Leadership diversity is a governance problem, not a slogan

Timothy Lesaca, MD July 17, 2026 

Hospitals would never rely on the idea that “we know good care when we see it” to control infections. Yet when choosing leaders, many still rely on the vague belief that “we know leadership potential when we see it.”

Medicine reviews nearly every process that affects patient care. But choosing leaders often happens privately, through conversations, informal nominations, search committees, and personal opinions about “fit.” This process is rarely reviewed as carefully.

Because of this, hospitals can name their leaders but often cannot explain how those people were chosen. If institutions do not track how opportunities are awarded, they cannot identify or address unfairness in advancement.

This is important because leaders do much more than just hold titles. Board members, executives, department chairs, deans, and managers decide which problems get attention, which programs get funding, what results are measured, who gets hired or promoted, and whose concerns are listened to.

Leadership representation is therefore a matter of governance.

The numbers show why we need to look at this process. The American Hospital Association reported in 2022 that health system boards were 74 percent White, 15 percent Black, 6 percent Hispanic or Latino, and 4 percent Asian. Freestanding hospital boards were 87 percent White. The survey included answers from 933 hospital and health system chief executives. While it was not a full census, the message was clear: The people leading health care institutions still do not look like the communities they serve.

Academic medicine further highlights where opportunities become limited. A national study in JAMA Network Open found that in 2019, White physicians made up 63.3 percent of medical school faculty but 78.1 percent of department chairs. Asian physicians were 20.5 percent of faculty but only 10.1 percent of chairs. Black physicians were 3.7 percent of both faculty and chairs, and Hispanic physicians were 3.4 percent of faculty and 3.6 percent of chairs.

These numbers show different issues. For Black and Hispanic physicians, having fewer in the faculty pipeline means fewer can reach senior leadership. For Asian physicians, even though many are faculty, they are not chosen as department chairs as often. There is no single reason that explains the differences across groups, specialties, genders, or institutions. Still, saying “the pipeline takes time” does not explain everything that happens after people join the profession.

Promotion data make this even more obvious. A 2024 national study in JAMA Network Open looked at 673,573 graduates of U.S. medical schools. Among those who graduated before 2000, Black women were 55 percent less likely than White men to become associate professors and 41 percent less likely to become full professors. The study could not consider every factor that affects a career, like publications, grants, faculty track, differences between institutions, or personal choices. It did not prove that discrimination caused every gap. But it did show that simply entering academic medicine does not guarantee a fair chance to advance.

This leads to a bigger question: Who gets the experiences that make a leadership application strong? Mentorship is helpful, but sponsorship can change someone’s career. A mentor gives advice. A sponsor uses their influence. Sponsors recommend people for important roles, introduce them to decision-makers, nominate them for visible assignments, and speak up for them when they are not present. Since sponsorship usually happens informally, access often depends on who you already know.

Underrepresented physicians often do work that institutions praise, but promotion systems do not value as much. They might mentor trainees, serve on equity committees, respond to discrimination, and build relationships with underserved communities. This work can be essential for an institution. But it also takes time away from publishing, getting grants, earning clinical revenue, and building national recognition.

The case for change should remain focused and evidence-based. There is not yet strong direct proof that simply changing the racial or ethnic makeup of a hospital board or executive team lowers mortality or reduces readmissions. Representation is not a clinical treatment, and an appointment is not a patient outcome. But it is still something hospitals can review.

A study of 1,088 hospitals in the Joint Commission Journal on Quality and Patient Safety found that hospitals with more racial and ethnic diversity in leadership reported broader efforts in strategic planning, workforce development, data collection, and reducing disparities. Since the study was observational, it could not prove that leadership diversity caused these actions. Still, the connection makes sense: Leaders set priorities, and those priorities shape what institutions measure, fund, and do.

Health systems do not have to wait for a study that links leadership diversity directly to mortality before improving a process that is still hard to see and measure. They should review leadership selection as carefully as they review other important systems because this is where opportunities are given.

First, track the entire path to leadership. The process starts long before a job is posted. Institutions should track who receives stretch assignments, interim roles, committee leadership, executive coaching, sponsorship, and budget responsibility. During each search, institutions should note who was encouraged to apply, who joined the applicant pool, who advanced at each stage, how candidates were evaluated, and why the final choice was made.

Second, make the selection criteria clear and consistent. Institutions should decide which skills and experience are needed for a job before discussing candidates. Every candidate should be asked similar questions and judged using clear, structured criteria. Search panels should be trained, diverse, and required to explain their decisions. Terms like “executive presence,” “readiness,” and “fit” should not be used without clear definitions.

Finally, measure actual power, not just who is represented. A leadership title by itself does not mean someone has real influence. Institutions should check whether leaders control budgets, have voting power, have enough staff, have access to top decision-makers, and have protection when they challenge established priorities.

Medicine learned from the patient-safety movement that good intentions alone do not create reliable systems. Measurement, standardization, transparency, and accountability do. Leadership selection should be reviewed in the same way.