Information about participant’s self-described characteristics and backgrounds is displayed in Table 1. The categories for these demographics use the participant’s own terms from the interview—as such, every term in the table comes directly from study respondents’ direct response to question 1 of the interview guide. Interviewees were mostly Black, majority female, and mostly heterosexual and had a variety of degree backgrounds and direct supervisors.

Table 1 Self reported identities and backgrounds of participants

The main finding of our study is the operationalization of how organizations are implementing DEIB interventions and identifying the role of the DEIB leader within the context of DEIB interventions. We identified context-specific implementation strategies which are unique to the implementation of DEIB organizational interventions compared to traditional organizational interventions related to organizational change.

We identified the DEIB leader as the champion of the implementation strategies and identified five strategies which describe the role of DEIB top-level leaders within DEIB intervention implementation: (1) People, (2) Health Equity, (3) Monitoring and Feedback, (4) Operational Planning and Communication, and (5) External Partners. Of these five, People, Monitoring and Feedback, and External Partners aligned with the theoretical framework we used to frame and understand the DEIB organizational interventions, top-level DEIB leaders, and DEIB implementation strategies. Health Equity, Operational Planning, and Communication were found to be specific and unique compared to the original framework where Okumus described how organizations implement interventions. These unique strategies explain the complexities of DEIB interventions and implementation strategies as compared to traditional implementation strategies adopted by organizations. Within these processes, we identified 19 significant initiatives for which DEIB leaders were responsible within an implementation strategy in this space, which have previously never been identified within the field of strategy implementation, implementation science, or studies examining the roles of DEIB top-level leaders. Our findings synthesize the operational processes that were present throughout the sample, but not necessarily in every healthcare organization’s DEIB implementation process. The results of our findings are described in detail using illustrative quotes, within the body of this section of the manuscript. Next, we also present these findings in Table 2 where we provide examples of each strategy, a mapping of the DEIB strategies to the ERIC discrete implementation strategies, and identify relevant literature related to each activity [32]. We mapped the DEIB strategies to the ERIC discrete implementation strategies to support the consistent classification of strategies throughout implementation science as well as to ensure readers understood the mechanisms adopted by DEIB top-level leaders within the context of implementation science.

Table 2 Implementation strategies, examples, and relevant literatureDEIB leader as the champion

DEIB Leaders stated that their primary responsibility within the organization was managing and driving all DEIB strategy efforts throughout the organization. They described that they were often hired by their healthcare delivery organization’s board or CEO to lead DEIB work in the organization. For example, one participant stated, “I lead the shaping of our organization as one that values diversity, equity, and inclusion…working around and leading our strategic development, promotion and implementation of a variety of initiatives.” (Participant #10).

DEIB implementation strategies led by the DEIB leaderPeople

This strategy describes a set of DEIB leader responsibilities that relate to a coherent approach to the implementation of DEIB initiatives within the existing human resource management systems of a healthcare delivery organization, as well as aligning the existing human resources systems to support an inclusive and equitable culture within the organization. DEIB leaders described that broadly speaking, a significant component of their position is focused on creating an environment within the organization that is inclusive and enables all individuals to thrive. It was often described that equity must start within the organization as it pertains to how the organization supports its employees. There are four activities within this implementation strategy:

Talent recruitment and retention

DEIB leaders are developing and implementing hiring and retention policies to ensure equitable hiring, recruitment, and retention practices. DEIB leaders described working in partnership with the organization’s existing talent acquisition team to implement human resources policies that align with and facilitate the DEIB strategy.

From a talent acquisition perspective, we want to make sure we have the broadest reach that we possibly can we're casting our net we're focusing on recruiting within our communities, so that the people that we recruit look like the communities that we serve. (Participant #7)

DEIB leaders may also serve as advisors or provide subject matter expertise during the development of employee learning materials (courses, training sessions) that address underlying inequities in talent recruitment and retention practices among organizations.

Employee learning

DEIB leaders oversee the identification of the learning needs of the organization that best support the workforce development germane to achieving the strategic plan. Some participants described working closely with the existing employee learning training infrastructure or team to achieve this.

