Those who identify as African American/Black, Hispanic/Latino, American Indian/Alaska Native or Native Hawaiian/Pacific Islander have been considered underrepresented in medicine (URiM) by the Association of American Medical Colleges (AAMC) since 2004. Seventeen years later, it is estimated that only 11.3% of Pediatric faculty at academic health centers (AHCs) are considered URiM (Yoo et al., 2021), and among trainees, only 16.5% of residents and 13.5% of fellows are in this category (Montez et al., 2021). Regarding other professionals employed by AHCs, recent data indicates that most medical assistants (48.9%; “Medical assistants,” 2020) and registered nurses (68.4%; “Registered nurses,” 2020) in the United States are White. Importantly, these percentages do not reflect the increasingly diverse patient populations that AHCs typically serve. In Chicago for example, recent census data shows that nearly 81% of its youth are children of color (Loury & Runes, 2021).

Physicians (Shanafelt et al., 2015) and other medical staff (Grace & VanHeuvelen, 2019) working in AHCs are at high-risk for burnout, a risk that has been exacerbated by a global pandemic (Morgantini et al., 2020). Employees who hold marginalized identities are at even higher risk, as they face microaggressions (Nfonoyim et al., 2021) and other forms of discrimination (Snyder & Schwartz, 2019) that contribute to hostile work environments. Thus, systemic discrimination permeates through academic medicine in several ways. In addition to its impact on the lack of diversity in medicine, systemic discrimination sustains environments that are not inclusive or equitable for those from marginalized backgrounds who work in AHCs. This contributes to troubling trends in attrition and lack of retention for URiM faculty (Lett et al., 2018), which has been evidenced by the recent exit of several Black physicians from AHCs (Miller, 2021; Blackstock, 2020). Failing to address issues of belonging and equity creates a revolving door of diversity: marginalized and minoritized individuals enter the healthcare organization but soon exit due, in part, to unsupportive environments characterized by an absence of mentorship and sponsors (Beech et al., 2013), barriers to career advancement (Kaplan et al., 2018), as well as the more overt forms of discrimination aforementioned. Thus, many AHCs have failed to understand the implications of bringing healthcare professionals from diverse backgrounds into non-equitable and non-inclusive environments.

The jarring collision of an unprecedented global pandemic with a renewed reckoning on racial tensions last summer (Krieger, 2020) led many organizations such as the AAP (American Academy of Pediatrics), AMA (American Medical Association), ACOG (American College of Obstetricians and Gynecologists) and more recently APA (American Psychology Association) to make statements of apology for or acknowledgement of health inequities and medical racism. Simultaneously, many healthcare institutions expanded their current diversity, equity, and inclusion (DEI) initiatives, or developed them, primarily focused on increasing the number of traditionally underrepresented minorities in the organization. While the importance of DEI work cannot be underscored enough, a significant challenge in this work has been that AHCs often primarily direct initiatives at increasing diversity, little on equity, and even less on inclusion (e.g., Rajaguru et al., 2021). According to APA’s Equity, Diversity, and Inclusion framework (“Equity, Diversity, and Inclusion Framework,” 2021), equity is a “an ongoing process of assessing needs, correcting historical inequities, and creating conditions for optimal outcomes by members of all social identity groups” and inclusion is “an environment that offers affirmation, celebration, and appreciation of different approaches, styles, perspectives, and experiences, thus allowing individuals to bring in their whole selves and to demonstrate their strengths and capacity” (p. 12).

Across the country, there has been a mounting pressure and exposed need among healthcare institutions to build effective infrastructures for moving DEI initiatives from idea to action to sustained change. Indeed, there is a rapidly growing body of work aimed at identifying and describing the apparent problems (e.g., Rosenkranz et al., 2021); providing suggested frameworks for potential solutions (e.g., Kang & Kaplan, 2019); and demonstrating favorable trends towards improvement (e.g., Nehemiah et al., 2021), particularly as it relates to increasing diversity in the recruitment and retention of students and trainees. In comparison, there has been notably less reporting on specific approaches for building or expanding institutional DEI work in academic healthcare settings despite its perceived value (e.g., Nora, 2021).

While comparatively limited, a review of this work reveals several recurring themes, including the importance of assessing the current DEI culture in a given space, developing a stepwise, strategic plan with specific interventions for addressing issues, and identifying specific outcomes to better track progress towards goals. In one example, Pino-Jones et al. (2021) outline a framework for advancing DEI in a new hospital medicine division that focuses on institutional structures (e.g., compensation, recruitment), people, environments, and core mission areas. Similarly, Lingras et al. (2021) describe their step-by-step approach for developing a DEI committee in a single department within a larger AHC. The authors highlight the importance of engagement, collaboration, and shared decision-making among all stakeholders, including from department membership at the grassroots level to promote local change (bottom up) and from leadership to support larger efforts at the systems level (top down).

Although these important contributions to the literature have demonstrated growth of the DEI space in academic medicine, we have found that the specific context in which an AHC functions (e.g., geographical location, size, characteristics of the patient population and neighboring communities) paints a unique picture. This picture captures the attributes that contribute to progress and, importantly, the unmet needs that contribute to inertia in advancing diversity, equity, and inclusion. Thus, an effective approach uses thoughtful assessment and careful tailoring of these broad frameworks to deliver on the needs of the communities within, around, and affected by a system holding as much institutional power as an AHC.

