POLICY BRIEF Advancing the diversity and inclusion agenda in healthcare organizations: The case of German university hospitals

Introduction: Diversity and inclusion (D&I) challenges in the hospital workforce continue to pose threats to an inclusive work environment. Acknowledging the benefits of a diverse and inclusive healthcare workforce, the Association of German University Hospitals signed the German Diversity Charter to encourage its member hospitals to apply policies to cultivate such a workplace. This policy brief explores the implementation of D&I policies aligned with the Charter in six university hospitals in Germany, aiming to identify the policy gaps and provide recommendations for improvement. Policy Options: The Charter´s commitments include a shared organizational vision of D&I as a source of great potential and the significant support of the senior management. It also includes D&I in employment processes, open communication about policies, and active employee engagement. Overall, a comprehensive D&I strategy has been shown to be vital for sustainable change. However, not all the hospitals have signed it, nor do all fully adhere to its policies. Therefore, recommendations are provided for the Association to support their constituents in working toward comprehensive D&I policies. Recommendations: Most importantly, the Association should further promote D&I awareness, enhance the support to the hospitals to improve D&I activities, and lead and monitor the implementation and outcomes of the adopted D&I strategies and policies. The comprehensive approach includes transparency; measurement and evaluation to assess the successes and failures of the strategies; the commitment by senior management to D&I efforts; and bottom-up involvement for employees to share their concerns and get involved.


Introduction
Numerous studies show that workforce diversity improves both the effectiveness and performance of an organization (1).This is no different in the field of healthcare.A diverse and inclusive healthcare workforce is the key to better patient-centred care.The diverse patient population has the right to be treated with inclusive and quality care, and a diverse healthcare workforce is a perfect facilitator to achieve this goal.These efforts are generally initiated at university hospitals as these organizations are the powerhouses of health advancement.Germany is in a unique situation as it has been experiencing a sharp increase of foreign physicians from 5,3% in 2010 to 13,7% in 2020.By 2030, it will need another predicted 160,000 (3).The Association of German University Hospitals acknowledges the importance of fostering a diverse healthcare workforce along with the accompanying challenges.They aimed to address these challenges by signing the Diversity Charter.However, not all the hospitals within the association have signed it.This charter, launched in 2006 by four German companies, provides the main building blocks for the cultivation of a diverse and inclusive workplace (4).This policy brief aims to identify potential policy gaps in broad acceptance and compliance of the Diversity Charter by all German university hospitals.Recommendations on how to further promote and integrate the Charter's tenets into the hospitals' overarching strategies are also provided.To accomplish this, this policy brief focuses on six of the largest university hospitals in Germany: Uniklinik RWTH Aachen, Klinikum der Universität München, Universitätsklinikum Hamburg-Eppendorf, Universitätsklinikum Carl Gustav Carus Dresden, Universitätsklinikum Frankfurt am Main, and Charité Berlin.It focuses on the dimensions of diversity and inclusion (D&I), associated challenges, and current strategies.It then provides a checklist to assess to what extent the aforementioned institutions adhere to the Charter.In the end, this policy brief provides recommendations to the senior management of the Association of German University Hospitals on how to improve the acceptance and compliance with the Diversity Charter; how to promote current D&I policy options; and how to fully integrate these into their D&I strategies.