So, for instance, last year, part of one of our balanced scorecard priorities was providing bias awareness training to all colleagues, so my team in conjunction with our learning and organizational development team select the content and then came up with the method through which we were going to distribute that to people across the system. (Participant #4)

These leaders may also be solely responsible (within their team or themselves) for developing the content and conducting employee trainings. Employee learning opportunities were being used within the DEIB strategy to address the cultural norms within the organization, (e.g., cross-cultural communication) as well as to promote fair and equitable processes within the organization (e.g., implicit bias training).

Employee resource groups

The implementation of organizational DEIB interventions includes the development and support of employee resource groups, which are defined as committees of an organization’s employees who share a common identity and work towards creating a more inclusive work environment. DEIB leaders describe they are responsible for driving the broader utilization of employee research groups within the DEIB strategic context of the organization, alongside overseeing their development, daily functioning, and budget.

I am someone now who can help with that and create a strategic plan for those employee resource groups that is tied to our strategic, [organization’s name] overall strategic plan, so they’re not just clubs hanging around hanging out going to happy hour, they have the business case and business initiative, that are connected to what we do as a system. (Participant #15)

Formal workforce development and talent pipeline

This describes how HCOs developed formalized approaches to recruit and train talent within their organization. DEIB organizational interventions support the development of diverse talent pipelines, which are an important avenue for both new and established employees to build competencies to ensure their skillsets align with future job growth. DEIB leaders oversee the development and transformation of existing leadership development programs, or they are creating talent development programs which are inclusive of individuals from minoritized populations, with the goal of building a foundation to support the organization’s future labor force needs.

We have been able to identify and develop high potential employees, so we are creating a talent pipeline, so trying to figure out like, we have a CEO development program that we want to diversify. And because that we’ve identified our key hospital management positions as those having an opportunity to have more diversity. (Participant #13)

Engaging top-level leaders

This describes how DEIB leaders work to support the development and growth of other top-level leaders in their organization to be able to communicate and engage with the DEIB strategy and issues in the organization.

So, I learned my first year that our leaders were not comfortable. So, this year we’re focused on leadership development around these topics because they’re not comfortable talking about culture, talking about race and ethnicity, talking about inclusion or any of those areas. I mean I'm not saying all leaders, but we got quite a few that are not... (Participant #23)

DEIB leaders describe that to be successful in this activity they work to develop relationships with their peers to build trust. Other top-level leaders may also approach the DEIB leader to coach them on issues related to DEIB.

Health equity

This operational process describes activities of DEIB top-level leaders that aim to advance the organization’s ability to address health equity and disparities in access, outcomes, treatment, and quality of care experienced by patients. A significant component of their role is to align the patient experience with the organization’s mission, vision, and values, which includes health equity and diversity dimensions. These processes and strategies are unique and exclusive enough to DEIB as it warrants the expansion of the original theoretical framework. There are four activities within the health equity operational processes:

Reduce disparities in clinical outcomes, access, and patient experience

DEIB leaders work to identify a systemic approach to reduce disparities in access, quality, and healthcare outcomes. Leaders described that their organization’s DEIB vision prompted them to partner closely with the existing patient experience, quality, and safety, medical, and nursing leadership to develop a clear understanding of the current initiatives, the areas of improvement, approach to monitoring outcomes, access, disparities, and patient experience of patients who are from minoritized communities.

kind of like what the DEI looks like for our patients and families, and then even our community so like, you know, a large scope of my job right now is really thinking about health equity, you know what would that look like for [organization name removed], how do we think about, you know, launching or at least, creating an inventory of all the health equity work across the hospital (Participant #22)

DEIB leaders also described that while there is evidence that disparities exist, the next steps the organization should be taking to reduce disparities are less clear. As a result, DEIB leaders facilitated work groups or committees to identify the outcomes the organization wanted to focus on.

Health equity research

DEIB leaders are developing, strategizing, and building research centers that focus primarily on health equity and advancing the contribution their organization makes to the scholarship in this area.