Overview

In this paper, we describe the formation and continued evolution of a DEI committee within the Department of Pediatrics at Rush University Medical Center (RUMC), a large AHC in Chicago, Illinois. Our DEI committee includes an executive board and five subcommittees. We will discuss the unique social and geographic context that motivates this work and the formation of our committee. We will also overview several DEI-related initiatives, including department climate surveys, changes in faculty and residency recruitment, community-building efforts, didactic and training opportunities, as well as changes in policy and procedures aimed at increasing diversity, promoting equity, and building a culture of inclusion in our department. Successful outcomes will be discussed within the context of barriers faced and areas in which continued work is needed. In this way, we hope that our paper can provide a practical guide for others who may be considering how to establish DEI initiatives in their departments.

RUMC: Socio-Geographic Context

RUMC is a large academic health center located just two miles outside of downtown Chicago in the Near West Side neighborhood, a notable location in a city as diverse yet historically segregated as Chicago (Sandoval, 2011). Directly to the east of RUMC is the affluent central business district commonly known as the Loop. At the same distance directly west of RUMC are the Garfield Park and North Lawndale neighborhoods, both predominantly Black communities affected by poverty and decades of disinvestment (Mumm & Sternberg, 2022). For additional context, consider that recent community data reveals a 14-year life expectancy gap between residents of the Loop and residents of East Garfield Park (82 years and 68 years, respectively), a gap that has been attributed to structural racism and socioeconomic deprivation (Ansell et al., 2021). Also within distance of RUMC are the majority Hispanic/Latino Lower West Side and Humboldt Park neighborhoods, both home to large foreign-born populations. This is the rich racial/ethnic and socioeconomic tapestry of the patient population served at RUMC.

Indeed, according to a recent Health Equity Report (2019), 72% of patients presenting to the RUMC emergency department, 49% of inpatient admissions, 56% of patients receiving primary care, and 40% of patients receiving specialty care identified as Black or Hispanic (Ansell et al., 2018). Given its size and location in a major city in the Midwest, RUMC also draws patients from the greater Chicagoland area, neighboring states, as well as international visitors, further diversifying the RUMC patient population not only with regard to race, ethnicity, and socioeconomic status, but also age, language, gender identity, sexual orientation, and religion/spirituality.

Trends in demographic data for the RUMC community of students, trainees, faculty and other staff are not as well reported. During the Fall 2021 term, 13% of the enrolled student body at Rush University identified as Hispanic, 12% Asian, and 8% Black/African American. In the same year, only 10% of faculty at the institution identified as Hispanic or Black/African American (“Rush University Report 2019 to 2021,” 2021). RUMC also reports that 46% of residents and fellows and 50% of all employees are from minoritized groups (“Diversity,” 2022). Taken together, these numbers help contextualize the state of DEI-related issues in the RUMC community. RUMC has been active in addressing such concerns (Ansell et al., 2021) from a top-down approach. Importantly, RUMC also recognizes that in order to fully meet the need of our patients and exist in accordance with our hospital’s values, we must encourage and support departments within the larger organization to also power the movement from the bottom up.

RUMC Department of Pediatrics: DEI Efforts

A diversity and inclusion (D&I) task force was first created by a prior department chair in 2017 (Fig. 1). At that time, two D&I co-chairs were appointed to organize the inaugural department-wide DEI retreat and develop a climate survey. In late 2019/early 2020, following the retirement of one co-chair and the transition of the second co-chair to other academic domains, a new DEI chair was appointed, and an executive board was established. The board was composed of three Black female pediatricians and two White female pediatricians, including the new DEI chair, the outgoing DEI chair (who has remained involved as an advisor in retirement), as well as three department members in leadership roles (department chair, residency program directors). Decisions about various initiatives and goals are discussed and agreed upon by a majority of executive board members.

Fig. 1
figure 1

Timeline of major events and initiatives

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Like many institutions, for better or worse, our DEI-related efforts received a newfound sense of attention and urgency in response to the murders of George Floyd, Breonna Taylor, and countless other people of color in 2020. In order to increase communication between the DEI committee and the department, encouraging visibility and accountability, a secretary position was also added to the executive board in 2020. This position also ensured that executive board meetings were scheduled and attended by all members on a biweekly to monthly basis, with agendas and minutes documented and distributed before and after each meeting.

The secretary position was advertised to the department and filled by a White male pediatric psychologist. The significance of a faculty member with several layers of societal privilege engaging with this work is worth mention. Because DEI work is often led by Black women and other women of color (Rogers & Jayasinghe, 2021), many are leading these efforts while simultaneously navigating issues of being marginalized in their daily lives, experiencing harm due to an incongruence of organizational DEI values and its actions or policies, being asked to facilitate trainings to educate others around painful lived experiences, or mitigating the potential consequences of calling out mistreatment. As such, it is crucial that those in power within organizations use their privilege to promote these efforts and then “step out of the way” for motivated and passionate colleagues from marginalized groups to use their voices, energy, and ideas toward building a more inclusive culture in the workplace (Tulshyan, 2022).

Climate Surveys

Perceived work climate has been studied extensively across disciplines and has been linked to a myriad of positive outcomes, including job satisfaction, productivity, and retention (Harter et al., 2003). Moreover, recent studies have suggested that for younger generations, workplace culture may be even more important to workplace satisfaction than pay or other benefits (Tulshyan, 2022). For our purposes, a climate survey was essential because employees draw conclusions about their employer’s priorities through their perceptions of work climate (Schneider et al., 1994), and we wanted to better understand the extent to which department members felt diversity, equity, and inclusion were prioritized in Pediatrics. In addition to assessing our culture, these surveys were also meant to identify targets for DEI-related initiatives and change.

