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Creating support infrastructure for women of color advancing toward clinical department administrator role

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Creating support infrastructure for women of color advancing toward clinical department administrator role

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Creating Support Infrastructure for Women of Color Advancing Toward Clinical
Department Administrator Role

Jianhong Hu

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2023

© Copyright by Jianhong Hu, 2023
All Rights Reserved

The Committee for Jianhong Hu certifies the approval of this Dissertation

Patricia E. Tobey
Esther C. Kim
Maria G. Ott, Committee Chair

Rossier School of Education
University of Southern California
2023
iv
Abstract
Using the Clark and Ester (2008) gap analysis framework along with Burana and Schunk’s social
cognitive theory (1981) and the leadership pipeline lens, this research delves into the critical
influences that contribute to the lack of diversity among clinical department administrators
(CDAs) in academic medical centers (AMCs) and understand the barriers that hamper women of
color from pursuing the CDA position in their career advancement. This research conducted
semi-structured one-on-one interviews among 14 volunteer CDAs and one associate CDA at an
AMC. The analysis results and findings from the coded interview data revealed that there are no
significant knowledge and motivation gaps among individual CDAs. However, CDAs
encountered a lack of on-the-job training, mentorship, sponsorship, and organizational support,
especially for women of color. Based on the findings, this study intends to call medical school
leaders’, department chairs’, and university HR’s attention to creating a series of on-the-job
training sessions, setting up formal mentorship and sponsorship program, developing a standard
hiring process, and providing more operating support to recruit and retain more qualified women
of color and promote them to the CDA positions as well as develop a diversity, equity, and
inclusion academic environment in AMC. This study highlighted the trajectory pathway for
women of color and hopes to inspire them to advance their leadership careers in the academic
medical administration field and fix the sharpest leakage of women of color at the step from
entry-level manager to middle-level manager in the healthcare leadership pipeline. This research
provided insight into a CDA role that research scholars have not adequately addressed, which
significantly impacts diversifying healthcare leadership, promoting DEI, and improving
employee satisfaction and healthcare treatment outcomes.

v
Acknowledgements
I want to acknowledge numerous individuals who assisted, encouraged, and supported
me along this journey. I am deeply indebted to my dissertation chair, Dr. Maria Ott, who is
instrumental in the journey of my OCL program. Dr. Ott offered her feedback and support when
I met her in the second semester and guided me through this tedious process, especially when I
faced unexpected hardships. Dr. Ott’s insight and advice are valuable and kept me on track to
achieve this milestone. This endeavor would not have been possible without Dr. Patricia Tobey,
my committee member, who encouraged me to reflect on my experience and aroused me to fight
for more equitable rights for women of color. I am extremely grateful to Dr. Esther Kim, my
third committee member, who took time out of her busy schedule to assist me with my final
defense. I would like to extend a special thank you to Dr. Erin Marsano, who reviewed and
provided constructive feedback on each chapter of my dissertation. I would also like to express
my most profound appreciation to my department chair, Dr. John Oghalai, who faithfully pushed
me on this journey and made my dream come true. My sincere thank you also goes out to Dr.
Guadalupe Montano, who helped me with editing.
At this juncture, I also want to express my sincere gratitude to my family, my husband
Wei Lu, my son David and Michael, and my parents, who are there to back me up and support
me in completing my degree. Thank you for your love and support. Congratulations, Michael, for
accomplishing your dream and graduating with me this summer. Fight on, David! I am glad you
will complete your master’s degree soon.
Lastly, I would like to dedicate this achievement to all participant CDAs and all women
of color employees who continued working at the healthcare frontline during the COVID
pandemic in the past three years.
vi
Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgements ..........................................................................................................................v
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................ ix
Chapter One: Introduction to the Study ...........................................................................................1
Background and Context of the Problem .............................................................................1
Purpose of the Project and Research Questions ...................................................................3
Importance of the Study .......................................................................................................4
Overview of Theoretical Framework and Methodology .....................................................7
Definitions............................................................................................................................8
Organization of the Dissertation ........................................................................................10
Chapter Two: Literature Review ...................................................................................................11
Diversity of Healthcare Leadership in AMC .....................................................................11
CDA Role and Required Competencies in AMC ..............................................................26
Challenges for CDAs, Especially Racial and Ethnic Minority CDAs ...............................33
Motivation Factors that Impact CDA Role ........................................................................43
Organizational Factors That Impact Diversity Among CDAs ...........................................47
Conceptual Framework ......................................................................................................51
Summary ............................................................................................................................57
Chapter Three: Methodology .........................................................................................................59
Overview of Research Design and Rationale ....................................................................59
Research Setting.................................................................................................................61
The Researcher ...................................................................................................................62
vii
Data Sources ......................................................................................................................63
Validity and Reliability ......................................................................................................68
Ethics..................................................................................................................................69
Chapter Four: Results and Findings ...............................................................................................71
Participating Stakeholders .................................................................................................71
Interview Results and Findings ..........................................................................................73
Summary ..........................................................................................................................110
Chapter Five: Recommendations .................................................................................................111
Discussion of Findings .....................................................................................................111
Recommendations for Practice ........................................................................................118
Limitations and Delimitations..........................................................................................131
Recommendations for Future Research ...........................................................................132
Conclusion .......................................................................................................................133
References ....................................................................................................................................136
Appendix A: Interview Protocol ..................................................................................................161