Context
As the world continues its quest for globalization, entire societies and cultures are seeing a population shift to more heterogeneous in terms of ethnicity, origin, languages spoken, and many other dimensions of diversity.D&I work as a team.Diversity is "the mixture of attributes within a workforce that in significant ways affect how people think, feel, and behave at work" along with "their acceptance, work performance, satisfaction, or progress in the organization", whereas inclusion "focuses new attention on the policies, practices, and climate of the workplace-the workplace culture-that shapes the experiences of employees with those characteristics" (5).Inclusion is the key to successfully leveraging diversity through the empowerment of others by respecting, appreciating, and valuing differences (6).The Dimensions of Diversity Wheel is a common way to illustrate the intertwining nature of diversity (Figure 1).It shows some of the key dimensions and the importance of understanding this intersectionality across the multiple dimensions that influence an individual's identity (7).Core dimensions are central to one's personal experience and have a long-term, direct impact on our lives.They are the dimensions with which we identify ourselves most strongly.Many of these aspects are more difficult to consciously modify (8).Though some of them may naturally evolve and be altered throughout our lives, the way we interpret them is frequently established during childhood and has a lasting impact on one's perceptions of identity (7).
A greater degree of self-determination to change accompanies secondary dimensions.Core dimensions and secondary dimensions are inextricably linked (7).For instance, one's country of origin can have an impact on earnings.In 2021, the median wage of a full-time employee with German citizenship was 3,541€ per month.However, foreigners in Germany earned significantly less than German citizens, which was an average of 2,638€ (9).Organizational dimensions are also linked to core and secondary dimensions.They influence how employees approach their work and interact with people in the working environment (7).The presented approach shows that D&I dimensions are cross-cutting.As the population continues to diversify, the ever-growing demand for a diverse healthcare workforce grows (8).D&I in the healthcare workforce is important for three main reasons.First, it is representative of population composition and, as such, it helps expand access to and quality of care for all population groups.Second, by enriching the team of stakeholders and policymakers by including more diverse viewpoints, it offers a fertile context for further exploring ways for improving the performance and quality of healthcare services at both workforce and patient levels.Third, it helps to cultivate a more equitable healthcare landscape by improving trust and empathy while strengthening the connection with patients and communities (10).Organizations that foster a diverse and inclusive workplace are more adaptable, innovative, and promising in terms of career advancement for employees (11).However, incorporating D&I into the workplace is not easy.It needs thorough consideration to address potential biases.One major challenge to D&I is that it is difficult to define in objective and quantitative terms.As D&I have so many different dimensions, it is challenging to know exactly what to measure.Many facets of diversity are intertwined with one's identity.Prioritizing certain components of diversity and measuring them incorrectly might be inherently dangerous if it is perceived that some aspects of identity are more valuable than others (12).Another challenge to D&I is internal resistance, which is mainly caused by the employees' reluctance to change the status quo (13).Hospitals are taking tangible steps towards diversifying their personnel by expanding recruitment to groups that have previously been under-represented.This is driven by a need to account for talent shortages.Even in nations with diverse workforces, members of demographically dominant groups tend to have more influence and face fewer barriers to recruitment and advancements than newcomers.Due to cultural hurdles and a general lack of support, diversity has made limited gains (14).The complexity of D&I in the healthcare workforce has been acknowledged in many hospitals and this is no different in Germany.
To assess the status of D&I strategies in German university hospitals and identify potential room for improvements at policy and implementation levels, an extensive search of the hospital websites was conducted.The current policies of the researched hospitals were then compared to the commitments of the German Diversity Charter signed by the Association of German University Hospitals.Although only published data on hospitals' official websites were used to inform the proposed recommendations, and potential internal information was not possible to access, the recommendations are considered relevant and applicable.

Existing Policy Options
Policy options for a D&I-friendly workplace in German university hospitals should build on existing legal requirements.In Germany, discrimination is prohibited by the "Grundgesetz", the German equivalent of a constitution.This requires employers to have a no-tolerance policy for discrimination of any kind, such as race, ethnicity, gender, religion, disability status, or sexual identity (15).Moreover, it establishes the obligation to dedicate at least one Equal Opportunities Officer for confidential complaints about discrimination in each company.Solely adhering to legal requirements does not assure inclusion.The Diversity Charter, formalized in 2010, is an open commitment to D&I without legal bindingness, and more than 4,000 Much of the literature shows that the formation of a comprehensive strategy, instead of disjointed measures, is most crucial for a successful and sustainable change towards integration (16, 17).Daya (18) highlighted that definitive support from the senior management is also important to the success of the D&I strategy.Another essential factor is the bottom-up involvement of employees, as it empowers and increases internal acceptance of the D&I policies (17).This has been successful at the Universitätsklinikum Hamburg-Eppendorf.The selected hospital in Dresden is an example where a comprehensive strategy for inclusion of all genders has led to success.According to "Medical Women on Top" by the Deutsche Ärztinnenbund in 2016, this hospital had the highest rate of female physicians in senior positions with 43% compared to the German mean of 31% (19).Another important aspect of a comprehensive strategy for D&I is transparency.Transparency consists of communicating the hospitals' D&I policies both openly and accessibly (18).Klingler and Marckmann (3) show that foreign physicians often did not receive transparent information about their future tasks, requirements, and support in the recruitment process.Making the change visible requires regular evaluation of the hospital's D&I performance.Winter (20) presents employee engagement surveys as a useful tool to assess inclusion in the workplace and proposes that unit managers should take the responsibility for the survey results to initiate improvements in their unit.The D&I policies of the six chosen German university hospitals identified after a comprehensive website search are presented in Table 1 below.In this table, the corresponding policy for each hospital is shown.Hospitals are coloured green if they have signed the Charter and red if they have not.The table also illustrates the institutional representative and the involvement of the management level in the strategic approaches.As shown, only two out of the six hospitals have signed the Diversity Charter.All the selected hospitals have at least one Equal Opportunities Officer, as required by law in Germany.However, only three have further staff dedicated to D&I.The selected hospitals in Hamburg and Berlin have a more developed strategy, including a department dedicated to D&I.However, for the hospitals in Aachen, Munich, and Frankfurt it was not possible to find information about the role of management whereas the other three hospitals state full support from the management level.In Aachen, Frankfurt, Munich, and Dresden, the universities have a D&I strategy, but the associated hospitals do not.It is uncertain to what extent the respective hospitals are integrated into the universities' strategies.Table 2 compares the published D&I policies of the six hospitals to the commitments from the German Diversity Charter.These commitments have been divided into six categories, written categories 1-6 in Table 2 (4).Categories 0, 7, and 8 were included additionally for a more detailed understanding and to account for the central role of a comprehensive approach identified in the literature (16).As can be seen above, the selected hospitals adopted D&I policies to a different extent and with a focus on different diversity dimensions (see Figure 1).A clear commitment to diversity was only found on the websites of the hospitals in Hamburg, Berlin, and Dresden.Inclusive human resource management is legally required in Germany through the Federal Equal Treatment Act (15), so all hospitals are considered in adherence to this even if no explicit information could be found.However, it must be noted that human resource processes might not discriminate openly while still not being inclusive (27).External communication of D&I efforts is especially developed at Charité Berlin, where the hospital has a website on all its D&I activities, topics, and representatives.Similarly, Universitätsklinikum Carl Gustav Carus Dresden communicated its commitment to stop gender-related and sexual harassment in easily accessible leaflets on its website.The involvement of employees in the D&I strategy was explicitly mentioned only in Hamburg and Berlin (28).
As visualized in Figure 1, diversity is complex.However, even the hospitals that presented the most extensive strategies, Hamburg and Berlin, did not explicitly mention many of these dimensions.For example, none of the hospitals mentioned a focus on faith.Good practice examples show that diverse religious backgrounds can be valued, for instance, by providing inter-religious praying rooms and by taking scheduled religious practices into account, such as fasting and holidays, when planning schedules (29).From the secondary and organizational dimensions, only parental status was addressed by most of the hospitals as they offer flexible working time and support after coming back from parental leave.The secondary and tertiary dimensions certainly influence the internal working atmosphere and are important to consider while designing diversity strategies.However, explicit strategies and actions focus more on the core dimensions, being the most personal of the dimensions.

