and accessible whilst
enabling personal and professional growth through a
lens of gender equity.
� The Lesbian, Gay, Bisexual, Transgender, Queer,
2-Spirited, Intersex, Asexual, and Allies Committee:
Members foster a collaborative, welcoming and safe
environment that is informed, inclusive, respectful,
equitable an accessible for all patients, families, staff,
physicians, and volunteers.
� Performance, Accommodation, Harassment, and
Human Rights Task Force: Senior leaders from patient
experience, human resources, legal counsel, ethics, and
equity and inclusion discuss/provide recommendations
that stem from PAHHR.
Change must begin with senior leadership with account-
abilities being shared among middle management. We cannot,
however, underestimate the power of including and engaging
all staff/individuals for positive transformation. Each of us
must serve as culturally competent role models and share our
skills and knowledge with others and we must engage in dis-
cussions and challenge questionable behaviours or institutional
The initiatives and practices shared have demonstrated
positive outcomes impacting individual employees, the team/
work environment, the organization as a whole, and patients/
families. The DEI initiatives are no longer departmental based
initiatives or projects but essential for cultural transformation.
1. Dr. Michelle van Ryn, PhD, Mayo’s Research Group.
2. David Williams, PhD, MPH, Ronald Wyatt, MD, MHA.
1. Census Canada (2016).
2. Healthy Work Environments Best Practice Guidelines. Embra-
cing Cultural Diversity in Health Care: Developing Cultural
Competence. Toronto, Ontario: RNAO; 2007.
3. Campinha-Bacote J. Cultural competence in nursing curricula: how
are we doing 20 years later? J Nurs Educ. 2006;45(7):243-244.
4. Sarmishta S. 6 Degrees – RBC Report, All of Us: What We Mean
When We Talk About Inclusion. 6 Degrees: 2017: 20.
5. World Health Organization. Available at: http://www.who.int/
6. Dreachslin JL, Weech-Moldano R, Dansky KG. Racial and ethnic
diversity and organizational behavior: a focused research agenda
for health service management. Soc Sci Med. 2004;59(5):961-971.
7. Govindarajan V. The First Two Steps Toward Breaking Down
Silos in Your Organization. Harvard Business Review; 2011.
8. Dobbin F, Kalev A. Why Diversity Programs Fail. Harvard
Business Review; 2016.
9. Thomas D. Diversity as Strategy. Harvard Business Review; 2004.
10. Hall E. The Silent Language. New York, NY: Doubleday and
11. Dreachslin JL, Hunt PL, Sprainer E. Workforce diversity: impli-
cations for the effectiveness of healthcare delivery teams. Soc Sci
12. Downey SN, Thomas KM, Plaut VC. The role of diversity prac-
tices and inclusion in promoting trust and employee engagement.
13. French BM. Cultural competent care: the awareness of self and
others. J Infus Nurs. 2003;26(4):252-255.
Gill, McNally and Berman 199
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