Upon creation of the executive board, our first identified task was to review prior climate survey data and distribute a revised version later in 2020. The initial climate survey was adapted from the climate survey used at Rush University’s medical school. It was distributed within our department on two occasions in 2017 (n = 101) and in 2019 (n = 99). In addition to demographic information, the climate survey contained a combination of quantitative and qualitative questions and took approximately 15 minutes to complete. Three primary items relevant to the current paper were as follows: (1) I am satisfied with the climate regarding diversity in the department, (2) members of the department create an environment that is conducive to free and open expression of opinions and beliefs, and (3) I feel a sense of belonging as a member of the department. Respondents who selected agree or strongly agree were aggregated and considered to have a generally positive perception. Across both 2017 and 2019 surveys, responses to all three items remained relatively positive and stable, ranging from 75 to 82% of respondents who provided positive opinions. However, an important comparison between the opinions of faculty and staff was not possible due to the manner in which survey demographics were constructed. Additionally, although initial responses were generally positive, it cannot be overlooked that approximately one quarter of respondents reported a neutral to negative opinion of diversity and inclusion.

In 2020, several changes were made to our climate survey to support our continued evaluation of department culture. This updated survey was sent to and completed by a larger group of department members (n = 147), including faculty, residents, fellows, nurses, medical assistants, research teams, clinic coordinators, and other administrative staff. Notably, reaching a larger and more diverse group of department members proved crucial in more accurately assessing our climate. While faculty and trainees continued to provide positive responses regarding free and open expression (87%) and a sense of belonging (88%), staff members had less favorable opinions, with only 72% feeling as though the environment was conducive to free and open expression and 71% feeling a sense of belonging in the department. Moreover, while 80% of faculty and trainees reported feeling as though faculty members in the department are sensitive to issues regarding diversity, this was contrasted with only 68% of staff feeling the same.

Questions unique to our 2020 survey also revealed that 34% of respondents (n = 50) described experiencing microaggressions, 8% described experiencing discrimination, 7% encountered racism, and 15% described being mistreated more generally in the workplace. When asked if respondents knew someone who experienced any of these forms of harassment at work, reports across categories increased to 49%, 25%, 19%, and 22%, respectively. Despite these alarmingly high numbers, very few respondents described making a report about harassment experienced by themselves or others. When asked to elaborate, several important themes emerged from the qualitative data. These ranged from people feeling unsure how to make a report, doubting that any change would occur, and feeling fearful of being identified or potential retribution. A few employees also reflected that their experiences have been so commonly occurring that it was not until reflecting on them that they realized they were being mistreated.

Strategic Plan and Goals

In mid-2020, the DEI executive board reviewed data from all three climate surveys as well as department demographic data and came to the following two conclusions. First, it was clear that there were not enough URiM employees in our department. Of our 103 faculty (i.e., MD, DO, PhD, APP) at the time, only 17% were considered URiM and only 7% identified as Black. The percentage of non-faculty department members (e.g., clinic coordinators, medical assistants, nurses, administrative and research staff) considered URiM was higher; however, this group was still minoritized (46%). Overall, only 35% of our 276 department members were considered URiM, a trend consistently observed within other AHCs in the United States (Ajayi et al., 2021). Second, it was clear that we had work to do regarding our departmental climate. In addition to troubling data on microaggressions, a significant proportion of employees, most notably staff, were not feeling heard or included, and denied that the department was a space that was sensitive to diversity issues.

Therefore, in 2020 the executive board established the following strategic plan that could both address identified departmental challenges as well as create meaningful programming and policy change to facilitate progression toward the following aims. Related to diversity, the DEI committee pledged to work toward achieving a workforce, faculty, and student body that are reflective of the unique communities, patients, and region we serve. Related to equity, the DEI committee set forth to increase employee’s knowledge of the historical impact of systemic discrimination on people from marginalized backgrounds through various trainings and initiatives so that all department members gain an increased understanding of the importance of treating others equitably, rather than equally. Related to inclusion, the DEI committee aimed to build a culture of excellence that fosters an environment of cultural humility and mutual respect for those who work at RUMC, those whom we care for, those whom we educate, those who benefit from the scientific advances we achieve, and those with whom we interact in our surrounding communities.

Subcommittees and Related Initiatives

To begin working toward these goals, five subcommittees were formed in 2020 (Fig. 2): (1) the grand rounds/book club subcommittee was tasked with identifying speakers to present DEI-related topics to our department as well as suggesting book ideas for our book club; (2) the faculty recruitment subcommittee’s primary goal was to identify and implement initiatives meant to bring more URiM candidates and employees into the department; and (3) similarly, the residency recruitment subcommittee aimed to increase URiM representation in the pediatric residency program. Of note, our committee has chosen to change our use of the commonly used term ‘URiM’ to ‘URiM/historically excluded (URiM/HE),’ given the latter’s clearer implication that the underrepresentation of certain minoritized groups in medicine has been a direct result of systemic racism and other forms of oppression. Our final two subcommittees included (4) the retreat subcommittee to coordinate logistics related to our annual retreat; and (5) the operationalization subcommittee, who was tasked with spearheading meaningful “next steps” for transformative action and change in our department, such as identifying and addressing inequities in policies and procedures, establishing a reporting system, or improving inclusion through community-building initiatives.