Recommendations
This policy brief aims to provide the Association of German University Hospitals with recommendations on how to promote the D&I and to enhance support to its member hospitals to better endorse and implement the D&I policies.Tables 1  and 2 show that all six selected hospitals have already built a base for D&I.However, to achieve strong and sustainable change towards not only diversity but also genuine, long-lasting inclusion, broader measures must be taken.
To accomplish this stated goal, the following policy options, presented in table 3, are recommended.The Association of German University hospitals can support the university hospitals in Germany and lead the process of application of D&I strategies.
A comprehensive approach, which includes the following recommendations: Even if the corresponding universities have already signed, signing explicitly as a hospital would emphasize their commitment to improving their D&I policies.For successful and sustainable change towards integration, a comprehensive, strategic approach instead of disjointed single measures is essential and should be supported by a strong vision and commitment (16,17).Such a comprehensive approach could face internal resistance coming from several sources, including the management since it requires more effort than occasional activities focused on individual dimensions.
However, only a comprehensive strategy will lead to sustainable change (16).The Association of German University Hospitals should take the lead to align the university hospitals into creating a strong D&I vision to move toward sustainable change strategies among the whole organization.

Transparency:
The hospitals should communicate their D&I strategy, along with their actions, in an easily accessible way on their websites.The workforce recruitment and development processes shall follow transparently communicated criteria.The Equal Opportunities Officers of the hospitals should be responsible for publishing the hospital's D&I policy, responsible contact persons, and D&I activities.The management needs to provide adequate time and resources.The human resources department should also be responsible for communicating requirements, tasks, and possible support in a transparent way to all job candidates.

Measurements and Evaluation:
The Association of German University Hospitals should urge all university hospitals to measure the success of their D&I policies in several ways, for example, through employee engagement surveys, publishing a yearly report on D&I activities and progress concerning the Diversity Charter's objectives.In this way, the association should establish a benchmarking system to compare the hospitals' performances, and to allow them to learn from best practice examples as well as to inform the public.The visibility and comparability through this benchmarking system will further motivate the hospitals to improve D&I performance.A well-developed D&I program makes hospitals more attractive for aspiring health professionals (29).

Commitment by senior management:
The senior management should be the main players in the guiding coalition.If they already envision the hospitals' D&I policy, their further support will be easy to obtain.If not, convincing them to adopt a vision of D&I and to show commitment and leadership to it is essential for the success of a further change (18).Leveraging the benefits of D&I in the argument, for instance by highlighting its positive impact on the hospital's attractiveness to patients, the most talented health workforce, and the overall performance of the hospital helps sell the management that the development of a D&I policy is a valuable investment.

