Implementation
The VA has begun initiating I*DEA concepts in its workforce, starting with the establishment and usage of Special Emphasis Programs.36 The goal of these programs is to increase the employment of historically marginalized groups, including women, people belonging to racial and ethnic minorities, people with disabilities, and individuals identifying as LGBTQ+.28,37-42 For example, each federal agency has a designated Federal Women’s Program whose responsibilities include helping with the recruitment and advancement of female employees.37
The VHA also has an affirmative action plan with goals for recruiting and retaining individuals with disabilities.28 To strengthen equity and inclusion, the VHA offers multiple educational courses (some mandatory), both virtual and in-person, on topics such as understanding microaggressions, managing implicit bias, and understanding the importance of gender and generational diversity.43 Creating awareness and addressing misconceptions about veteran demographics at VA medical centers is important, as is enhancing awareness among the physician workforce about VA strategies and action plans to increase I*DEA. The VHA has hired officers specifically tasked with focusing on these initiatives.
Workforce Strategies
It is important to recognize overlaps between organizational ethics, quality improvement, and I*DEA initiatives. Establishing an I*DEA Council to ensure the delivery of quality care to veterans is commendable. At the facility level, individual I*DEA officers can make observations and recommendations but are not empowered to effect change. Without participation and buy-in from individuals in leadership positions, the efficacy of I*DEA initiatives is limited.
We propose implementing simple strategies to enhance the inclusion of diverse ideas and perspectives, equity of opportunities, and accessibility to clinical leadership roles within the VHA (Table 2). A competitive selection process with specific, objective criteria to enable the selection of qualified clinical leaders is vital. Specific achievements in or contributions to quality improvement, education, research, professional publications, or diversity enhancing efforts should be required qualifications for clinical leadership roles.44
Establishing term limits for clinical leadership positions—something already being implemented at the National Institutes of Health—would be of tremendous value in the VHA.45-47 Term limits would facilitate I*DEA initiatives and accessibility of leadership roles to qualified clinicians fromvarious demographics. Improving diversity of thought among clinical leaders is especially important, given how buy-in from leadership is critical in transforming the culture of an organization. Term limits would enable access to leadership roles for forward thinking, qualified clinical leaders who could institute and support changes that would promote continuous process improvement initiatives. Leaders could have the option to reapply following the completion of a term, with the ability to demonstrate specific achievements.
Another strategy for increasing equity is to ensure transparency of committee structures, with the rotation of committee members and term limits set for committee chairs whenever possible. This provides access to leadership roles, which enables participation in decision making processes. Residents and fellows who work and train at VA hospitals should have awareness of the facility’s organizational structure and the ability to participate in certain committees. The VHA workforce should be regularly informed about educational opportunities, leadership openings, and I*DEA initiatives to increase their access and use.
Exit interviews for clinicians leaving the VA would enable feedback, provide focused reviews of any problematic issues that need to be addressed, and serve as assessments of organizational ethics.48 Transparency and truth telling could be encouraged by having these exit interviews conducted by staff in the human resources department or others outside the home department of the departing clinician.
Mentorship has played a significant role in exposing individuals from historically underrepresented groups to careers in health care, while also advancing and enhancing their careers after they become health care professionals.49-51 Implementing and publicizing VA and veteran health care-focused mentorship and volunteer programs targeted at local communities, rural areas, schools, undergraduate programs, and medical students could increase the likelihood that students and trainees from these groups are exposed to the VHA which may lead them to join the workforce.
Conclusions
Veterans receiving care from the VHA are becoming increasingly diverse. I*DEA strategies could optimize the VHA workforce and enhance the provision of quality care for veterans. The inclusion of diverse perspectives and backgrounds, equity of opportunities, and accessibility to leadership positions is important. Careful selection of qualified clinical leaders within the VHA—with established term limits for leadership positions, rotation of committee chairs and members, and exit interviews to obtain insights from clinicians who leave the VHA—all align with these strategies. This will foster energy and culture change, create an environment conducive to collaboration, learning, and professional growth and will enable continuous process improvement within individual VA medical centers.