viii
List of Tables
Table 1 Influences for Knowledge, Motivation, and Organization in Conceptual Framework ...57
Table 2 Data Sources .....................................................................................................................60
Table 3 Keywords Related to KMO Categories ............................................................................67
Table 4 Demographic Information of Participants ........................................................................73
Table 5 Direct Quotes of Business Strategy and Planning Influence ............................................76
Table 6 Direct Quotes of Accounting, Finance, and Budgeting Influence ....................................78
Table 7 Direct Quotes of HR and Teambuilding Skill and Influence ............................................81
Table 8 Direct Quotes of Communication and Networking Skill and Influence ...........................84
Table 9 Direct Quotes of Personal Attributes and Influence .........................................................87
Table 10 Direct Quotes of Lack of On-the-Job Training ...............................................................91
Table 11 Direct Quotes Related to Sponsorship/Mentorship/Training..........................................93
Table 12 Direct Quotes of Department Chair Support and Influence ...........................................98
Table 14 Direct Quotes of Lack of School Support and Resources for Career Development .....109
Table 15 Comparison of Knowledge, Motivation, and Organizational Results and Findings With
Literature Review Factors ............................................................................................................117
Table A1 Interview Protocol ........................................................................................................162

ix
List of Figures
Figure 1: A KMO Diagnosis Framework for Individual Advancement in the Leadership
Pipeline ..........................................................................................................................................55
Figure 2: Process Diagram for Factual, Conceptual, Procedural, and Metacognitive
Knowledge and Skills for CDA Role.............................................................................................56
Figure 3: Applying the New World Kirkpatrick Model to CDA’s On-the-Job Training ............123
Figure 4: Applying Kotter’s Change Model to Enable Organizational Transformation and
Promote Diversity among CDAs .................................................................................................131

1

Chapter One: Introduction to the Study
Lack of diversity among clinical department administrators (CDAs), a middle-level
leadership position in healthcare, diminishes the career potential of people of color in academic
medicine/medical centers (AMC). Although the healthcare workforce’s diversity is slightly
better than the U.S. population, the majority of people of color in this field still work in entry-
level and lower-paying jobs and lack advancement opportunities (Wilbur et al., 2020, p. 224).
While Whites make up 66% of entry-level positions and 78% of middle-level senior manager
positions (41% of White women; 37% of White men), people of color make up 34% of entry-
level positions and only 21% of middle-level senior manager positions (11% of women of color;
10% of men of color), demonstrating the problem (Berlin et al., 2022).
Although there is limited peer-reviewed research on the diversity of leaders in the CDA
role, given the fact that CDA is part of healthcare leadership, the lack of diversity is evident in
numerous studies (Berlin et al., 2019; Goode & Landefeld, 2018) and is likely similar to the
situation regarding the CDA role in AMCs. Due to continually increasing racial and ethnic
diversity in the general population, the need for diversifying the healthcare workforce,
particularly in middle and upper-level management, is growing (Togioka et al., 2021). The lack
of diversity needs to be addressed at all stages of the healthcare workforce pipeline (Goode &
Landefeld, 2018), including middle-level leadership in academic medicine. This dissertation
addressed the gap in the literature by examining CDAs’ knowledge and skills, motivation
influences, and organizational factors that contribute to a lack of diversity in the role.
Background and Context of the Problem
In the past, the lack of diversity in leadership in AMCs has been masked by the nobility
of an AMC’s mission: high-quality treatment for complex medical conditions and excellent
2