Fig. 2
figure 2

Structure and goals of the DEI Committee

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Grand Rounds, Book Club, and Communication

Since 2017, the DEI committee has hosted five grand rounds per academic year. Previous speakers, historically identified by the department chair or prior D&I chair, have presented on a wide variety of topics, including social determinants of health, implicit and systemic bias in healthcare, sexual harassment in medicine, racial trauma, and caring for transgender patients. Following the creation of subcommittees in 2020, one member of the department volunteered to lead the grand rounds subcommittee by identifying speakers, soliciting ideas from other department members, and coordinating logistics for each presentation.

The DEI committee also established a monthly book club in 2019, led by one of our executive board members, that has collectively read over thirty books since its inception. Books range from fiction to nonfiction, often are written by women or people of color, and typically focus on issues related to discrimination. Although small group discussions have been well-received by those who regularly attended, book clubs have historically been less attended than the committee would have hoped (i.e., 5–7 people). To increase attendance, in 2020 we began including podcasts, videos, and other forms of media as well as changed the meeting time to fall during the lunch hour instead of after work. These changes have broadened the scope and impact of this initiative through increased participation, with more than twenty department members attending our most recent Book Club meeting. Grand rounds and book clubs have been occurring virtually since the onset of the COVID-19 pandemic, with minimal impact on attendance or participation for department members and generally greater ease and access for invited speakers.

Lastly, to improve communication with the department, the executive board debuted our “DEI Corner” in 2020, a monthly departmental newsletter that summarizes DEI-related events and trainings, provides updates on ongoing initiatives (including Grand Rounds and Book Clubs), offers information on community engagement opportunities, and highlights minority-owned businesses to support in Chicago. The information included each month is reviewed amongst members of the executive board and the residency program manager before being finalized and distributed via e-mail by a resident who volunteered to take this role.

Faculty Recruitment

To begin addressing our diversity issue at its core, the executive board examined our recruitment process. Regarding faculty positions specifically, since 2019 only 8% of our candidate pool has identified as URiM/HE. Although this number is likely an underestimate given that 56% of candidates did not report race or ethnicity, greatly increasing the number of URiM/HE candidates was identified as a top priority by our department in collaboration with Faculty Recruitment at the hospital level. Given that a more purposeful and targeted search for URiM/HE candidates from the start of the hiring process has been shown to increase diversity in new hires (Bhalla, 2019), open positions are now posted to over 50 different organizations and associations, many of which specifically focus on diversity in medicine (e.g., Minority Nurses Association, Professional Women of Color Network). Open positions are also advertised at conferences and career fairs that center UriM and other historically excluded minorities, including the National Medical Association (NMA), Student National Medical Association (SNMA), Health Professionals Advancing LGBTQ Equality (GLMA), and National Hispanic Medical Association (NHMA) conferences.

Collaboration with Faculty Recruitment has aimed to better integrate DEI into our interview process as well. Specifically, it was established that one ‘DEI liaison’ (either an executive board member or faculty recruitment subcommittee member) now participates in every faculty interview. Specific interview questions created by the executive board relate to topics such as how a candidate approaches their work with diverse patients, past experiences in which a project or decision was enhanced by including diverse perspectives, or ways in which the candidate has promoted or added to diversity, equity, or inclusion in previous positions. Candidates may also be asked questions related to their specialty; for example, a neonatologist might be asked to speak to racial disparities in low birth weight and infant mortality.

Notably, through collaboration with Faculty Recruitment on this initiative, a DEI liaison position has been formally created as a role to fill in every department at RUMC. By more purposefully centering DEI during the interview process, we can both illustrate our commitment to this work to prospective candidates (Bhalla, 2019) as well as identify and mitigate biases that may have impacted URiM/HE hires in the past (Tulshyan, 2022). Although we are currently focused on faculty interviews, we plan to eventually expand these efforts into interviews for all employee types.

Although we can only speak to correlation with recent efforts, we have seen an increase in URiM/HE hires in Pediatrics from 17% in 2019 to 43% of all new faculty hires in 2021. Moreover, from 2020 to 2021, the percentage of Black new staff hires increased from 19 to 25% and the percentage of Hispanic/Latino new hires increased from 26 to 37%. Despite these promising increases, continuing to improve in this area remains a priority of our committee. For example, we realized through collaboration with Faculty Recruitment that we were failing to assess the full impact of our initiatives by not asking candidates for feedback, especially URiM/HE candidates who were not employed by RUMC after being interviewed. To better assess the interview experience and candidates’ perception of Pediatrics and RUMC, Faculty Recruitment is creating a survey to be distributed to all candidates following interviews. Moreover, analysis of attrition data revealed that although our diversity trends are encouraging, the importance of equity and inclusion efforts are crucial to ensure that increased diversity in our department is not only temporarily observed. In 2020, 65% of voluntary and involuntary departures in the department were by URiM/HE employees, and in 2021 this percentage increased to 72%.

