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I*DEA in the VA: Optimizing the Physician Workforce to Enhance Quality of Care
Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”1 To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.
The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.2 One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.
This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.
Veteran Demographics
Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.3 Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.4 Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.5 Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).3
With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.3,6 In addition, about 30% of veterans have ≥ 1 disability.7 About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).8 Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.9 Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.9
Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.11 Female veterans have unique health care needs and report preferences for being treated by female clinicians.17,18
Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.13 Black veterans are also denied VHA benefits more often than White veterans.19 Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.14 Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.20 Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.9
To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.21-25
VA Workforce Demographics
According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.26 Women comprise about 60% of the permanent VA workforce.27 About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).28 Five percent of VA employees identified as LGBTQ+.29
Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.26 Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.26
I*DEA in the VA
The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.30 In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.
Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.31 To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.31
There are several potential benefits of increased I*DEA integration into the health care workforce.21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.
I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.32 This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.
Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.31
It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.35
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.
1. US Department of Veterans Affairs, Office of Research & Development. Health equity. Accessed July 1, 2024. https://www.research.va.gov/topics/health_equity.cfm
2. US Department of Veterans Affairs. Equity action plan. Accessed July 1, 2024. https://department.va.gov/wp-content/uploads/2024/02/Department-of-Veterans-Affairs-Equity-Action-Plan.pdf
3. Schaeffer K. The changing face of America’s veteran population. Pew Research Center. March 2021. Updated November 8, 2023. Accessed May 23, 2024. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population/
4. US Department of Labor, Veterans’ Employment and Training Service. 2021 employment situation of women veterans. Accessed May 23, 2024. http://www.dol.gov/agencies/vets/womenveterans/womenveterans-employment
5. US Department of Veterans Affairs, National Center for Veteran Analysis and Statistics. National survey of veterans (NSV9503). Accessed June 20, 2024. https://www.va.gov/vetdata/docs/surveysandstudies/vetpop.pdf
6. US Census Bureau. Veterans Day 2022: November 11. News release. October 26, 2022. Updated April 4, 2024. Accessed May 23, 2024. https://www.census.gov/newsroom/facts-for-features/2022/veterans-day.html
7. ADA National Network. Employment data for veterans with disabilities. 2017. Accessed June 23, 2024. https://adata.org/factsheet/employment-data-veterans-disabilities
8. LGBTQ+ Veterans. DAV. Accessed July 26, 2024. https://www.dav.org/get-help-now/veteran-topics-resources/lgbtq-veterans/
9. US Department of Veterans Affairs, Office of Rural Health. Rural Veterans. Updated May 14, 2024. Accessed June 20, 2024. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp
10. Mikton C, de la Fuente-Núñez V, Officer A, Krug E. Ageism: a social determinant of health that has come of age. Lancet. 2021;397(10282):1333-1334.
doi:10.1016/S0140-6736(21)00524-9
11. Heise L, Greene ME, Opper N, et al. Gender inequality and restrictive gender norms: framing the challenges to health. Lancet. 2019;393(10189):2440-2454.
doi:10.1016/S0140-6736(19)30652-X
12. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med. 2006;21(6):667-669. doi:10.1111/j.1525-1497.2006.0512.x
13. Carratala S, Maxwell C. Health disparities by race and ethnicity. Center for American Progress. Updated May 11, 2020. Accessed June 23, 2024. https://www.americanprogress.org/article/health-disparities-race-ethnicity/
14. Clemente KAP, Silva SVD, Vieira GI, et al. Barriers to the access of people with disabilities to health services: a scoping review. Rev Saude Publica. 2022;56:64.
doi:10.11606/s1518-8787.2022056003893
15. Krehely J. How to close the LGBT health disparities gap. Center for American Progress. December 21, 2009. Accessed May 23, 2024. https://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap/
16. Dawson L, Frederiksen B, Long M, Ranji U, Kates J. LGBT+ people’s health and experiences accessing care. KFF. July 22, 2021. Accessed May 23, 2024. https://www.kff.org/womens-health-policy/report/lgbt-peoples-health-and-experiences-accessing-care
17. Disabled American Veterans. DAV report spotlights issues facing women veterans. September 12, 2018. Accessed June 23, 2024. https://www.dav.org/learn-more/news/2018/new-report-spotlights-continuing-challenges-facing-women-veterans/
18. Sheahan KL, Goldstein KM, Than CT, et al. Women veterans’ healthcare needs, utilization, and preferences in veterans affairs primary care settings. J Gen Intern Med. 2022;37(Suppl 3):791-798.