nursing care without considering the cost. All settings and processes at an AMC are built to
achieve a tripartite mission of educating future physicians, providing healthcare for the most
complex medical conditions, and conducting research to find new treatments to improve
healthcare outcomes (Blumenthal & Meyer, 1993; Valletta & Harkness, 2013). An AMC usually
includes a medical school, one or more hospitals and satellites. Typically, a medical school has
about 15 clinical departments that provide direct patient care services and another 15 research
departments/institutions focusing on medical-related education and research. Each clinical
department has one department chair and one CDA to run it. As evidence of healthcare
disparities among underrepresented groups mounts, the demand for a more diverse healthcare
workforce becomes greater (Goode & Landefeld, 2018). There is increasing awareness of the
importance of leadership in healthcare operations; however, the research has focused
predominately on physicians and top managers, while healthcare middle managers (HMMs) are
overlooked, leaving limited research on diversity in this group (Birken et al., 2012; Engle et al.,
2017).
The HMMs play a central role in healthcare “as a bridge to connect senior leaders and
frontline staff” (Engle et al., 2017, p. 14) and in “bringing policies to life” by encouraging
frontline employees and supporting their career development (Carlström, 2012, p. 91). As part of
HMMs, a CDA plays a key role akin to a combined chief financial officer (CFO) and chief
operating officer (COO) role in clinical departments. A CDA works with their chair to create the
department budget, participate in decision-making, and implement and monitor the
administrative processes for departmental healthcare, education, and research to ensure the
AMC’s goals are sustainably met. They directly supervise the frontline workforce to implement
and conduct numerous new regulations, policies, procedures, and mandates (Browning et al.,
3

2011). Although it is laudable that many studies address the gender disparities in the leadership
of faculty and the C-suite (Berlin et al., 2022; Birken et al., 2012), the lack of diversity in
middle-level leadership, especially regarding non-clinician staff members’ career advancement,
is marginalized in the research.
This study focused on the CDA group at one AMC on the west coast of the United States.
For anonymity, the pseudonym “WMC” replaces the actual name of the AMC. The WMC AMC
is associated with a large private research university. This organization has 16 clinical
departments under a medical school associated with four hospitals and multiple satellites. Its
medical school has 2,173 staff employees, of whom 69.58% are female, 30.09% are male, and
less than 0.33% are GNC. Among those employees, 52% are 18 to 39 years old, 43% are 40 to
64, and 5% are over 65. In terms of demographics, 29.45% are White, 25.21% are Asian
(including South Asian), 6% are African American, 12.8% are Hispanic/Latino, 10.03% are of
multiple races and ethnicities, and 16.51% declined to self-identify. According to the U.S.
Bureau of Labor Statistics (2021), among 147,795 (numbers in thousands) individuals aged 16
and older in the civilian workforce, Whites make up 62.42% (92,249), Blacks or African
Americans are 12.09% (17,873), Asians are 6.39% (9,437) and Hispanics 17.65% (25,952).
Although there are only 16 CDAs at WMC, its employee demographics are more diverse, which
makes this institution more suitable for studying diversity in leadership development.
Purpose of the Project and Research Questions
This study sought to reveal the causes of the lack of diversity among CDAs at WMC.
Utilizing Clark and Estes’s (2008) knowledge, motivation, and organization (KMO)
improvement model in combination with Bandura and Schunk’s (1981) social cognitive theory,
4

this study examined perceptions of the most important influences that contribute to a lack of
diversity in the CDA role. Three research questions guided the study:
1. What knowledge influences among clinical department leadership contribute to a lack
of diversity among CDAs?
2. What motivational influences among aspiring candidates contribute to the lack of
diversity among CDAs?
3. What organizational influences contribute to the successful promotion, recruitment,
and retention of women of color CDAs among clinical departments?
Importance of the Study
Many studies have indicated the need for diverse healthcare leadership and workforce in
the United States (Edwards et al., 2018; Goode & Landefeld, 2018; Silver, 2017; Stanford,
2020). Due to new patterns of illness, the emerging complex challenges in the healthcare sector,
and demographic shifts in the U.S. workforce (Browning et al., 2011), inclusive leadership is
essential to meet the needs of today’s patient-centered healthcare model (Edwards et al., 2018).
Patient-centered care requires leaders at every level to design and nurture a diversity strategy
deliberately and purposefully (Edwards et al., 2018). Diversity is broadly defined as “the
inclusion of varied attributes or characteristics,” which refers to various healthcare professionals,
trainees, educators, researchers, and diverse patients of varied races, ethnicities, social statuses,
and languages (Togioka et al., 2021, p. 1). Diversifying the healthcare workforce will enhance
diversity in organizational cultures and behaviors to promote health equity and reduce healthcare
disparities by improving the patient experience, increasing patient satisfaction (Wilbur et al.,
2020), and enhancing employee engagement, thus leading to the contribution of more ideas,
skills, time, and talent to healthcare (Browning et al., 2011). The lack of diversity among CDAs
5