And I envisioned that the Center for Health Equity would become the research and evaluation arm of this work. Given that we have talent all across campus, my hope is to be able to tap into that talent and interest, including you, obviously, so that we can begin to create a vibrant phase of work of scholarship and in the broad areas of health equity across social and economic, psychological, and physical health domains. (Participant #24)

Language translation services

DEIB leaders are often responsible for the language translation services department and its associated employees. Language translation services describe a process where English translation is provided to patients and family members who do not speak English. DEIB leaders sometimes managed employees within this critical service for patient accessibility and communication, as well as any contracts the organization had as a part of providing translation services.

I am fully responsible for language services across the system, so interpretation and translation. (Participant #19)

Community health outcomes evaluation

DEIB leaders facilitate and oversee a systematic approach for the organization to measure and evaluate the health of the community as it relates to a broad set of health, social, economic, and environmental disparities.

We do robust measurement of the community health, I’ll call it the dashboard that we use that we ourselves developed in partnership with a with a nonprofit organization, is all about underpinnings of equity and health related disparities, so not just medical care disparities, but more particularly social and economic disparities, health behavior disparities, physical environment disparities, as well as disparities and clinical care which is primarily… Access and quality related based on social and economic factors to include race, ethnicity, sexual orientation, gender, all those things, right. (Participant #8)

Such evaluations served to support a broader and more contextualized understanding of the populations served by the organization, as well as to facilitate future DEIB interventions.

Monitoring and feedback

This describes the activities that DEIB leaders do to facilitate informal and formal ways of monitoring activities being carried out during the implementation process.

Board engagement

DEIB leaders frequently present and meet with the organization’s board regarding the status of DEIB strategic plan implementation. This may include seeking their approval, presenting the status of various projects, and requesting input for changes or variations from the original DEIB strategic plan.

Sure, I have presented both to our system level boards and we also have hospital advisory boards that I’ve done some presenting with as well. And so far, because of the timing that has happened virtually, I look forward to the opportunity now that we can start kind of having those meetings in person to be able to do so in person. And so you know I think it’s I was a good experience that I was invited back (Participant #10)

DEIB leaders also expressed that boards are intimately involved and responsible for the implementation of the DEIB strategies/interventions. This type of involvement has supported the DEIB leaders’ ability to drive and lead the execution of the DEIB interventions, as it communicates the importance of the initiatives to other decision-makers in the organization. It also reinforces values, holds other leaders accountable, and can allocate resources to support the work.

DEIB scorecards

DEIB leaders are responsible for identifying and developing items for an already existing scorecard, or for a new scorecard. Scorecards with DEIB measurements help ensure that all leaders within the organization (board, top-level, committees) are aware of the accomplishments and opportunities the organization has with regard to the implementation of the strategy.

So, we have a balanced scorecard that we use to govern our entire organization. In one of the quadrants is the culture quadrant, and so our DE&I and culture data is input into that quadrant. And that is reported out on a quarterly basis, and then on an annual basis. And the metrics in that quadrant drive compensation. (Participant #12)

Listening sessions

Some DEIB leaders lead and facilitate listening sessions between top-level leaders and other employees. These may occur following a major event, such as the murder of George Floyd or Breonna Taylor. The DEIB leaders monitor the external environment and the experience of employees within the organization as well as organizing and facilitating listening sessions when needed.

We did [removed] listening sessions… And it was really leaders that had to get out of their comfort zone because they didn’t know me, and so I was a complete stranger telling them that they had to do something that they’ve never done and do it in a very vulnerable, authentic way because it was a real moment right and so not to oversell what we were going to do, but we accelerated what we had to do because out of those listening sessions. (Participant #18)

Operational planning and communicating

This describes the development of infrastructure, processes, communication channels, and interpersonal relationships that support the implementation of DEIB initiatives. Much of the DEIB leader’s work is predicated on the concept that the organization may need to change processes or policies, or human behaviors that have existed in the organizations for decades. Five activities describe this process:

Negotiating the DEIB leader role

DEIB leaders are constantly working through formal and informal channels to determine and establish what the DEIB top-level leader function should include and how to best position the role in the organization to achieve the organizational strategies. This may include approaching specific opportunities as a trial and error, directly negotiating or making a case to their supervisor for function autonomy and brainstorming with other top-level leaders to determine the best strategies to support the organizational DEIB interventions. Such work is laborious and is related to the evolving scope of DEIB values and strategies in organizations and our society. DEIB leaders were establishing what parts of the work should be completed by their team as opposed to holding another function responsible.

