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NEJM Catalyst: Lead In: Women of Impact in Health Care on Advancing Equity in the Workplace

 This article originally appeared on the NEJM Catalyst page.  It was written by Women of Impact members Vivian S. Lee, MD, PhD, MBA & Joanne Conroy, MD. 

Women of Impact Co-Authors include: Vineet Arora, Anne Beal, Chloe Bird, Ann Bonham, Kathy Buto, Lynne Chafetz, Deborah Chang, Ceci Connolly, Lisa David, Karen DeSalvo, Karen Feinstein, Liz Fowler, Della Lin, Christine Malcolm, Dora Anne Mills, Edith Peterson Mitchell, Darilyn Moyer, Karen Remley, Vivian Reznik, Lisa Shah, Kate Walsh, Elizabeth Yano, Laurie Zephyrin

In July 2013, a group of 20 executive-level women from diverse sectors of the U.S. health care industry came together to advance our personal legacies and to apply the concept of collective impact to address health care challenges. The Women of Impact (WOI) agreed on a shared goal: realign the health care system to meet the needs of all Americans. Since then, we have met annually and grown to 65 members. Together, through our individual personal legacy work and our collaborative efforts, we want more women to imagine themselves as leaders and, with the benefit of a network to support and advise them, realize their aspirations within health care.

Women leaders can influence the culture of our environments in ways that reset the rules. Beyond advocating for women to "lean in," we should aim to disrupt underlying biases, challenge normative behaviors, and reimagine the dynamics that result in policies and practices that discriminate against women and other groups. We should "Lead In." By sharing ideas and experiences, we hope to inspire other leaders to lead change in their workplaces.

We asked all members of the Women of Impact: What is the one policy or practice you have implemented (or seen implemented) that you feel has had the greatest impact on improving equity, especially gender equity, in the workplace? The synthesis of the 28 responses are discussed here, as well as incorporated with the co-authors' collective experiences, to propose a workplace checklist meant for advancing equity in the health care environment.


Leadership

Diversity among a group of problem solvers improves the quality of solutions, especially when the problems are complex. Public companies with more diversity in management or on boards see higher returns. Beyond the benefits of broader perspectives, leaders with diverse backgrounds shape the culture of their organizations both implicitly and explicitly.

Leadership styles can influence culture subtly and effectively. One woman executive in academic medicine described the importance of knowing something personal (hobbies, family, pets) about everyone in her clinical department, even if the number is over 100.

Another leader addressed the prevailing practice in biomedical research of rewarding scientists who seek job offers from other institutions. With offers of higher salary and research funding in hand, researchers demand retention counteroffers. Over time, large discrepancies in salary and research resources develop, contributing to gender inequity.

When a prominent scientist came with yet another outside offer, this WOI leader did not extend a counteroffer, and the individual eventually departed. The savings from the unused retention package instead was used to provide five outstanding scientists with "you're a star" unsolicited discretionary funds. Rewarding outstanding science and institutional commitment proved successful in long-term retention of these "star" faculty.


Recruitment

Workplace diversity relies on effective mechanisms of recruitment. Women of Impact respondents reinforced the importance of standardizing interview questions and processes so that each candidate is treated consistently. As part of the process, after defining key desired characteristics of candidates for a given position, interview questions are selected in advance that provide consistent assessment. Besides unconscious bias training, WOI leaders established behavioral norms on search committees and directly addressed inappropriate comments in the interview process that reflected bias, such as "Do we know what her work is and not her mentor's?" or "She seems a little aggressive," or comments about physical appearance.


Other simple interventions include not allowing pictures on resumes and using initials instead of first names on applications to avoid gender and other biases. One WOI leader specifically challenges her team to make sure that the pool of candidates being interviewed has diversity, even if it necessitated extra calls and solicitations to entice individuals to be considered, citing the recent article provocatively entitled, "If there's only one woman in your candidate pool, there's statistically no chance she'll be hired."


Workplace Equity

Workplace equity was the focus of one Women of Impact leader who promoted unconscious bias training for all 3000+ employees in her organization. After training, each 50-person cohort identified initiatives to support gender inclusion, such as renaming conference rooms (from explorers who were all white males to more diverse representatives such as Amelia Earhart and Rosa Parks). Another WOI leader led a "Respect for People" organization-wide initiative that articulated foundational principles like Listen to Understand, Walk in Their Shoes, and Express Gratitude. This initiative not only enhanced employee culture, but it also improved patient satisfaction, measured in terms of feeling respected by health care professionals, communication openness, and effectiveness of staff teams.


Multiple Women of Impact executives cited focused efforts to address salary equity, such as (1) peg compensation to fixed standards; (2) regularly analyze salary data for new hires, current employees, and leadership on an annual basis; and (3) make salaries (or average group salaries) transparent. In one organization, where gender differences among established faculty were attributed to differences in workload (men tended to take more calls and perform more lucrative procedures), a significant difference in starting salaries prompted wide-scale salary adjustments.


