1. Introduction

As chair of Diversity and Inclusion for a large academic radiology department, I am a huge proponent of the important efforts incorporated in our Diversity and Inclusion strategy. However, to be “fair and balanced,” it would be appropriate to state the obvious counterpoint. Within any organization, there will inevitably be barriers, challenges and impediments to the successful implementation of a diversity and inclusion strategy. Despite their best efforts, change agents championing diversity and inclusion should expect to confront a persuasive case being made (by some) against this initiative. These naysayers will point out that, among other observations, diversity in the workplace just does not always work. In these situations, it is highly likely that the more forcefully you attempt to advance the agenda, the greater will be the resistance.

2. Discussion

Studies show that, understandably, while homogeneous groups have more confidence in their interpersonal interactions, diverse groups have more confidence attaining better performance results (Apfelbaum, 2014). Proponents for a homogeneous rather than diverse workforce suggest it is just simpler when everyone “speaks the same language.” There is an undeniable comfort to groupthink, where everyone sees things in the same way. The problem with this logic, of course, is that the number of potential blind spots only becomes that much more pervasive.

Because of the inevitability of strongly vocal resistance, a successful diversity and inclusion effort requires that the process involves “subtle disruption” to help establish change. There will be those who dismiss the effort as being a manifestation of an agenda to propagate political correctness. It behooves us to convince them, instead, that this is an important tool to improve patient satisfaction, enhance innovation, spur creativity and … improve the business bottom line.

Traditional diversity training efforts and programs composed of mandated on-line modules or half-day classes are unlikely to succeed. Employees will balk at these initiatives, wanting to know how much extra effort will be required of them. They will want to know why change is needed, given that their perception is: “things are fine just the way they are." Others will ask, “Don’t we just hire the best people, regardless of their background?” Perhaps heard most often is “we like to hire our own trainees, they’re a known entity, we know them, we trained them; they understand our culture.” These fallacies in logical thinking, along with the ubiquitous phrase, “that’s the way it’s always been done here,” must be purged from any 21st century, forward-thinking organization.

While seemingly counterintuitive, these conversations may actually only serve to breed even more bias; especially if diversity is perceived negatively as promoting certain groups over others. Some will stand against diversity, saying it is nothing more than political correctness, affirmative action, or an attempt to counter discrimination. Some will be even more vocal, suggesting that diversity programs and government regulations are not only unnecessary and counter-productive, but de-value deep rooted American beliefs, including that “everyone is created equal.” (Clegg, 2012)

Even those who would otherwise espouse strong pro-diversity viewpoints or perhaps fundamental social and moral principles may lobby against diversity. In a comment regarding the LBGT community, Dr. James Dobson (n.d.) once said while hosting his radio broadcast, Focus on the Family, “we need to be careful what we are being tolerant of.” Similarly, after 20 years as global director of human resources and six months into her new role as Apple’s Chief of Diversity, Denise Young-Smith was mired in controversy after stating, “I get a little frustrated when diversity is [only] tagged to people of color, women, LGBT….. A room of 12 white, blue-eyed, blond males can have diversity of experiences too. ” (Daily Mail, 2017). Despite what one may think of her firing, an argument can very likely be made that, yes, even ‘a room full of white guys’ can represent diversity. Diversity is, after all, multifactorial.

Many will be uncomfortable with, will become defensive regarding, will remain unmotivated to change, or will actively resist, diversity and inclusion efforts. This type of change management is particularly difficult to promote in those environments and cultures that emphasize harmony above all else. In these (and other) settings, some will unfortunately be unprepared and/or unwilling to deal with the inevitable initial conflicts that are bound to arise. Entertaining a wide range of ideas from people of differing backgrounds should be expected to result in short-term conflicts and adverse side-effects. For those willing to take on the challenge, the reward is long-term success.

3. Conclusions

Inevitable resistance dictates a need for a “marketing campaign” for diversity and inclusion. Ideally, this would serve to demonstrate to all stakeholders that the initiative is much more than a moral nicety, or a legal necessity. It would convince doubters that the effort is not designed simply to enforce rules and policies of external accreditation or regulatory agencies so as to maintain compliance. Rather, the naysayers --- with respect to the case against diversity and inclusion --- must be effectively engaged to realize that there is also an undeniable and powerful economic imperative associated with a truly diverse and genuinely inclusive workplace.