in medical schools’ clinical departments contributes to poor employee engagement, which
directly impacts patient care outcomes.
Clinical department administrators (CDAs), as HMMs, are key personnel who can
significantly impact a medical department’s culture and the behaviors of faculty and residents
and positively influence the engagement of other clinical department employees. These
administrators are closest to daily clinical practice, education, and research and play central roles
in translating and implementing all policies and strategies to improve patient care and medical
education and in developing healthcare treatment research (Hartviksen et al., 2018). Empirical
evidence has found that “effective leadership and management are important to the success of
healthcare organizations” (Hernández et al., 2018, p. 158). Due to healthcare’s change from
hospital-centeredness to patient-centeredness and the increasing diversity of patients’
demographics, healthcare administration requires diverse cultural competency in order to deliver
quality care for diverse populations (LaVeist & Pierre, 2014). Diversity among CDAs can assist
in and improve diversity in a healthcare environment and supportive services (Weech-
Maldonado et al., 2018).
Research on the diversity among HMMs is in its beginning stages. Although more
women were promoted to CDA positions, per Berlin et al. (2022), the majority of HMMs, such
as senior managers, are still White men (37%) and White women (41%). Women of color in
HMM positions are still underrepresented, which impedes creating an equitable culture and
working environment (Berlin et al., 2022). Despite women making up 40% of physicians and
75% of the overall healthcare workforce, diversity among AMC leadership does not reflect this
gender shift (Rabinowitz & Rabinowitz, 2021). While White men make up 22% of healthcare
employees and occupy 37% of HMM positions, women and women of color constitute 67% and
6

22% of healthcare employees but only 41% and 11% of HMM positions (Berlin et al., 2022).
Evidence shows that women’s leadership can improve organizational performance and that
gender equity increases an AMC’s ability to achieve the tripartite mission (Jagsi & Spector,
2020). However, women of color faculty face not only the challenge of genderism but also racial
discrimination because AMC top leaders frequently sideline conversations on racism (Westring
et al., 2021). Moreover, staff who are women of color face triple jeopardy (gender, race, and job)
in their career advancement compared with faculty who are women of color. Although CDAs are
closest to clinical practice, their capacity and capability are often neglected and rarely
acknowledged (Hartviksen et al., 2018).
Evidence provides testimony that the lack of gender and racial equity at each level of
academic medicine leadership is due to a slow pipeline and multiple complex factors (Baker et
al., 2019; Bingmer et al., 2020; Fuller & Young, 2022; Jagsi & Spector, 2020). Ignoring leaders’
ethnicity not only implicated the descriptive characteristics (Tolleson-Rinehart, 2016) but also
impeded the substantive leaders’ career advancement and demoralized employee engagement.
Diversity of leadership has evolved over the past quarter-century; however, the goal of diverse
AMC leaders proportionally representing the diversity of the population has not yet been
achieved (Tolleson-Rinehart, 2016). Diverse healthcare leadership research has predominantly
focused on high-ranking faculty (such as the department chair and school dean) in medical
schools, C-suite hospital leaders, or nurse administrators in healthcare settings. Studies seldom
focus on non-clinician or middle-level leaders (Baker et al., 2019; Birken et al., 2018; Engle et
al., 2017; Hartviksen et al., 2018) settings. While there is an increasing awareness of the
importance of diversity of leadership in healthcare (Davenport et al., 2022), middle-level
administrative leaders who are staff and belong to medical schools but are also involved in daily
7

