In recent years, hospitals and medical practices have increasingly recognized that promoting diversity, equity, and inclusion (DE&I) in the workplace is important in many ways: gaining the benefits of different cultural points of view, giving opportunities to clinicians who might otherwise not be recognized, and aiming for fairness in treatment of medical staff and patients.

You have probably already seen in your practice or hospital that there are many efforts to embrace the value of DE&I. An important goal is to create health equity, which assures optimal health and medical treatment for all people. A legacy of health inequity is responsible for widespread health disparities — the variances in incidence, prevalence, mortality, disease burden, and other health problems between different cultural and ethnic groups.

But ingraining DE&I culture in a medical setting is often harder than it seems. Many physicians, administrators, and practice leaders are not sure how to make it happen, and how to have it respected and intuitively understood and implemented into daily practice. It often requires a change of thinking that only comes through sustained effort by medical practice leaders, as well as overcoming ingrained biases of staff members and dealing with those who are skeptical.

The term "DE&I" is an acronym for three words — diversity, equity, and inclusion — that cover a lot of territory. Although the concepts of diversity, equity, and inclusion are related, each has its own important meaning.

Until fairly recently, organizations frequently launched "diversity" initiatives that primarily sought to employ workers from underrepresented groups, such as Black people or women. When it became clear that was insufficient to create needed change, the addition of the word "equity" became commonplace, conveying the importance of fair treatment for all employees.

But diverse representation and equitable practices alone do not ensure that all individuals are valued for their full selves, prompting the addition of the word "inclusion" to create a three-part vision for a diverse workplace.

The terms break down this way:

• Diversity refers to a range of different backgrounds and perspectives. It encompasses race and ethnicity, socioeconomic status, sexual orientation and gender identity, age, religious beliefs, disability status, global locations, cultures, and experiences such as military service.

• Equity in the workplace means that everyone has the same fair chance, the same fair process, and the same fair treatment. This means that each employee is paid fairly and is not discriminated against.

• But equity entails more than that. It requires all employees to have access to the same resources, eliminating the possibility that only a chosen few receive certain privileges or opportunities for advancement or professional growth.

• Equity also means that everyone goes through the same due process when it comes to hiring and performance evaluation.

• Inclusion means that people feel like they belong. Employees feel included when their workplace environment makes it safe for them to show up as their authentic selves and not be judged in a way that makes them feel isolated or different.

• Employees who work in inclusive settings feel comfortable speaking up in meetings and putting their ideas forward. Inclusion means that their ideas are represented and they feel involved in the decision-making process.

Any group that is less represented in a subset — for example, the staff of a medical office — than in the general population is an underrepresented group.

Underrepresented groups are sometimes referred to as underserved, meaning that structural or societal disparities place them at a disadvantage in relation to other groups. An example would be residents of a low-income neighborhood with no healthcare facilities, which makes it harder for them to access medical care than those in well-resourced communities.

The terms "minorities," "underrepresented minorities," and "marginalized populations" are often used as synonyms for underrepresented groups, although that may not always be appropriate. Men are underrepresented in the nursing profession, for example; male nurses may be marginalized in some organizations but not others.

Common examples of marginalized groups include Black and Brown people, Indigenous people, women, individuals with disabilities, people who practice religions that are not dominant in a given culture, LGBTQ+ individuals, senior citizens, and military veterans.

The huge disparities in health and healthcare in the United States that many underrepresented groups experience result from a wide range of social, economic, and environmental factors that includes disparate access to and treatment by healthcare providers.

Embracing DE&I within hospitals and medical practices has long been recognized as one strategy to improve health equity and reduce disparities. Many organizations have been promoting DE&I for years, and some have reaped benefits — for their employees, their patients or customers, and themselves — from their efforts.

But many others have treated DE&I as a box to check off, rather than committing to ongoing and systematic strategies to create a workplace that values diverse individuals and their diverse perspectives. Typical DE&I initiatives have included designating a diversity committee, offering classes on diversity and inclusion topics, and designating an individual to be a DE&I officer.

