Introduction to the series

Equity, diversity, and inclusion (EDI) is a term used to describe policies and programs that promote the representation and full participation of all members of a population, reflective of a rich variety of lived experiences and with a special focus on historically underrepresented groups. [1]. Recent events including the COVID-19 pandemic have brought attention to healthcare disparities. Consequently, EDI has become an important nidus for change. The Canadian Association of Emergency Physicians (CAEP) set a new strategic focus to establish and operationalize advancing EDI in its practices and programs. There is no universally accepted method for incorporating EDI into an organization. Leading organizational change requires a multipronged approach [2].

In this four-part series, we present CAEP’s framework for leading organizational change to advance EDI. Each paper will build on the last but also stand on its own. The first paper in this series provides an overview of existing EDI strategies and programs that are used by medical associations, healthcare organizations and clinicians practicing in Canada and abroad. The second paper focuses on the work that CAEP has done to put EDI principles into practice. The third paper outlines a practical and reproducible multifaceted approach to work towards culture change. The final paper in the series translates the work that CAEP has done to provide a pathway for individuals to lead change through local EDI initiatives.

We are a team of Emergency Physicians, scholars in EDI and members of CAEP. Our group represents a variety of racial, gender, sexual orientation, economic, and geographic backgrounds. As emergency physicians with lived experience and relevant expertise, we were invited to work with CAEP to develop an approach for leadership to better meet their EDI goals.

We use the terms discrimination and bias throughout this series as a pragmatic shorthand for complex concepts. We recognize that these terms are insufficient to fully encompass the underpinnings and impact of racism, colonialism, gender bias, heteronormism, ableism, ageism and other forms of perpetuated inequities. Each of these forms of oppression occurs at interpersonal, institutional, and systemic levels [3] and they do not exist in isolation but as interlocking phenomena [4] further complicated in our setting by disparities in wealth and social status between EM physicians and much of the population we serve.

This paper presents the findings of a narrative review of EDI practices and programs used by healthcare organizations, academics and practicing clinicians. Establishing an understanding of existing strategies was an important initial step for CAEP in creating its own pathway to advancing EDI as the leading Canadian EM organization.

Methods

We completed a review of EDI practices used by major North American medical and healthcare organizations (AMA, CMA, CMPA, etc.) and of major international organizations of Emergency Medicine (CAEP, ACEP ACEM, RCEM, EuSEM, etc.) limited to those available in English. We focused on EDI work related to organizational change using environmental scan methodology [5]. We gathered and summarized data on published EDI policies, processes, and approaches through a search of organizational websites, gray literature, and white papers from these organizations. EDI strategies for these organizations are listed in Supplementary Appendix A-1 for medical organizations and A-2 for EM organizations.

A literature search was conducted in PubMed using the following search terms: Equity, Diversity and Inclusion AND Emergency Medicine AND Organization. The search was limited to English publications. This yielded 34 papers, 16 of which were selected after screening for relevance by CL and KJ. These results are listed in Supplementary Appendix B.

A series of Google Scholar™ searches for “strategic leadership”, “organizational change”, “Equity, Diversity, Inclusivity, and Accessibility”, and “Canadian government EDI”, provided strategic planning documents, reports, articles, and policies that included approaches to EDI. From the first 100 items ten were selected based on our focus of organizational change toward EDI in healthcare. These results are found in Supplementary Appendix C.

A list of key literature was put forward by the authorship group who serve as content experts in EDI (Supplementary Appendix D). This list provides a background of useful references for those interested in undertaking any EDI work. We have mapped these references on to the key domains of action for EDI initiatives as seen in Fig. 1.

Fig. 1
figure 1

Venn diagram that displays the intersection of each EDI domain with key references that pertain to each. Addressing bias and discrimination is a core underpinning of any EDI intervention

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Results

Our review included 22 articles and reports and 20 organizational websites. A summary of findings from the reviews is provided in Appendices A–D.