clinical operations are marginalized in healthcare leadership studies and higher education
leadership research. Therefore, this research focused on CDAs, as they are a critical part of this
middle-level non-clinician group.
Overview of Theoretical Framework and Methodology
Theories provide researchers with lenses to shape their research questions and guide
broad explanations for behaviors and attitudes (Creswell & Creswell, 2018). This research aimed
to identify influences contributing to the lack of diverse CDAs in AMCs. The gap analysis model
and social cognitive theory were selected to examine the individual and organizational behaviors
and attitudes contributing to the problem. The KMO model is also acknowledged as a gap
analysis framework developed by Clark and Estes in 2008. This framework is widely used to
clarify organizational goals and identify the gap between actual performance and proposed
organizational performance from KMO factors. In this study, it was used to examine the
influences of the lack of diversity in AMC leadership from KMO aspects.
The social cognitive theory was developed from social cognitive learning theory (SLT) in
the 1960s by Albert Bandura (LaMorte, 2019). Individual social cognition impacts human
behavior and motivation. In 1986, SLT was developed into social cognitive theory (SCT), which
posits a motivational and self-regulatory mechanism rooted in a cognitive learning activity
(Bandura & Schunk, 1981; Bussey & Bandura, 1999) that influences individuals to learn new
knowledge and skills. This study utilized SCT to examine how individuals’ motivation and
organizational factors influence aspiring candidates to learn and develop the leadership
knowledge and skills required for the CDA role.
In the 1970s, Walter Mahler developed a leadership pipeline model to identify leadership
core competencies at different leadership levels. The leadership pipeline lens aligns with
8

conceptions of CDA career advancement as entry-level manager and senior manager stages. The
leadership pipeline can help to define a roadmap for aspiring Black Indigenous People of Color
(BIPOC) candidates to follow through with their advancement.
This research used a qualitative methodology. All CDAs at the organization were invited
to participate in semi-structured interviews. Interviews were scheduled and conducted in
approximately 1-hour Zoom meetings. Each interviewee answered 12 open-ended questions,
with the goal of collecting information related to their KMO factors as they related to the lack of
diversity among CDAs at WMC AMC. Interviews were recorded and transcribed via Zoom. The
analysis took place utilizing keywords to code interview transcripts.
Definitions
This section provides definitions and citations of key terms from the relevant literature.
These terms set the foundational context of this study.
AAMC: Association of American Medical Colleges.
Academic medicine is distinct from local community healthcare. In this paper, academic
medicine is interchangeable with AMCs because, among 141 degree-granting medical schools in
the United States, only a few entirely focus on educating students (Johnston, 2019). AMCs
usually integrate hospitals with medical schools and are affiliated with degree-granting
universities to fulfill the tripartite mission of education, research, and healthcare in order to
provide the best treatment with cutting-edge technologies, resources, and therapies to benefit
public health (Blumenthal & Meyer., 1993; Penn Medicine, 2022).
An academic medical center (AMC) is an organization formed by a fully accredited
medical school and one or more hospitals. An AMC typically has three distinct goals: providing
patient care, educating future doctors, and acquiring new medical knowledge (Johnston, 2019).
9

BIPOC: Black, Indigenous, and People of Color.
A clinical department administrator (CDA) is an administrative staff member and
second-in-command in a clinical department in charge of the department’s operations. This
person assists the chair in implementing all strategies and policies to help the faculty, staff, and
students fulfill the department’s mission. The job title may differ, but the job functions are
similar.
Clinicians include physicians, physician assistants, nurse practitioners, audiologists, and
speech-language pathologists, who provide clinical services to patients.
Historically, faculty at an AMC means a cadre of physicians hired as full-time faculty
members to devote the majority of their efforts (~80%) to research and only a small amount of
time to teaching and patient care (Levinson & Rubenstein, 1999). These faculty usually become
regional, national, and international experts in their fields, publish their work in peer-reviewed
journals, and obtain grants. They are appropriately promoted in academic rank. The AMC values
their accomplishments even though they may not achieve excellence in clinical care or teaching
(Levinson & Rubenstein, 1999).
Healthcare middle-level non-physician managers (HMMs) are service line directors,
clinical directors, CDAs, and others in similar positions.
Aspiring leadership candidates were inspired to pursue entry-level and middle-level
leadership positions at an AMC. In this research, it refers to individuals interested in pursuing a
CDA role at an AMC.
Physician: As an academic center expands its clinical base, AMCs start to hire more
outstanding doctors as clinician-educator physicians for teaching and patient care only.
Clinician-educator physicians who “work on the main campus and in newly created community
10