doi:10.1007/s11606-022-07585-3
19. Habeshian S. VA denied Black veterans health benefits more often than White vets, data shows. Axios. June 23, 2023. Accessed June 20, 2024. https://www.axios.com/2023/06/23/veterans-benefits-black-white-rate-disproportionate
20. Shipherd JC, Darling JE, Klap RS, Rose D, Yano EM. Experiences in the Veterans Health Administration and impact on healthcare utilization: comparisons between LGBT and non‐LGBT women veterans. LGBT Health. 2018;5(5):303‐311. doi:10.1089/lgbt.2017.0179
21. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006
22. Gill GK, McNally MJ, Berman V. Effective diversity, equity, and inclusion practices. Healthc Manage Forum. 2018;31(5):196-199. doi:10.1177/0840470418773785
23. Balinda IG, Reza N. Diversity, equity, inclusion, and belonging in cardiovascular disease fellowship training. Methodist DeBakey Cardiovasc J. 2022;18(3):67-77. doi:10.14797/mdcvj.1080
24. Parsons SK, Fineberg IC, Lin M, Singer M, Tang M, Erban JK. Promoting high-quality cancer care and equity through disciplinary diversity in team composition. J Oncol Pract. 2016;12(11):1141-1147. doi:10.1200/JOP.2016.013920
25. Stanford FC. The importance of diversity and inclusion in the healthcare workforce. J Natl Med Assoc. 2020;112(3):247-249. doi:10.1016/j.jnma.2020.03.014
26. US Department of Veterans Affairs. Diversity and inclusion strategic plan, fiscal years 2021-2022. Accessed May 23, 2024. https://www.va.gov/ORMDI/docs/StrategicPlan.pdf
27. US Department of Veterans Affairs (VA). US EEOC. Accessed July 1, 2024. https://www.eeoc.gov/federal-sector/department-veterans-affairs-va-0
28. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Individuals with disabilities employment program. Updated August 15, 2022. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/IWD.asp
29. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). VA workforce diversity: FY 2022. Accessed July 1, 2024. https://www.va.gov/ORMDI/Diversity_Inclusion.asp
30. US Department of Veterans Affairs. Same mission, new I-DEA: VA supports inclusion, diversity, equity and access. News release. April 28, 2023. Accessed June 20, 2024. https://news.va.gov/118609/same-mission-va-supports-inclusion-diversity/
31. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion. Inclusion, diversity, equity, & access (I-DEA) action plan. September 2021. Accessed June 20, 2024. https://www.va.gov/ORMDI/docs/VA_I-DEA_Action_Plan-SIGNED.pdf
32. Sue DW, Alsaidi S, Awad MN, Glaeser E, Calle CZ. Disarming racial microaggressions: microintervention strategies for targets, White allies, and bystanders. Am Psychol. 2019;74(1):128-142. doi:10.1037/amp0000296
33. Cruz D, Rodriguez Y, Mastropaolo C. Perceived microaggressions in health care: a measurement study. PLoS One. 2019;14(2):e0211620. doi:10.1371/journal.pone.0211620
34. Ehie O, Muse I, Hill L, Bastien A. Professionalism: microaggression in the healthcare setting. Curr Opin Anaesthesiol. 2021;34(2):131-136. doi:10.1097/ACO.0000000000000966
35. US Department of Veterans Affairs. VA all employee survey. Accessed May 23, 2024. https://www.data.va.gov/stories/s/VA-All-Employee-Survey-AES-/r32e-j4vj/
36. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion. Special emphasis programs (ORMDI). Updated May 3, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Special_Emphasis_Programs.asp
37. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Federal women’s program. Updated August 9, 2022. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/FWP.asp
38. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Hispanic Employment program. Updated May 16, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/HEP.asp
39. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). American Indian & Alaska Native Program. Updated September 27, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/AIAN.asp
40. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Asian American, Native Hawaiian and Pacific Islander program. Updated September 27, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/AAPI.asp
41. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Black/African American program. Updated May 3, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Black_African_American.asp
42. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). LGBTQ+ program. Updated May 21, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/LGBT.asp
43. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Diversity, equity and inclusion training. Updated March 18, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Diversity_Inclusion_Training.asp
44. Rotenstein LS, Reede JY, Jena AB. Addressing workforce diversity - a quality-improvement framework. N Engl J Med. 2021;384(12):1083-1086. doi:10.1056/NEJMp2032224
45. Beeler WH, Mangurian C, Jagsi R. Unplugging the pipeline - a call for term limits in academic medicine. N Engl J Med. 2019;381(16):1508-1511. doi:10.1056/NEJMp1906832
46. Smith DG. Term limits in academic public health administration. Public Health Rep. 2020;135(6):859-863. doi:10.1177/0033354920954495
47. Kaiser J. Shake-up at NIH: Term limits for important positions would open new opportunities for women, minorities. science.org. May 2, 2019. Accessed May 23, 2024. https://www.science.org/content/article/shakeup-nih-term-limits-important-positions-would-open-new-opportunities-women
48. Giacalone RA, Jurkiewicz CL, Knouse SB. Exit surveys as assessments of organizational ethicality. Public Pers Manage. 2003;32(3):397-410. doi:10.1177/009102600303200306
49. Bonifacino E, Ufomata EO, Farkas AH, Turner R, Corbelli JA. Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review. J Gen Intern Med. 2021;36(4):1023-1034. doi:10.1007/s11606-020-06478-7
50. Brown IM. Diversity matters: mentorship is the missing ingredient in DEI. Emergency Medicine News. 2021;43(8):28. doi:10.1097/01.EEM.0000771148.76632.35
51. Sinha A, Kuy S. The future of surgery - increasing diversity, equity, and inclusion through early mentorship. Am J Surg. 2023;225(4):800-802. doi:10.1016/j.amjsurg.2022.12.011
Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”1 To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.
The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.2 One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.
This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.
Veteran Demographics
Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.3 Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.4 Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.5 Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).3
With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.3,6 In addition, about 30% of veterans have ≥ 1 disability.7 About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).8 Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.9 Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.9
Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.11 Female veterans have unique health care needs and report preferences for being treated by female clinicians.17,18
Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.13 Black veterans are also denied VHA benefits more often than White veterans.19 Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.14 Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.20 Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.9
To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.21-25
VA Workforce Demographics
According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.26 Women comprise about 60% of the permanent VA workforce.27 About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).28 Five percent of VA employees identified as LGBTQ+.29
Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.26 Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.26
I*DEA in the VA
The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.30 In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.
Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.31 To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.31
There are several potential benefits of increased I*DEA integration into the health care workforce.21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.
I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.32 This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.
Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.31
It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.35
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.
Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”1 To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.
The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.2 One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.
This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.
Veteran Demographics
Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.3 Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.4 Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.5 Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).3
With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.3,6 In addition, about 30% of veterans have ≥ 1 disability.7 About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).8 Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.9 Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.9
Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.11 Female veterans have unique health care needs and report preferences for being treated by female clinicians.17,18
Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.13 Black veterans are also denied VHA benefits more often than White veterans.19 Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.14 Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.20 Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.9
To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.21-25
VA Workforce Demographics
According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.26 Women comprise about 60% of the permanent VA workforce.27 About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).28 Five percent of VA employees identified as LGBTQ+.29
Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.26 Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.26
I*DEA in the VA
The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.30 In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.
Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.31 To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.31
There are several potential benefits of increased I*DEA integration into the health care workforce.21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.
I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.32 This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.
Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.31
It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.35
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.
1. US Department of Veterans Affairs, Office of Research & Development. Health equity. Accessed July 1, 2024. https://www.research.va.gov/topics/health_equity.cfm
2. US Department of Veterans Affairs. Equity action plan. Accessed July 1, 2024. https://department.va.gov/wp-content/uploads/2024/02/Department-of-Veterans-Affairs-Equity-Action-Plan.pdf
3. Schaeffer K. The changing face of America’s veteran population. Pew Research Center. March 2021. Updated November 8, 2023. Accessed May 23, 2024. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population/
4. US Department of Labor, Veterans’ Employment and Training Service. 2021 employment situation of women veterans. Accessed May 23, 2024. http://www.dol.gov/agencies/vets/womenveterans/womenveterans-employment
5. US Department of Veterans Affairs, National Center for Veteran Analysis and Statistics. National survey of veterans (NSV9503). Accessed June 20, 2024. https://www.va.gov/vetdata/docs/surveysandstudies/vetpop.pdf
6. US Census Bureau. Veterans Day 2022: November 11. News release. October 26, 2022. Updated April 4, 2024. Accessed May 23, 2024. https://www.census.gov/newsroom/facts-for-features/2022/veterans-day.html
7. ADA National Network. Employment data for veterans with disabilities. 2017. Accessed June 23, 2024. https://adata.org/factsheet/employment-data-veterans-disabilities
8. LGBTQ+ Veterans. DAV. Accessed July 26, 2024. https://www.dav.org/get-help-now/veteran-topics-resources/lgbtq-veterans/
9. US Department of Veterans Affairs, Office of Rural Health. Rural Veterans. Updated May 14, 2024. Accessed June 20, 2024. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp
10. Mikton C, de la Fuente-Núñez V, Officer A, Krug E. Ageism: a social determinant of health that has come of age. Lancet. 2021;397(10282):1333-1334.