To provide excellence for its diverse patients, an organization must employ a diverse workforce (Nivet, 2011). The business case for enhancing a health care organization’s diversity is also indisputable. Many funding sources and grants are awarded, at least in part, based on achieving diversity metrics. Many awards and accolades are based on specific diversity metrics. The prestige and recognition afforded by these honors provide valuable marketing to a healthcare organization.

The power derived from diversity and inclusion creates better and more profitable organizations. Optimizing efforts to improve patient outcomes requires building an inclusive work environment. Underrepresented groups need to be actively recruited, retained and advanced. A workforce composed of employees of multiple cultures creates myriad opportunities to leverage differences toward enhancing organizational excellence in education, research, and patient care; along with enhancing patient and provider satisfaction. Robust diversity and inclusion practices are an important strategic tool and goal to help an organization adapt to fluctuating market opportunities. Depending on how effectively these concepts are mastered determines if doors are opened or closed, bridges built or destroyed; value is added or detracted (McClean, 2010). Organizations can help build bridges between silos by championing a deep understanding of, and a mutual respect between disparate cultures.

Creating an organizational structure and culture that maximizes the potential of a diverse and inclusive organization requires a long-term strategic plan. The challenges of implementing successful solutions will not respond to a “one size fits all” approach (Cochran, 2017). Achieving and fostering a diverse and inclusive workforce requires sustained thoughtful effort, and well-planned strategic management (Nivet, 2011).

Embracing the many dimensions of diversity and benefits of inclusion begins with education, training, awareness and willingness to learn and enhance ones “multicultural IQ.” This is followed closely by tactful implementation and management practices to realize the full potential and benefits of meaningful change. Demographic mismatches between providers and patients will increase unless active steps are taken, and formal processes are in place, to foster diversity, and embrace inclusion.

Success in diversity and inclusion will directly contribute to achieving the goals set forth by the IHI’s “quadruple aim” of health care system improvement (IHI). To achieve these ambitious goals, diversity and inclusion must be prioritized. They will strengthen the mission and values. The successful execution of strategies and tactics will also be reflected in the business’s bottom line.

For optimal employee and patient outcomes; gather, blend and leverage the strengths of disparate cultural perspectives (Minguet, 2014). Providing culturally competent patient care helps create a competitive advantage (McClean, 2010); attracting more patients. The members of a pluralistic society respect their inherent differences and actively seek to understand them (Cochran, 2017). Diverse organizations work hard to align and intertwine the perspectives of each rich, complex, deeply imbedded culture (Schein, 1996). Fostering an environment of diversity and inclusion allows individuals to learn from each other for their ultimate mutual benefit. Bringing out the best in everyone optimizes patient outcomes.

A diverse and inclusive workforce with a global mindset employed in a global institution portends improved patient-centered care. Given an increasingly global economy, this strategy is good for business. The list of global multinational companies championing diversity and inclusion efforts continues to grow exponentially (Moran, 2017).

There are many actions that can be undertaken to help create a road map for promoting and fostering diversity and inclusion. These begin with broad education and creating awareness of existing weaknesses, gaps, threats and opportunities. Strategic implementation begins with tactfully and respectfully challenging the status quo. Starting a dialogue by asking “the difficult questions” facilitates debate and sparks conversation. Embedding these principles in the corporate mission, vision and value statements is just the beginning. Clear metrics must be created, measured and benchmarked. The realization of optimal results from significant changes requires comprehensive buy-in, collaboration and commitment of the entire team, especially leadership. Success for a major change initiative such as diversity and inclusion depend on many factors. None is more crucial than the robust and consistent commitment of senior leadership (Sirkin, 2005). Leadership must make diversity and inclusion a key strategic priority. Great leaders will inspire everyone to take action by starting with the “why?” providing a vision and guidance, then contribute to the implementation (the what? and the how?), and maintain oversight. Someone must assume responsibility and accountability for results. Visible leadership support and advocacy for inclusive policies and practices while embracing different viewpoints is a core component. If leadership is on-board, the rest will follow.