sites” affiliated with the AMC “are often members or leaders of hospital committees on quality
assurance, implementation of guidelines, and information management” (Levinson &
Rubenstein, 1999).
The tripartite Mission of AMC indicates the three goals of an AMC: teaching, research,
and patient care (Blumenthal & Meyer, 1993; Johnston, 2019).
Underrepresented and marginalized minority (URM): a U.S. citizen who identifies as
Black/African American, Asian, Hispanic/Latinx, Native American (Alaskan, Hawaiian, and
other Pacific Islander) U.S. citizens (University of California San Francisco, 2022).
Organization of the Dissertation
This five-chapter study begins with an overview of the problem of practice and the
importance of the study in Chapter One. Chapter Two outlines the related literature regarding the
diversity of healthcare leadership. Chapter Three introduces the research methodology and
describes the limitations of the study. Chapter Four highlights the findings and provides an in-
depth analysis of the interviews and survey data. Chapter Five concludes the study by proposing
recommendations for improving CDA diversity. The purpose of the research was to increase this
diversity by identifying why it is lacking using the KMO, SCT, and leadership pipeline lenses.
11

Chapter Two: Literature Review
This chapter reviews the literature related to the lack of diversity among academic
medicine leadership, especially in the AMC setting. The first section gives an overview of the
evolution of genderism and racism and shares related research on gender and diversity in AMC
leadership. The second section reviews the CDA role and its required competencies in the AMC
leadership hierarchy. The third section reviews research on challenges for CDAs to gain the
required knowledge and skills. Further, it discusses the existing biases that have impacted
BIPOC candidates’ pursuit of the CDA position. The fourth section discusses what research
shows as organizational factors that affect leadership diversity. In closing, the conceptual
framework that guided the data collection will be discussed. Since there is limited research
specifically on the CDA position, research that informs this study presented in this section comes
from a combination of peer-reviewed literature in the medical field as a whole, including studies
related to nursing leadership, the diversity of medical students and faculty, and clinical practice.
Only two current studies discuss the medical administrator position (Popejoy, 2016; Scheidt,
1994); however, the research did not specify whether the role was specific to the clinician or
non-clinician leadership. Middle managers have received little attention in health services
research, making further research in this area a necessity (Birken et al., 2012).
Diversity of Healthcare Leadership in AMC
Diversifying healthcare leadership can align with vast community needs and serve the
changing U.S. demographic (Weech-Maldonado et al., 2018). According to the U.S. Bureau of
Labor Statistics, by 2050, over 50% of the workforce will be ethnic minorities and immigrants
(Artiga et al., 2020; Groves & Feyerherm, 2011). Leadership is a vital aspect of the work
environment and a central component of organizational settings (Widodo, 2014). Understanding
12

the history of diversity in academic medicine can help to identify the root causes of bias and
promote diversity of leadership intelligently. This section will discuss the history and current
status of the diversity of gender and race evolvement in healthcare and academic medicine as
well as in healthcare leadership. It will also share what literature suggests are the benefits of
diverse leadership in academic medicine due to U.S. demographic changes and what leads to a
lack of diverse leadership.
History of Race and Gender Disparity in Healthcare and Academic Medicine
Genderism and racism are deeply embedded in the history of healthcare and academic
medicine. Explicit or implicit racism has been deep-rooted in medicine for over 2500 years and
has extensively impacted the healthcare sector in all aspects (Byrd & Clayton, 2001, as cited in
Massie et al., 2021). Most hospitals only granted privileges to White physicians in the early 20th
century, and African American patients were admitted to segregated wards and provided with
substandard treatment (Wilkins et al., 2021). Meanwhile, gender discrimination blocked women
from attending medical schools and being promoted to healthcare leadership positions. Elizabeth
Blackwell became the first female MD in 1849 after being turned away by more than ten medical
schools (Weiner, 2020). Although Ann Preston was appointed as the first female dean of a U.S.
medical school in 1866 after fighting intense hostility (Weiner, 2020), the top healthcare leaders
and organizations remain hesitant to promote women to leadership positions, which contributes
to the slow rise of women to leadership positions (van Esch et al., 2018).
Although Medicare solved the segregation issue in 1966, gender and race discrimination
are not addressed seriously in all hospitals and medical schools in the United States (Wilkins et
al., 2021). Women only comprised 29.5% of all medical school applicants in 1980–1981, and the
gender gap persisted until 2018-2019 (Association of American Medical Colleges [AAMC],
13