doi:10.1016/S0140-6736(21)00524-9
11. Heise L, Greene ME, Opper N, et al. Gender inequality and restrictive gender norms: framing the challenges to health. Lancet. 2019;393(10189):2440-2454.
doi:10.1016/S0140-6736(19)30652-X
12. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med. 2006;21(6):667-669. doi:10.1111/j.1525-1497.2006.0512.x
13. Carratala S, Maxwell C. Health disparities by race and ethnicity. Center for American Progress. Updated May 11, 2020. Accessed June 23, 2024. https://www.americanprogress.org/article/health-disparities-race-ethnicity/
14. Clemente KAP, Silva SVD, Vieira GI, et al. Barriers to the access of people with disabilities to health services: a scoping review. Rev Saude Publica. 2022;56:64.
doi:10.11606/s1518-8787.2022056003893
15. Krehely J. How to close the LGBT health disparities gap. Center for American Progress. December 21, 2009. Accessed May 23, 2024. https://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap/
16. Dawson L, Frederiksen B, Long M, Ranji U, Kates J. LGBT+ people’s health and experiences accessing care. KFF. July 22, 2021. Accessed May 23, 2024. https://www.kff.org/womens-health-policy/report/lgbt-peoples-health-and-experiences-accessing-care
17. Disabled American Veterans. DAV report spotlights issues facing women veterans. September 12, 2018. Accessed June 23, 2024. https://www.dav.org/learn-more/news/2018/new-report-spotlights-continuing-challenges-facing-women-veterans/
18. Sheahan KL, Goldstein KM, Than CT, et al. Women veterans’ healthcare needs, utilization, and preferences in veterans affairs primary care settings. J Gen Intern Med. 2022;37(Suppl 3):791-798.
doi:10.1007/s11606-022-07585-3
19. Habeshian S. VA denied Black veterans health benefits more often than White vets, data shows. Axios. June 23, 2023. Accessed June 20, 2024. https://www.axios.com/2023/06/23/veterans-benefits-black-white-rate-disproportionate
20. Shipherd JC, Darling JE, Klap RS, Rose D, Yano EM. Experiences in the Veterans Health Administration and impact on healthcare utilization: comparisons between LGBT and non‐LGBT women veterans. LGBT Health. 2018;5(5):303‐311. doi:10.1089/lgbt.2017.0179
21. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006
22. Gill GK, McNally MJ, Berman V. Effective diversity, equity, and inclusion practices. Healthc Manage Forum. 2018;31(5):196-199. doi:10.1177/0840470418773785
23. Balinda IG, Reza N. Diversity, equity, inclusion, and belonging in cardiovascular disease fellowship training. Methodist DeBakey Cardiovasc J. 2022;18(3):67-77. doi:10.14797/mdcvj.1080
24. Parsons SK, Fineberg IC, Lin M, Singer M, Tang M, Erban JK. Promoting high-quality cancer care and equity through disciplinary diversity in team composition. J Oncol Pract. 2016;12(11):1141-1147. doi:10.1200/JOP.2016.013920
25. Stanford FC. The importance of diversity and inclusion in the healthcare workforce. J Natl Med Assoc. 2020;112(3):247-249. doi:10.1016/j.jnma.2020.03.014
26. US Department of Veterans Affairs. Diversity and inclusion strategic plan, fiscal years 2021-2022. Accessed May 23, 2024. https://www.va.gov/ORMDI/docs/StrategicPlan.pdf
27. US Department of Veterans Affairs (VA). US EEOC. Accessed July 1, 2024. https://www.eeoc.gov/federal-sector/department-veterans-affairs-va-0
28. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Individuals with disabilities employment program. Updated August 15, 2022. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/IWD.asp
29. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). VA workforce diversity: FY 2022. Accessed July 1, 2024. https://www.va.gov/ORMDI/Diversity_Inclusion.asp
30. US Department of Veterans Affairs. Same mission, new I-DEA: VA supports inclusion, diversity, equity and access. News release. April 28, 2023. Accessed June 20, 2024. https://news.va.gov/118609/same-mission-va-supports-inclusion-diversity/
31. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion. Inclusion, diversity, equity, & access (I-DEA) action plan. September 2021. Accessed June 20, 2024. https://www.va.gov/ORMDI/docs/VA_I-DEA_Action_Plan-SIGNED.pdf