One executive created a "Safe Space" initiative for employees to report incidents of workplace inequity without fear of repercussions. To allay fears of retribution, employees could also communicate concerns through peer employees trained to support safe communication.


Another Women of Impact leader changed the job titles of administrative assistants to titles that offered greater possibilities of career advancement. For example, in her academic medical environment, she re-titled one assistant as a "research assistant." This role gave her assistant greater opportunities for direct mentorship, more exposure to leaders, and a more favorable resume entry, ultimately leading to a career in genetic counseling.


Several Women of Impact executives addressed policies that inadvertently reinforce bias and gender-related career penalties. For example, where maternal or paternal leave or flexible job-share/part-time work arrangements are considered one-off exceptions or opt-in arrangements, they may be construed as detrimental to career advancement. Administering family leave as a benefit (opt-out) and regularizing flexible job arrangements can neutralize stigmatizing effects. In her nonprofit foundation, one WOI leader's policy of allowing staff to leave on Fridays at noon (as long as a 40-hour work week had been completed) enabled women and men to take care of matters that might be viewed negatively if taken during the ordinary course of the work week (such as family or childcare commitments).


Visibility, Recognition, and a Seat at the Table

A number of Women of Impact leaders emphasized the importance of systematically improving the visibility and recognition of women in the workplace, whether ensuring that women are in the "room where it happens" or at the podium in professional conferences. One WOI leader regularly points out the relative absence of women at decision-making sessions or on meeting programs and offers recommendations to planners or program organizers. Another WOI leader goes as far as to pay registration and travel expenses for women on her team to attend networking opportunities as a way to nudge them into greater visibility.


Some Women of Impact leaders focused on local engagement and participation. One initiative, "No Women Left on the Rim," ensured that women literally took seats at the table and not the seats against the wall, regardless of their role in the organization. Once at the table, another executive leveled the playing field, both within the medical profession and across health care professionals, by establishing at the beginning of meetings whether the standard would be to use full names and titles (Dr. Jones, Nurse Smith) or first names only.

Several Women of Impact members highlighted practices to ensure women's ideas and accomplishments are appropriately recognized and credited. When a man repeats something she has said in a meeting without acknowledgement, one WOI leader unabashedly calls out the behavior, saying, "I absolutely agree with you, since I just said it 10 minutes ago!" Women who support and expand on the ideas or points made by women (and men) colleagues at meetings with appropriate attribution can enhance the culture of equitable respect. Rather than self-promote, members of a small group of women agreed that when one received an honor or recognition, another one of the group would email the leader of the organization to draw attention to the great work of her colleague. This process improved morale among the group, and members were pleasantly surprised that their leader would often share the news with others in the institution.


Subtle exchanges and power dynamics can also hinder or advance the effectiveness of budding leaders. Early in her career, one leader's boss effectively empowered her to lead and make decisions. When others demanded that he be present at a meeting, he pushed back and said, "She is leading this effort."


Equity for All

Women of Impact are particularly sensitive to issues of equity and diversity, yet our commitment extends beyond simply addressing gender equity. Promoting inclusiveness and transparency with our words, actions, and policies is not intended to reflect advocacy for one group at the expense of another. Our aim is to raise the standards of equity and overall wellness in our workplaces so that our organizations can more effectively advance health for the populations we serve.


WOMEN OF IMPACT CHECKLIST: ADVANCING WORKPLACE EQUITY

    • Is the attainment of equity a strategic goal for your organization?
    • Do you regularly set improvement goals for each measure of equity and transparently share progress across your organization?
    • Do you routinely undertake anonymous surveys to assess perceptions of equity and bias and perceived barriers to career mobility?
    • Do you have an independent ombudsman or ambassador program who can address complaints, maintain confidentiality, and allow a due process for individuals who wish to draw attention to workplace inequity without fear of repercussions?
    • Do you formally examine the diversity of your leadership team and of the leadership pipeline?
    • Do you ask vendors and contractors about the diversity within their leadership teams as part of your contracting / Request for Proposals process?
    • Do you have a recruitment practice that mitigates conscious and unconscious bias?
    • Does your organization conduct a salary equity assessment, at least every year or every other year?
    • Do your leaders have access to a leadership development program?
    • Do you encourage sponsorship programs to enhance external visibility of your budding leaders?
    • Do you have an active mentoring program that pairs women leaders with emerging women leaders?
    • Are there opportunities to create physical spaces and structures or processes to celebrate women's accomplishments in the workplace?
    • Are your family-friendly policies, such as family leaves, opt-out benefits and do you embrace flexible job arrangements where practical?
    • Do you regularly hold standardized exit interviews, with specific queries on culture of inclusion and perceived opportunities for advancement?​



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