Employee engagement:
Employees of all levels should be encouraged to share their suggestions and concerns.This way, employees feel part of the change (17).Hence, broad internal acceptance of D&I policies will grow and Establishing networks as places of exchange and empowerment is especially valuable for employees of minority populations.Internal opposition against D&I from employees is one of the greatest challenges for inclusion as this creates resistance towards employees belonging to minority groups and jeopardizes D&I activities.This can be combated by being transparent in the D&I policies and by communicating that diversity values everyone for their differences, not only minorities.German university hospitals have already started on the road towards a diverse and inclusive working environment.However, to achieve considerable and sustainable success in creating an inclusive workplace, and to attract and retain an excellent healthcare workforce, a comprehensive D&I strategy is needed.This strategy should be based on the principles of transparency, regular measurements, and evaluations, a strong commitment by the senior management as well as bottom-up involvement of employees.The Association of German University Hospitals has the position to lead the hospitals in this process.

Conclusion
A compliance gap between the D&I policies proposed by the Diversity Charter in Germany and the policies of the university hospitals in Germany was identified and considered critical for their overall performance.It is recommended to the Association of German University Hospitals to further promote the D&I awareness in the health workforce and to facilitate the university hospitals in Germany to apply a comprehensive implementation framework.This includes transparency, measurements, and evaluation of the applied D&I policies, senior management commitment, and bottom-up involvement of all employees.This will help to further advance the D&I agenda in the university hospitals in Germany and foster an equitable, inclusive, and sustainable healthcare landscape for all.

Figure 1 :
Figure 1: Dimensions of Diversity Wheel: A common way to illustrate the complexity of the concept of diversity.Core, secondary, and organizational dimensions are inextricably linked and impact one another.Empty spaces in the figure indicate that different components of dimensions are not set and can be changed depending on an individual (7) Gobianidze, M., Hammond, J., Jürgens, K. & Reisser, K. Advancing the diversity and inclusion agenda in healthcare organizations: the case of German university hospitals (Policy brief).SEEJPH 2022, posted: 23 June 2022. .DOI: 10.11576/seejph-5600 P a g e 5 | 14 Gobianidze, M., Hammond, J., Jürgens, K. & Reisser, K. Advancing the diversity and inclusion agenda in healthcare organizations: the case of German university hospitals (Policy brief).SEEJPH 2022, posted: 23 June 2022. .DOI: 10.11576/seejph-5600 P a g e 6 | 14 companies have signed it (4).It establishes six main commitments.The Charter calls for the creation of an environment where everyone shares the value of mutual respect; recommends an evaluation of the inclusion of diversity in the workforce recruitment and development processes; emphasizes the shared understanding of diversity as a source of great potential; enables both internal and external dialogue about D&I strategy; supports open communication about D&I activities and progress, and reinforces the idea that companies must actively engage employees in their D&I strategy.

Transparency•
Strategies should be easily accessible • Processes should be transparent Measurement and evaluation of strategies • Measure the success of strategies through surveys and feedback forms • Comparison of the results with other hospitals Commitment by senior management • Inclusion of the senior management in the guiding coalition Bottom-up involvement of employees • Employees should share their suggestions or concerns • Establishing support and exchange networks Gobianidze, M., Hammond, J., Jürgens, K. & Reisser, K. Advancing the diversity and inclusion agenda in healthcare organizations: the case of German university hospitals (Policy brief).SEEJPH 2022, posted: 23 June 2022. .DOI: 10.11576/seejph-5600 P a g e 11 | 14 Comprehensive strategy: As a first step towards commitment and transparency, all university hospitals should sign the German Diversity Charter.

Table 1 : D&I policies of the university hospitals in Aachen, Munich, Hamburg, Dresden, Frankfurt am Main, and Berlin:
Analysis of adherence to the Diversity Charter, current D&I policies, current D&I institutional representative and involvement of hospital leadership Gobianidze, M., Hammond, J., Jürgens, K. & Reisser, K. Advancing the diversity and inclusion agenda in healthcare organizations: the case of German university hospitals (Policy brief).SEEJPH 2022, posted: 23 June 2022. .DOI: 10.11576/seejph-5600 UKE Inside: part of the strategic goals & human resources department:Established infrastructure to communicate the strategy with all employees via newsletter, flyer, information office, e-book Vision: D&I is always a work in progress Goals of the strategy: participation of all employees;

Charité Berlin (26) Signed in 2013 Special
website on diversity and inclusion (diversity network)Gender: In 2014 on place 4 of the best employers for gender equity: Frauen-Karriere-Index (quantitative index

Table 2 : D&I policy adherence:
Extend to which the selected university hospitals adhere to the D&I policies as proposed by the German Diversity Charter

Table 3 :
Policy Recommendations: A comprehensive, holistic D&I approach with a particular focus on transparency, measurement, and evaluation, a commitment by senior management, and bottom-up involvement of employees