2019). The AAMC reported that only 2% of deans and 5% of chairs were women in 1992
(AAMC, 2021). Compared with gender disparity, race differences in academic medicine are
even more pronounced. Women represented about 40% of full-time faculty in medical schools in
2015, while non-White Women only constituted 11% of this 40% (Haggins, 2020). By 2018-
2019, U.S. medical schools accepted 49.8% White, 7.1% Black or African American, and 6.2%
Hispanic applicants (AAMC, 2019), which does not appropriately represent the current
demographics in the country. The considerable demographic changes and well-documented
disparities in healthcare call for the urgent need for diversity of leadership, faculty, students, and
staff to align with the diverse patient care and medical student education needs (Nivet, 2010).
This demand is reflected in the current gender and racial trends in academic medicine.
Current Gender and Racial Trends
The healthcare setting has seen an increase in opportunities for women overall (Berlin et
al., 2019; Jagsi & Spector, 2020). After battling genderism for over 53 years, among all active
physicians aged 34 years and younger in the nation, there are more women than men in most
BIPOC groups (AAMC, 2019). Over 50% of all medical school students and residents (Jagsi &
Spector, 2020) and more than 60% of healthcare employees are women (Berlin et al., 2019),
which makes career advancement by gender better than in many industries. However, according
to the AAMC 2019 report, 64.1% of active physicians and 58.6% of faculty in medical schools
are still men (AAMC, 2019). According to AAMC statistics from 2019, 65.5% of White
physicians were male, and 60.1% of American Indian or Alaska Native physicians were male, as
were 59.5% of Hispanic physicians, 55.7% of Asian physicians, and 46.9% of Black or African
American physicians, which shows that male physicians were predominant in all racial groups
except Black or African American. Although the White-male-dominated trend in medicine is
14