Residency Recruitment

Importantly, we recognize that an interest in pursuing a medical career develops earlier than residency, and unfortunately, minoritized groups are often excluded in efforts aimed at bringing undergraduates to medical school (Freeman et al., 2016). From 2018 to 2021, URiM/HE applicants have ranged from only 13% to 15% of our pediatric resident candidate pool. In response, we created the Building Blocks: Rush Scholars Program, modeled from a similar program that one of our directors participated in as a URiM/HE high school student. This mentorship program focuses on underrepresented minority junior and senior students attending high schools on the neighboring West Side of Chicago who are interested in medicine. The mission of this program is to provide an integrative curriculum of clinical immersion, personalized mentorship, and community service to prepare underrepresented minorities for matriculation into college, graduate education, and medicine. Students engage in monthly hands-on classroom activities taught by medical students and pediatric residents centered on professionalism, resume building, interviewing skills, life as a medical student, and clinical experiences. Students partner with a medical student and physician mentor to aid in the preparation of their college applications. Students also shadow their medical student mentor in the pre-clinical setting as well as their physician mentor in the clinic/hospital. By participating in this cross-generational community service experience, pediatric residents learn through advocacy, and we hope that student participants will eventually matriculate at Rush University.

In 2017, we began tracking the number of URiM/HE applicants that we invite, interview, rank, and match for our residency program. This data are used as a surrogate measure of department initiatives to increase diversity. Our curriculum for faculty has evolved over the years and currently, in accordance with the Accreditation Council for Graduate Medical Education (ACGME) guidelines for creating a diverse and inclusive workforce, includes implicit bias and bystander training, formal education regarding holistic applicant review, and guidance for expressing a genuine and authentic commitment to the success of each resident during recruitment (Gonzaga et al., 2020). Since 2020, we have adhered to the ACGME guidelines in addition to blinding interviewers to applicants’ academic metrics so they may focus on the other aspects of the holistic review. We also began sending representatives from our program to annual national recruitment and networking events, including SNMA, the Latino Medical Student Association (LMSA), and the Howard University Residency Fair.

In 2019, a panel of URiM/HE graduates from our program traveled back to RUMC to share their experiences during a grand rounds panel titled “Personal Reflections on Navigating Bias and Microaggressions.” The panel was moderated by a skilled facilitator from outside of our department who stimulated reflection and discussion. That year, we also collaborated with program leadership from an East coast psychiatry program who had seen significant success in their match after several years of efforts to increase diversity. Using feedback discussed in our meeting, program leadership developed a plan that included creating additional opportunities for applicants to meet URiM/HE faculty and residents at the end of their interview day as well as during monthly meetups. During these “hang-back sessions,” URiM/HE faculty and residents share their experiences with the applicants about the climate at RUMC, mentorship experiences, and career development. We have continued to hold these sessions virtually during the pandemic, receiving excellent feedback from participants.

In 2020, our residents stepped up with the seven other pediatric residency programs in the Chicagoland area, creating a pledge of solidarity with the Black Lives Matter movement. The statement is front and center on our pediatric residency website. Our residents also outlined their DEI goals for the year: to participate in departmental, institutional, and regional DEI committees; to improve the content of DEI curriculum, including creating programming to address bias, microaggressions and mistreatment; and to advocate for equitable policies affecting child health at RUMC while supporting scholarly work and community engagement activities to address health equity. Residents currently sit on our department’s DEI subcommittees as well as the RUMC-wide Housestaff DEI committee. We also created a formal Advocacy Track for residents specifically interested in community involvement and career development.

In 2021, additional programming to support all residents was added including a board preparation program, programs to support finding mentors of similar backgrounds, early research mentor pairing, career development counseling, and guidance in professional identity formation (Gonzaga et al., 2020). The residency program also funded networking and mentoring events for URiM/HE faculty and residents, including those who identify as LGBTQ+, to foster inclusion, support, and mentorship. Working closely with the residency program directors, we also added DEI-specific goals to resident rotations focusing on equity, disparities, and how to discuss race and ethnicity as it relates to health outcomes (Blanchard et al., 2022).

Although again we can speak only to its correlation with our efforts, URiM/HE applicants invited to interview for our program increased from 20 to 30% from 2019 to 2020. Although this number fell slightly to 27% of invited applicants in 2021, the percentage of URiM/HE applicants who matched with us increased significantly. After only one URiM/HE candidate matched with our program across our 2019 and 2020 classes, 36% (4/11) of residents in our 2021 class are considered URiM/HE. Although we are encouraged by this trend, we remain committed to continuing to increase the number of URiM/HE applicants who are interviewed and ultimately match at RUMC.

DEI Retreat

Our inaugural half-day DEI retreat took place in 2017 and has been held annually ever since. To maximize participation at our retreats, all outpatient clinic schedules are blocked months in advance and inpatient responsibilities are minimized as much as possible. In October 2020, our retreat took place virtually with approximately 240 participants in attendance, including faculty, trainees, nurses, research assistants, medical assistants, clinic coordinators, and other staff. Compared to prior retreats, overall attendance increased in 2020 due to the flexibility afforded by virtual attendance, a benefit of the change from an in-person format due to the COVID-19 pandemic. However, the effectiveness of aspects of the retreat meant to be more interactive (i.e., breakout rooms) was variable over the virtual platform, especially given that many rooms included participants who had never met previously.

Our 2020 retreat included a powerful keynote address by an invited speaker: a Black pediatrician, public health advocate, and scholar who is renowned for her work on the relationship between structural racism, inequity, and health. The retreat also included a facilitated discussion among a panel of invited RUMC leaders involved in DEI work across the system, a dedicated wellness break, as well as small group breakout discussions among participants. The keynote speaker provided thoughtful suggestions in response to some of our department’s most pressing questions, including how organizations can “move past symbolism and make actual change,” and how we as providers and staff can approach discussions of racism and other forms of oppression with our patients. Compared to previous years, the 2020 retreat included an even more purposeful and pointed emphasis on uncomfortable truths and dialogues about systemic racism in medicine.