I think my responsibility is to help identify ways to support and amplify the work that’s working that’s going well, and also to measure what’s working well, and to be able to be really transparent about where we need help by looking at the numbers of like retention and things and courses. So but I don’t feel like I’m in it by myself. I feel like everybody is kind of doing stuff, and but they what they really could use is some support in terms of knowing what other people are doing and coordination across all of these different elements (Participant #29)

Building collaborations to support sustainable change

DEIB leaders lead change in their organization by building relationships across the organization. This created trust and buy-in from other leaders, which facilitated the furthering of the DEIB vision.

I would say I wouldn’t have any success if I didn’t have the relationships that I have... and when I mean collaboration, I really want folks to understand that this is critical to not just my role, but also the roles that they are individually serving as well (Participant #17)

Developing DEIB personnel infrastructure

DEIB leaders are building and advocating for the team and personnel needed to support the business systems and organizational change associated with implementing the DEIB strategies/interventions. A central component of achieving organizational change that emblemizes DEIB is the existence of an established team and budget. However, many leaders were constantly reckoning with a lack of resources, which required substantial effort put towards creating a sustainable infrastructure:

So, it’s just a matter of how you organize it, but I would say unequivocally we’re not adequately resourced now based on the breadth of what we want to do, but we do have some open positions that we’re trying to get filled. (Participant #8)

Developing governance structures

DEIB leaders are building infrastructure to guide decision-making within the organization to support DEIB organizational interventions. Each organization has an existing governance structure, which refers to the rules, procedures, roles, and division of responsibilities within a decision-making process and most notably defines the role of the board and executives in decision-making. DEIB leaders work with different stakeholders within the governance structure (e.g., Board, CEO, Committees, Councils) to establish and manage expectations for how these groups will support the DEIB organizational interventions as well as potentially establish and negotiate for new formalized roles and processes when needed.

I’ve recruited a number of individuals to create a governance structure … and so we created a governance of diversity and equity committee for them, share the framework, um, walking hand in hand with them in terms of setting goals for their campus that are aligned with the overarching goals of the equity plan at the organization (Participant #21)

DEIB consultation to support DEIB interventions

DEIB leaders communicate the DEIB initiative implementation plan and encourage implementation through informal communication channels, which frequently involves consultation with other executive function leaders so they can drive implementation of the DEIB strategy.

I’m a part of a huge organization and there’s only two of us, so I can’t lead everything, I can't be a part of everything. So, that’s why I really kind of want to act as a consultant to some of these leaders to help get them up to speed (Participant #13)

External partners

DEIB leaders support the development of processes or policies to support the ways the health delivery system engages with other organizations or community members. Within this, there are two activities: community engagement and supplier diversity.

Community engagement

This is defined as the DEIB leaders working to understand current practices related to community engagement and then identifying ways to improve engagement with people and communities who in the past have been excluded and disenfranchised. To do this, DEIB leaders work alongside the organization’s community engagement team, who are responsible for the application of institutional resources to address issues facing communities they provide healthcare services for. DEIB leaders are responsible for understanding the current practices of these teams and establishing ways that community engagement can be done to support communities which have been excluded or disenfranchised. They also partner with the existing community engagement teams to identify ways that their team can support the DEIB organizational interventions.

I help to inform a strategy, support the synergies that are necessary because what we find is that the community wants certain things, and the hospital designs things in a different way. So, how do we make those much more closely aligned, so that there is more impact for the limited resources that we actually have, both the community in organization. (Participant #21)

Supplier diversity

DEIB leaders partner with the finance and/or purchasing team to implement a supplier strategy that incorporates the sourcing of products, which support their DEIB strategies/interventions, and to grow the percentage of supplier spending among minority-owned businesses or contracts.

The supplier person has kind of a dotted line to me and I consult a lot on the way they’re collecting those kinds of data and then how they’re thinking about a long-term plan for some of our suppliers. (Participant #30)