After thorough review of the documents included in the search, using a consensus-building approach authors KJ and CL identified four relevant domains which were associated with successful EDI strategies for organizational change. The four domains are: Addressing bias and discrimination; Equitable policies and procedures; Collaborative leadership; and Training and education for allyship. The domains were used to create a Venn diagram that displays the intersections of each, with the overarching domain of addressing bias and discrimination as a core underpinning of any EDI interventions (Fig. 1).

Discussion

As a voluntary association of 2500 members, CAEP has recognized the importance of having an EDI strategy. Prior to this process, it was clear that the organization’s governance structures did not represent or include the range of diverse voices that make up the membership. For instance, in June 2020, CAEP released a position statement on racism and received feedback that many Canadian emergency physicians did not feel represented by the organization and so did not join. Governance structures have significant influence over the direction and activities of an association; thus, it is important that they have inclusive practices and reflect the diversity of the membership (and those who might seek membership). In taking action to address bias and discrimination starting at the executive board level, CAEP joins other national and international organizations also doing this work, including the Canadian Medical Association, Canadian provincial medical associations, the British Medical Association, the American Medical Association, and the International Federation for Emergency Medicine. Today CAEP has integrated EDI into its mission, vision and values. Examples of how CAEP has actively employed EDI throughout the organization and its activities are given in papers 2–4 in this series.

Advancing EDI in medical organizations requires active, intentional, and ongoing efforts to examine how we value the full participation and contributions of all members and how that is reflected in the systems within which we practice and the kind of care we provide patients.

The four domains identified in this narrative review (Fig. 1) present a structure to inform and guide the development of organizational approaches to improve equity, diversity and inclusivity and are used to frame concepts discussed in this series.

The circle that envelopes the others depicts a higher order domain of addressing bias and discrimination, at the personal, institutional and systemic level. This overarching commitment is essential to all successful EDI strategies, and ultimately resulting in culturally safe care. Cultural safety is defined as an outcome whereby a respectful, engaging space free of discrimination and racism is provided, where power differentials are dismantled and patients feel safe. [6]

The equitable policies and procedures domain includes addressing the structural inequities that are built into an organization’s processes and policies. Mission/vision, bylaws, selection of board members, and selection of award recipients are all examples of where an EDI lens must be applied, and changes made.

Including collaborative leadership as a core domain underscores that in order to make progress on EDI, leaders must work together to acknowledge inequities. The landmark paper by Nixon (2019) defines privilege as the unearned advantages that, if left unchecked, contribute to inequitable hiring and promotion practices. [7] Leaders must recognize that their organization is not an equal playing field, challenging the myth of meritocracy in medicine. [8] We emphasize the importance of leading change from all levels of an organization (e.g., physicians co-leading with nurses, social workers, managers) and shared leadership across organizations (e.g., healthcare organizations working together with community advocates). Leadership must become representative through collaboration not only as a moral imperative, but also as a demonstrated necessity for advancing innovation and providing effective patient care [9]. This includes valuing lived experience and distance traveled in the selection of organization leaders and existing leaders develo** the humility to identify and mitigate bias, respect differences, build empathetic relationships and foster opportunities for advancement for those from groups underrepresented in medicine. [9]

Training and education for allyship involves not only introducing EDI-specific programs for board members and leaders across organizations, but also the incorporation of EDI principles and allyship concepts throughout all existing and future organization education programs.

CAEP has demonstrated a strong commitment at the organizational level to advancing EDI. The paucity of literature in this area speaks to this industry-leading approach. We encourage readers to review the works included in the appendices to use as key references in leading organizational EDI changes and for further information on important EDI initiatives being undertaken by medical organizations in Canadian settings and beyond.

Conclusion

This paper is the first of a series of four on how to advance equity, diversity, and inclusion in healthcare organizations.

In this paper, we provide a framework for successfully leading change to create a more equitable, diverse, and inclusive organization that benefits our patients, our learners, and ourselves. We have reviewed the existing literature and approaches of other leading organizations and identified four key areas for intervention: addressing bias and discrimination, collaborative leadership, training, and education for allyship, and equitable policies and procedures. The next papers in this series will describe the changes CAEP has implemented following this framework to become a leader in advancing EDI. The final paper of the series describes and how this framework applied for individuals to lead change through local EDI initiatives.