The impact of the 2020 retreat was immediate; in addition to positive qualitative feedback from department members, participation in DEI subcommittees increased from nine to twenty-nine people and included a more diverse group of faculty, trainees, and staff. Thus, the retreat achieved its goal of challenging department members to engage in self-reflection and community building, and for some, to fuel motivation toward action and change.

Our 2021 retreat also was conducted virtually and was attended by approximately 200 people. It too included a keynote address, this time by speakers from a regional organization aimed at dismantling systemic racism in large institutions. The retreat also included several breakout groups and dedicated wellness breaks.

Operationalization

The fifth and final subcommittee, which focused on operationalizing ideas generated within the department into concrete initiatives, experienced significant growth following our 2020 retreat. In response to the results of our 2020 climate survey, one of their first goals was examining the system for reporting microaggressions and other forms of harassment occurring in the work environment. Unlike residents, who have access to a standardized and formalized process for reporting through graduate medical education, no formalized system exists at the department level for faculty or staff. Although a reporting system exists through the Human Resources (HR) department at the hospital level, their approach and system are not well understood by our department members. As such, the operationalization subcommittee formed three subgroups that included education (e.g., how do we ensure that everyone receives appropriate education and knows what to do when a harm has occurred), logistics (e.g., what does our current system look like and how can it be improved?), and consequences (e.g., what happens when harm has occurred?).

Conversations with HR are ongoing; however, some progress has been made through efforts to integrate aspects of restorative justice (RJ) into our department. RJ is a community-centered and relational approach that brings together those who have harmed and been harmed that brings accountability and healing to all involved in a meaningful way (DeWolf & Geddes, 2019). At this time, an informal system has been established by the executive board in which, following a report of mistreatment, all involved parties are invited to take part in a RJ-based conversation facilitated by one of our identified RJ facilitators. Although this system is not adequate for all types of reports, we intend to continue utilizing it when appropriate (e.g., microaggression, perceived unfair treatment) and when both parties are open to this type of healing.

Although examining RJ as a philosophical framework is outside the scope of this paper, one primary component that we are also beginning to implement is the community-building circle. These circles are designed to build connection and address conflicts that disrupt a group’s ability to function as a community; through facilitation by a trained circle-keeper, RJ circles allow for safe, inclusive spaces that foster personal connections and center on humanistic values (Behel, 2019). Although most often utilized in criminal justice settings, RJ practices are more recently being implemented in healthcare settings (Long et al., 2022).

Thus far, our residents have taken part in RJ circles, both during their orientation as well as intermittently throughout their training, and this year we had opportunities for division chiefs to participate as well. To further integrate this approach into our department, our next DEI retreat in 2022 will purposefully broaden the scope of the RJ framework by inviting all department members to participate in RJ circles. Specifically, we plan to create 14 circles based on job description and clinic location that will each meet with a RJ facilitator during our retreat as well as periodically throughout the year. Initially, circle prompts will focus solely on strengthening interpersonal connections; however, we hope that future circles can also address harms when they have occurred and promote healing among colleagues, therefore improving retention as well.

Changes in hospital policy have also been achieved through the operationalization subcommittee. In response to an incident in which a patient’s parent used racist language toward a Black pediatrician, we initiated dialogues with clinical and HR leaders, Patient Relations, and RUMC’s legal team to enact policy change. As a result of these conversations and ongoing advocacy, RUMC’s patient rights and responsibilities policy was updated to better protect and advocate for all RUMC employees who are victims of racist language and actions in the workplace. Knowing how important visibility is to DEI-related issues (Bourke & Titus, 2019), our policy now more explicitly refers to discrimination based on age, race, ethnicity, ancestry, marital or parental status, veteran’s status, religion, culture, language, disability, sex, sexual orientation, gender, gender identity/expression, socioeconomic status or any other category protected by federal/state law or country/city ordinance as behavior that is not tolerated.

Another initiative identified by the operationalization committee and executive board was improving the availability of resources (e.g., compensation, protected time) for DEI-related efforts, as these speak volumes about an organization’s commitment to DEI. As Singleton et al. (2021) recently noted, “by providing these resources in a top-down manner, it signifies that the voices of historically excluded scholars are not just heard but valued and essential to creating a productive and collaborative community” (p. 3366). Our department chair has successfully advocated for access to funds that allow our department to host nationally renowned speakers and provide relevant training during our DEI retreats. In terms of retention, our department recently participated in an analysis and adjustment of faculty compensation to better reflect national benchmarks as well as to eliminate any identified pay disparities among faculty. Medical assistants across RUMC were also offered a retention bonus.

Our efforts also focused on securing protected time given the myriad costs of DEI work on those who are asked to carry it out, especially employees of color. This is not only true at RUMC; research shows that UriM/HE faculty generally have greater clinical responsibilities and are more active in diversity efforts than non-UriM/HE faculty (Campbell, 2013; Palepu et al., 2000). This is one of several factors contributing to the ‘minority tax’ in academic medicine, defined as “the tax of extra responsibilities placed on minority faculty in the name of efforts to achieve diversity,” which “impact their recruitment, advancement, and retention” (Campbell, 2021; Rodríguez et al., 2015, Campbell & Pololi, 2015).