32. Sue DW, Alsaidi S, Awad MN, Glaeser E, Calle CZ. Disarming racial microaggressions: microintervention strategies for targets, White allies, and bystanders. Am Psychol. 2019;74(1):128-142. doi:10.1037/amp0000296
33. Cruz D, Rodriguez Y, Mastropaolo C. Perceived microaggressions in health care: a measurement study. PLoS One. 2019;14(2):e0211620. doi:10.1371/journal.pone.0211620
34. Ehie O, Muse I, Hill L, Bastien A. Professionalism: microaggression in the healthcare setting. Curr Opin Anaesthesiol. 2021;34(2):131-136. doi:10.1097/ACO.0000000000000966
35. US Department of Veterans Affairs. VA all employee survey. Accessed May 23, 2024. https://www.data.va.gov/stories/s/VA-All-Employee-Survey-AES-/r32e-j4vj/
36. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion. Special emphasis programs (ORMDI). Updated May 3, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Special_Emphasis_Programs.asp
37. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Federal women’s program. Updated August 9, 2022. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/FWP.asp
38. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Hispanic Employment program. Updated May 16, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/HEP.asp
39. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). American Indian & Alaska Native Program. Updated September 27, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/AIAN.asp
40. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Asian American, Native Hawaiian and Pacific Islander program. Updated September 27, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/AAPI.asp
41. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Black/African American program. Updated May 3, 2023. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Black_African_American.asp
42. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). LGBTQ+ program. Updated May 21, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/LGBT.asp
43. US Department of Veterans Affairs, Office of Resolution Management, Diversity & Inclusion (ORMDI). Diversity, equity and inclusion training. Updated March 18, 2024. Accessed June 20, 2024. https://www.va.gov/ORMDI/DiversityInclusion/Diversity_Inclusion_Training.asp
44. Rotenstein LS, Reede JY, Jena AB. Addressing workforce diversity - a quality-improvement framework. N Engl J Med. 2021;384(12):1083-1086. doi:10.1056/NEJMp2032224
45. Beeler WH, Mangurian C, Jagsi R. Unplugging the pipeline - a call for term limits in academic medicine. N Engl J Med. 2019;381(16):1508-1511. doi:10.1056/NEJMp1906832
46. Smith DG. Term limits in academic public health administration. Public Health Rep. 2020;135(6):859-863. doi:10.1177/0033354920954495
47. Kaiser J. Shake-up at NIH: Term limits for important positions would open new opportunities for women, minorities. science.org. May 2, 2019. Accessed May 23, 2024. https://www.science.org/content/article/shakeup-nih-term-limits-important-positions-would-open-new-opportunities-women
48. Giacalone RA, Jurkiewicz CL, Knouse SB. Exit surveys as assessments of organizational ethicality. Public Pers Manage. 2003;32(3):397-410. doi:10.1177/009102600303200306
49. Bonifacino E, Ufomata EO, Farkas AH, Turner R, Corbelli JA. Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review. J Gen Intern Med. 2021;36(4):1023-1034. doi:10.1007/s11606-020-06478-7
50. Brown IM. Diversity matters: mentorship is the missing ingredient in DEI. Emergency Medicine News. 2021;43(8):28. doi:10.1097/01.EEM.0000771148.76632.35
51. Sinha A, Kuy S. The future of surgery - increasing diversity, equity, and inclusion through early mentorship. Am J Surg. 2023;225(4):800-802. doi:10.1016/j.amjsurg.2022.12.011
1. US Department of Veterans Affairs, Office of Research & Development. Health equity. Accessed July 1, 2024. https://www.research.va.gov/topics/health_equity.cfm