Although those steps may be appropriate, they are not enough to create real change within an organization's culture. For example, if Black or Brown patients see no one who looks like them in a medical practice, the fact that the practice offered diversity training to their all-White staff may not matter. Similarly, hiring individuals from underrepresented groups may make a practice's diversity numbers look good on paper, but if those individuals are discriminated against, left out of decision-making, or made to feel "less than," the practice —and its patients — don't benefit from their perspectives and ideas.

Across the country, corporations and other organizations have pledged to redouble their efforts to promote DE&I. The healthcare sector, which has been grappling with disparities in both health outcomes and healthcare services for decades, became particularly active.

In 2020, the American Medical Association announced that its newly organized Health Equity Work Group would collaborate with its AMA Center for Health Equity, formed a year earlier. In 2021, the health policy journal Health Affairs published its guide to improve equity in scholarly publishing in health services and launched a new Health Equity Fellowship for Trainees. In early 2022, Health Affairs published a theme issue devoted to racism and health, with an emphasis on structural racism in healthcare.

Earlier this year, the American Hospital Association announced its Health Equity Roadmap, a framework to support efforts of hospitals and health systems to dismantle structural barriers to health.

These and similar initiatives are prompting more medical practices to consider their role in advancing health equity. Embedding DE&I as an organizational value requires clear action to promote change and an ongoing commitment so that everyone in the organization takes ownership of DE&I as a value.

A medical practice that embraces DE&I differentiates itself from other practices in the eyes of its most important constituents.

• Patients who are looking for the right physician are likely to be drawn to a practice where they see others who look like them and where they feel their self-reports, feelings, and values would be embraced.

• Workers in the job market will gravitate to practices in which other employees share their race, age range, disability status, or other identity component.

• Practices that promote DE&I attract a larger talent pool. Having more people with diverse experiences and perspectives in an organization can foster the innovation and collaboration that medical practices need to thrive.

Although promoting DE&I is both a smart business strategy and the right thing to do, certain attributes of DE&I are also required by law.

• Under Title VII of the Civil Rights Act of 1964, it's illegal to discriminate against someone on the basis of race, color, national origin, sex (including pregnancy, sexual orientation, and gender identity), or religion.

Illegal discrimination can occur in many aspects of employment, including hiring and firing; compensation; transfers, promotions, or layoffs; job recruitment; testing; and retirement plans and benefits.

Discriminatory practices include:

• Harassment on the basis of race, color, national origin, sex, or religion.

• Failure to reasonably accommodate an individual's religious observances or practices.

• Employment decisions based on stereotypes or assumptions of an applicant's ability because of race, color, national origin, sex, or religion.

• Denial of employment to a person because of their relationship with an individual of a particular race, color, national origin, sex, or religion.

It's also illegal to retaliate against anyone because the person complained about discrimination, filed a charge claiming discrimination, or participated in an employment discrimination investigation or lawsuit.

• The Age Discrimination in Employment Act of 1969 prohibits age discrimination against people who are age 40 or older. (However, it is not illegal for an employer to favor an older worker over a younger one, even if both workers are at least 40.)

Discrimination must be avoided in hiring, firing, pay, promotions, and all other conditions of employment. It also makes harassment — including derogatory remarks about a person's age — unlawful if it is so frequent or severe that it creates a hostile work environment. Under this law, harassers can be supervisors and co-workers, but also customers.

• The Americans with Disabilities Act of 1990 forbids private and state and local government employers with 15 or more employees from discriminating against qualified individuals with disabilities in hiring, firing, promotion, and other conditions of employment.

If an employee or applicant with a disability can perform the essential functions of a job if they have reasonable accommodation, the employer must accommodate. This can include restructuring a job, adjusting work schedules, or providing qualified readers or interpreters.

• The Pregnancy Discrimination Act of 1978 prohibits discrimination in all aspects of employment and forbids policies that limit or prevent women from doing jobs simply because they are pregnant or of childbearing age. The law covers workplaces with 15 or more employees.

In all cases, medical practice leaders must familiarize themselves with these laws and comply with them. For that reason, embracing DE&I is not only the right thing to do; it also decreases the likelihood of being exposed to the legal ramifications of unfair discrimination.

As a board-certified family physician, Lisa Herbert does speaking engagements with healthcare organizations through her company, Just The Right Balance LLC.