After dedicating 0.1 FTE (full-time equivalent) to the chair of our DEI committee in 2020, Pediatrics was the first department at RUMC to offer dedicated effort to support a department DEI chairperson through the chair’s endowment fund, followed more recently by the Department of Obstetrics and Gynecology (OB-GYN). In collaboration with other departments, our committee has asked hospital leadership for a dedicated DEI chairperson for every department at RUMC, and the interim dean is advocating for this to be departmentally funded in the future. In this way, DEI work can be created and salaried as a priority that is recognized as a contribution towards advancement, rather than as a supplemental experience that employees put uncompensated time and effort toward, often at the expense of their primary academic and clinical roles or personal lives.

Establishing department DEI chairpersons across RUMC also encourages collaborations among departments and promotes ongoing learning and improvement, another important aspect of DEI work in AHCs. Partnerships across sections, divisions, and teams represent a meaningful way to make connections, share ideas, and improve the culture of the AHC system at large. Our DEI committee has made efforts to not only connect with others outside our department about DEI-related initiatives, but to lead by example with our own efforts for others to follow. We have presented our efforts to other departments as well as to RUMC’s Racial Justice Action Committee (RJAC), a hospital-level group whose mission is to advance social and racial justice along with health equity at RUMC. We also have partnered with The Rush Center for Gender, Sexuality and Reproductive Health (AFFIRM), an organization that works to provide safe, comprehensive, and affirming care to LGBTQ+ patients and employees at Rush. More recently, our committee connected with physicians in Surgery and Psychiatry to better coordinate similar efforts around creating a faculty reporting system at the hospital level. We remain committed to meaningful partnerships across RUMC that promote equity and inclusion for all employees, as well as the patients that we serve.

2021 Check-in Survey

In response to departmental feedback following our 2020 retreat (i.e., comments made during the retreat to the secretary; comments made in the climate survey), the executive board implemented a new biennial climate check-in survey to more efficiently “check the pulse” of the department. Compared to the climate survey, the check-in survey was shorter (5–10 min to complete), easier to analyze (related questions eliminated or combined), and more specific and purposeful in its approach. Additionally, this survey was intended to better capture participation in DEI events, as well as provide an opportunity for department members to anonymously voice their opinions of the various initiatives put forth by the executive board and subcommittees since the 2020 retreat.

A few positive findings from the inaugural check-in survey included that 76% of respondents agreed that diversity, equity, and inclusion is moving in the right direction in the department and 81% of respondents agreed that the department is a safe and welcoming space for employees and families. A smaller majority, 62% of respondents, described feeling listened to by department/DEI leadership, and 43% of respondents indicated that they had been more engaged with DEI initiatives compared to the past. Qualitatively, some respondents reported that increased efforts by the DEI committee have made it easier to bring up related concerns and have more open dialogues in the department. Many respondents commented feeling grateful that DEI efforts became “more visible” in response to the events of 2020. Others described feeling inspired by grand rounds speakers and having learned a great deal through participation in book clubs and our retreat.

However, several concerning findings emerged from the data as well. First, although the number of respondents (n = 100) was commensurate with participation in the 2017 and 2019 surveys, it was a notable decrease from 2020 and represented a response rate of only 33%. For those who did complete this survey, the majority (62%) were faculty or trainees, meaning that the group who was most critical of the department climate in 2020 (i.e., staff) was largely missed. Although 25% of respondents reported having taken an active role in DEI efforts by volunteering as a subcommittee member, regular participation in DEI-related grand rounds (35%) and book club (11%) was extremely low. When asked to indicate their attendance more specifically for 14 DEI-related events over the past academic year, book club attendance (seven total meetings) ranged from 2 to 20% of respondents and grand rounds attendance (five presentations) ranged from 24 to 35%. Most notably, nearly half (48%) of respondents reported that they regularly have “no DEI involvement.”

When asked to elaborate on what barriers prevented more frequent involvement, several administrative and logistical challenges were identified, including lack of time, scheduling conflicts, and feeling overburdened by their primary work responsibilities (e.g., clinical time, documentation, staffing issues, other meetings). However, beyond these types of challenges, some respondents also described negative feelings (e.g., feeling alienated by the department) or philosophical differences (e.g., describing DEI initiatives as hostile) that led to a more intentional disengagement with the DEI curriculum. This begs these questions for leadership: which types of barriers are most easily changed in the short-term via allocation of additional resources, and how do we overcome barriers related to the attitudes and beliefs of those who do not buy-in to the benefits of this work in the long-term?

Concerning trends also emerge when looking closer at the department culture data. In response to the question regarding DEI moving in the right direction in the department, 8% disagreed and 16% described feeling neutral. In addition to addressing those who disagreed, more critically analyzing the ambivalence of the 16% is crucial. Do these respondents feel indifferent because they lack awareness of the prevalence and impact of institutional oppression in the department and in medicine more generally? Or are they aware yet burnt out, feeling helpless or lacking faith in leadership’s ability to enact real change? A comment from a subcommittee member raises this exact issue, as they noted that putting in hours of work related to identifying an adequate reporting system without seeing tangible change “takes the wind out of our sails.”

Similar questions arise during analysis of the remaining questions. Twelve percent of respondents disagreed when asked if they feel listened to by department leadership, and another 26% of respondents described feeling neutral about this. Also requiring attention are the additional 14% of those who replied neutrally when asked if the department is a safe and welcoming space. Of course, burnout, fatigue, or perceptions that there has been a lack of meaningful change in the past may be to blame. However, it is also possible that these department members are afforded the privilege of not needing to speak with leadership about DEI-related matters or needing to consider whether they feel safe or welcomed at work. Regardless of their cause, these findings represent a direct challenge to leadership to continue to work toward meaningful change through initiatives focused on equity and inclusion.