2. US Department of Veterans Affairs. Equity action plan. Accessed July 1, 2024. https://department.va.gov/wp-content/uploads/2024/02/Department-of-Veterans-Affairs-Equity-Action-Plan.pdf
3. Schaeffer K. The changing face of America’s veteran population. Pew Research Center. March 2021. Updated November 8, 2023. Accessed May 23, 2024. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population/
4. US Department of Labor, Veterans’ Employment and Training Service. 2021 employment situation of women veterans. Accessed May 23, 2024. http://www.dol.gov/agencies/vets/womenveterans/womenveterans-employment
5. US Department of Veterans Affairs, National Center for Veteran Analysis and Statistics. National survey of veterans (NSV9503). Accessed June 20, 2024. https://www.va.gov/vetdata/docs/surveysandstudies/vetpop.pdf
6. US Census Bureau. Veterans Day 2022: November 11. News release. October 26, 2022. Updated April 4, 2024. Accessed May 23, 2024. https://www.census.gov/newsroom/facts-for-features/2022/veterans-day.html
7. ADA National Network. Employment data for veterans with disabilities. 2017. Accessed June 23, 2024. https://adata.org/factsheet/employment-data-veterans-disabilities
8. LGBTQ+ Veterans. DAV. Accessed July 26, 2024. https://www.dav.org/get-help-now/veteran-topics-resources/lgbtq-veterans/
9. US Department of Veterans Affairs, Office of Rural Health. Rural Veterans. Updated May 14, 2024. Accessed June 20, 2024. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp
10. Mikton C, de la Fuente-Núñez V, Officer A, Krug E. Ageism: a social determinant of health that has come of age. Lancet. 2021;397(10282):1333-1334.
doi:10.1016/S0140-6736(21)00524-9
11. Heise L, Greene ME, Opper N, et al. Gender inequality and restrictive gender norms: framing the challenges to health. Lancet. 2019;393(10189):2440-2454.
doi:10.1016/S0140-6736(19)30652-X
12. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med. 2006;21(6):667-669. doi:10.1111/j.1525-1497.2006.0512.x
13. Carratala S, Maxwell C. Health disparities by race and ethnicity. Center for American Progress. Updated May 11, 2020. Accessed June 23, 2024. https://www.americanprogress.org/article/health-disparities-race-ethnicity/
14. Clemente KAP, Silva SVD, Vieira GI, et al. Barriers to the access of people with disabilities to health services: a scoping review. Rev Saude Publica. 2022;56:64.
doi:10.11606/s1518-8787.2022056003893
15. Krehely J. How to close the LGBT health disparities gap. Center for American Progress. December 21, 2009. Accessed May 23, 2024. https://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap/
16. Dawson L, Frederiksen B, Long M, Ranji U, Kates J. LGBT+ people’s health and experiences accessing care. KFF. July 22, 2021. Accessed May 23, 2024. https://www.kff.org/womens-health-policy/report/lgbt-peoples-health-and-experiences-accessing-care
17. Disabled American Veterans. DAV report spotlights issues facing women veterans. September 12, 2018. Accessed June 23, 2024. https://www.dav.org/learn-more/news/2018/new-report-spotlights-continuing-challenges-facing-women-veterans/
18. Sheahan KL, Goldstein KM, Than CT, et al. Women veterans’ healthcare needs, utilization, and preferences in veterans affairs primary care settings. J Gen Intern Med. 2022;37(Suppl 3):791-798.
doi:10.1007/s11606-022-07585-3
19. Habeshian S. VA denied Black veterans health benefits more often than White vets, data shows. Axios. June 23, 2023. Accessed June 20, 2024. https://www.axios.com/2023/06/23/veterans-benefits-black-white-rate-disproportionate
20. Shipherd JC, Darling JE, Klap RS, Rose D, Yano EM. Experiences in the Veterans Health Administration and impact on healthcare utilization: comparisons between LGBT and non‐LGBT women veterans. LGBT Health. 2018;5(5):303‐311. doi:10.1089/lgbt.2017.0179
21. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006
22. Gill GK, McNally MJ, Berman V. Effective diversity, equity, and inclusion practices. Healthc Manage Forum. 2018;31(5):196-199. doi:10.1177/0840470418773785
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