Creating and implementing a strategic plan means developing a broad-reaching system of steps to develop, promote and foster diversity and inclusion. Effective and meaningful change amounts to cultural change. To truly alter deeply ingrained concepts (e.g. unconscious bias) and thinking, diversity and inclusion must be incorporated into the culture of the organization. Change agents would benefit by demonstrating the economic value of the change initiative. Patient outcomes, patient satisfaction, referring provider satisfaction are all important. In today’s ever-changing healthcare landscape, more than ever, net operating income, margins, and return on investment also matter.

The first step is articulating the reason for change. Make a compelling argument for moving away from the status quo so everyone understands why the unknown potential is preferred to the existing reality. Provide relevant objective data to help outline current strengths, deficiencies and opportunities to make a strong evidence-based case. Next, build a team of people tasked with implementing the change so as to incorporate the requisite influence, talent, skill and experience necessary for success. Leverage networks and relationships. Comprehensive buy-in of an aligned, collaborative team of change agents, is optimal. Create a vision of what the new change will look like, why it’s preferable and what the benefits will be. Portray a story that’s compelling and impactful for stakeholders. Communicating frequently and with transparency keeps stakeholders aware of progress and helps celebrate milestones. Sustainability requires that new metrics and dashboards are established and highlighted and that change is continually emphasized as “the new normal;” to help prevent reverting back to the old (Battilana, 2013). Achieving clear goals means following the S.M.A.R.T. approach (Bogue, 2005), goals must be Specific, Measurable, Achievable, Relevant and Time-bound.

Providing comprehensive unconscious bias training along with assuring cross cultural competence proficiency are a baseline mandate. Implementing formal goals, processes and policies related to actively recruiting, hiring, retaining, mentoring and promoting diverse individuals is essential. Sharing stories of success and failure helps others relate to “real-life” anecdotes. Successful implementation of a diversity strategy is followed up by feedback about program effectiveness and improvement opportunities to help guide the creation of a plan to address gaps. Active involvement in national organizations, continuing medical education conferences, and committees all help foster sharing of best practices among colleagues. Small group discussions foster valuable critical analysis and thinking in an open, honest and transparent forum. Positive results are rewarded with recognition programs to bestow well-deserved accolades upon individuals and teams that best exemplify the desired values.

Creating a sense of belonging to all who work toward advancing the company mission also helps achieve business objectives. If people feel included and believe that what they bring to the table is valued, they are more likely to be engaged and “go the extra mile” with discretionary effort in helping others, including their co-workers, and patients. More welcoming and inclusive work environments enhance employee engagement. This ultimately benefits a diverse patient population and improves patient satisfaction.

Altering racial and gender underrepresentation requires active outreach efforts and enhanced pipeline initiatives. These may include medical student electives, summer internships, mentoring programs, and networking opportunities. Diverse search committee members should implement specific selection criteria for across-the-board hiring practices in addition to active URM recruitment efforts.

As demographics continue to dramatically change, an increasingly diverse population will result. Healthcare organizations aggressively seek to stand out as unique players on an ever-expanding global stage. Taken together, these observations mandate that a successful health care organization provide culturally appropriate care, in a welcoming environment, to all patients. This can only be achieved by first improving the inclusiveness and the participation of diverse employees at all levels of the organization. Maintaining the status quo is no longer an option; only creating undesired and unintended consequences; including financial ones.

Diversity and Inclusion as a priority for organizations cannot continue to be simply discussed. The time has come for mandating real actions and implementing actual, substantial and meaningful changes. Addressing the challenges and embracing the opportunities may require an organization to undergo a significant culture shift.

A compelling business case exists for ensuring diversity and inclusion play a prominent organizational strategic role. Actively embracing and passionately advancing the diversity and inclusion agenda will benefit employees and patients; and enhance the bottom line; thus fulfilling both the “nice to have” and the “need to have” components of a successful modern healthcare organization.