Conclusion and Future Directions

Our DEI committee was established with the aim of improving diversity in the Department of Pediatrics while simultaneously improving our culture to become more equitable and inclusive. We have made progress over the past several years but recognize that the work must continue. Although we have observed significant increases in URiM/HE new hires, faculty and staff members who identify as URiM/HE remain minoritized in our department and comprise a disproportionate majority of our attrition. Our residency recruitment subcommittee has successfully integrated several DEI initiatives into our program; however, our metrics remain lower than our targets. Although we are proud of the range and depth of educational opportunities we provide through grand rounds, book clubs, and retreats, barriers to greater departmental participation remain. While our operationalization subcommittee has been successful in changing some policies and fostering collaboration, our reporting system is a work in progress and our RJ work is in its infancy. Our climate surveys have shed light on several positive aspects of our department yet has also highlighted several ongoing barriers to DEI work, harassment and discrimination experienced by URiM/HE department members, as well as a difference in opinion across department members related to DEI efforts and their perceived importance.

Although difficult work remains, we believe it is important to highlight that engaged leadership has been a primary reason for the successes we have experienced. As outlined, the chair of Pediatrics sits on our DEI executive board and has made clear that DEI initiatives are a priority through (1) creative, economical, and flexible use of funds and (2) positive relationships with hospital finance and leadership. Through actions such as using the chair’s endowment money to fund speakers and trainings, planning months in advance to block schedules for the retreat, meeting with various administrators and leaders throughout the AHC to build the case for DEI-related resources, and advocating for protected FTE time, hospital leadership has received the message that this work is important to our department. Importantly, RUMC as a system embraces DEI efforts, which we know may not be the case at all institutions. In addition to frequently corresponding with employees about DEI-related current events and opportunities to celebrate diversity (i.e., Pride, Black History month), RUMC recently established the RUSH BMO Institute for Health Equity, an institution focused on funding education and training programs, school-based health centers, and community outreach and research initiatives meant to address health inequities.

Unfortunately, the systemic issues reviewed here do not only negatively impact our departmental climate; they also negatively impact the patients and communities that AHCs serve. A stark example of this was discussed in a recent study which found that racial concordance between Black infants and their physicians cuts infant mortality in half, especially in complicated cases as well as in hospitals that treat more Black infants (Greenwood et al., 2020). This is especially relevant for RUMC, given that its primary service area includes several predominantly Black neighborhoods and that our state-of-the art neonatal intensive care unit treats many medically complex children. Despite these realities, as previously mentioned, less than 10% of our Pediatric faculty members currently identify as Black. Although only one example of many, this disparity highlights the urgent need for a continued emphasis on DEI initiatives in AHCs. We have an obligation to ensure equitable healthcare is available for all who seek out our institutions.

Our findings demonstrate how vitally important it is for DEI initiatives to extend beyond recruiting people with diverse identities into our institutions to place equal, if not greater, emphasis on creating an inclusive culture that will cultivate success and a desire to stay in the RUMC community for those who work here. AHCs with successful DEI initiatives develop comprehensive strategies that are driven by institutional leadership; they are inclusive and centering of the most marginalized voices and, most importantly, they are transformative. As an anchor, commitment to these initiatives should include cluster hires (Valantine, 2020), dedicated budgets, autonomy, consideration for leadership roles, pathways for advancement for URiM/HE employees, and sufficient compensated FTE for DEI-related roles. However, initiatives providing only these basic supports are unlikely to produce meaningful and sustained changes to institutional culture. A commitment to doing this work is, categorically, a commitment to changing the institutional structures from the inside out, as this work cannot effectively occur in the absence of substantive change.

Several AHCs, including RUMC, were recently featured in a piece highlighting successful strategies to confront racism in healthcare by centering equity as a foundation (Hostetter & Klein, 2021). These strategies included the invaluable role of metrics as a tool in this work, engaged leadership, the need for safety and anonymity in reporting systems, and accountability for those engaging in harmful behaviors or failing to participate in DEI initiatives. For example, at Penn State, a digital platform is being piloted that allows employees to report racism anonymously and in real time. In its first two weeks of use, nine reports were generated using the program with 15 people reporting from a single department. At UCLA, an equity dashboard monitors a variety of metrics, including racial and other differences across hiring, promotion, training, contracting, patient and employee grievances, and vendors providing goods and services, and is reviewed by an equity council monthly.

This work requires tremendous courage. It requires pulling back the veneer and examining the source of deeply entrenched structural oppression and inequity. This is necessary work for healthcare institutions that endeavor to be equitable in their care delivery because it starts with equity inside the institution. It is not enough to declare our DEI values in mission statements. We must also demonstrate our commitment with actions that reflect these values. This means actively dismantling current harmful structures, and reimagining and rebuilding a health system that values those marginalized based on race or gender, those with disabilities, those who prefer care in a language other than English, and all other variations of marginalization that occur in our health system. This can be accomplished, but it will certainly mean making uncomfortable choices: choices about redistribution of resources, money, and power to be more just and equitable. It will require rebuilding our healthcare system to decentralize experiences and ideas that advance dominant culture so that marginalized groups are appropriately represented, evaluated, and cared for in our hands.