apparent among physicians, research demonstrates an increase in women in medicine among
those 34 years and younger, closing the gender gap overall (AAMC, 2019). In addition to gender
variance, there is racial variance as well.
There are several disparities in the current racial makeup of the medical field as a whole
(Berlin et al., 2019; Raphael, 2019). Raphael (2019) posited that the healthcare faculty and
workforce continually experience racial disparities. These are evidenced in the AAMC (2019)
report, given that 56.2% of active physicians are White, 5% are African American, 3% are
Hispanic, and only 1% are Native Hawaiian or other Pacific Islander, while BIPOC represented
39% of the U.S. population in 2016 (Artiga et al., 2020). Thus, AAMC faculty and workforce
data for 2018–2019 show that medical school faculty continue to be predominantly White, as
White individuals make up 63.9% of all medical school faculty, especially at the higher faculty
ranks (AAMC, 2019). Certain racial and ethnic minority groups, such as African Americans and
Hispanics/Latinos, and women remain underrepresented in faculty positions, as they make up
3.6% and 3.2% of faculty, respectively (AAMC, 2019). In the U.S. academy, only 3.7% of
tenure track positions and 2.2% of tenured positions were held by Black women (Ngunjiri &
Hernández, 2017). The rate of BIPOC faculty in U.S. academic medicine has remained at 7% to
8% over the last two decades, and the percentage of African American faculty is lower than it
was in 1978 (Raphael, 2019). Gender and racial disparities are also evident in academic medical
staff and leadership roles in medicine.
Current Gender and Racial Status of Leadership in Academic Medicine
Evidence shows there is a lack of women in leadership in academic medicine. Research
indicated that women were more unlikely to achieve senior rank positions or remain in academic
fields than their male counterparts (Carr et al., 2018). While women have made some progress in
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career advancement in healthcare in the past decades, women have yet to have the equal
opportunity to represent a substantial proportion of faculty or administrator roles in higher
education, including within medical schools (Parker, 2015). It took over 150 years for women to
occupy 22% of department chairs and 22% of medical school deanship in 2021, which is still
much lower than 78% of male chairs and male deans (AAMC, 2021). As AMCs become more
patient-centric and need more ambulatory satellites, there is an opportunity for women to expand
their talents and skill sets in different AMC segments (Hardy-Waller, 2015). However, women
find it difficult to be promoted to leadership and are still underrepresented in board positions
(Hardy-Waller, 2015).
Berlin et al. (2022) reported that the proportion of men in healthcare leadership positions
increases from entry-level (33%), manager (40%), senior manager/director (47%), VP (58%),
senior VP (67%), C-suite level (71%), and on to the board level (69%) of the leadership ladder
(Berlin et al., 2022). While the representation percentage of men in entry-level positions stands
at 33%, that number moves up to 69% at the board level. For women, the percentage of women
declines from 67% at the entry-level, 60% at the manager level, 53% at the senior manager level,
42% at the VP level, 33% at the senior VP level, 29% at the C-suite level and 31% at the board
level, demonstrating the disparity of women in leadership roles (Berlin et al., 2022). These
disparities particularly impact women of color. Research scholars also studied the healthcare
leadership problematics by focusing on gender but neglecting race identity (Ngunjiri &
Hernández, 2017).
Genderism and racism are intersectional and hinder women of color from advancing to
leadership positions. Women of color remain a small minority in many critical and powerful
positions (Jagsi & Spector, 2020). Only 4% of women of color and 9% of men of color are at the
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C-suite level, compared with 26% of White women and 62% of White men (Berlin et al., 2019).
White men comprise 31% of the U.S. population; however, they occupy 40% of medical school
faculty and leadership positions (Tolleson-Rinehart, 2016). Meanwhile, BIPOCs comprise 40%
of the U.S. population and only hold 9% of medical school faculty and 18% of medical student
positions (Davenport et al., 2022).
Furthermore, there are inequities in the promotion rate among White men, White women,
and women of color. The proportion of White men in healthcare leadership positions actually
increases from entry-level (24%), manager (29%), senior manager/director (39%), VP (48%),
senior VP (57%), and on to the C-suite level (62%) of the leadership ladder (Berlin et al., 2019;
Tolleson-Rinehart, 2016). While the percentage of White men in entry-level positions of 24%
moves to 62% at the C-suite level, the percentage of White women declines from 41% at the
entry-level, 40% at the manager level, 39% at the senior manager level, 33% at VP level, 27% at
the senior VP level, and 26% at the C-suite level. The percentage of women of color declines
further, from 22%, 17%, 12%, 8%, 6%, and 4% across those same levels, respectively,
demonstrating inequities (Berlin et al., 2019).
Although there has been an increase in women leaders, women of color are still a small
proportion of the top leadership in AMCs (Berlin et al., 2022; Tolleson-Rinehart., 2016). In
addition to the changing demographic and community needs, the demand for diversity in
healthcare leadership has further intensified because of the awakening of the increased need for
racial diversity in medicine during the COVID-19 pandemic (Mullin et al., 2021). With this
awakening, healthcare organizations must continue to diversify leadership, as evidence shows
that increasing diversity of gender and race has many benefits (Gould et al., 2018).
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Benefits of Diversity of Healthcare Leadership
Diversifying leadership in the AMC setting brings multiple benefits, including enhancing
employee engagement, improving patient care outcomes, and reducing healthcare disparities
(Deas et al., 2012). The persistent race discrimination contributes to disparate healthcare
outcomes, especially toward minority groups (Togioka et al., 2021). This section will review the
benefits of employee engagement, employee retention and satisfaction, and patient care
outcomes contributed by diverse healthcare employees and leadership.
Enhancing Employee Engagement
Many studies have found that diversity of leadership enhances faculty and staff
engagement. Engagement can be defined as a commitment and level of connectedness in the
organization (Saks & Gruman, 2014; Sun & Bunchapattanasakda, 2019). Several studies have
found that diversified leadership leads to improved outcomes, such as a sense of belonging, a
trust climate by inclusion, cross-cultural mentorship with diverse trainees, and promoting self-
esteem (Carasco-Saul et al., 2015; Haggins, 2020; Sabharwal, 2014). This is evidenced by
Downey et al. (2015), who completed a study of 4,597 health sector employees from large
healthcare organizations and found that diversity can promote a sense of belonging to enhance
the retention and promotion of diverse employees. Further, an additional study found that the
lack of diversity in leadership led to racial/ethnic groups feeling a lack of belonging or decreased
engagement (Haggins, 2020). Keller et al. (2019) emphasized that a lack of belonging
exacerbated the limited diversity of leadership candidates, which significantly impacted the sense
of belonging and engagement as well as job satisfaction among employees.
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Improving Employee Satisfaction and Recruiting and Retention of BIPOC
Another benefit of improved diversity among leadership is improved recruitment and
retention of BIPOC stakeholders and improved employee satisfaction. Diversity of leadership
can promote a diverse culture of medicine (Beeler et al., 2019). Diversity of leadership not only
adds a variety of perspectives and enriches the problem-solving capacity of the institution but
also is a way to welcome and engage with a diversified group of staff, physicians (Tolleson-
Rinehart, 2016), students, and patients. Diversity, equity, and inclusion (DEI) is a powerful
“vehicle toward excellence in patient care, research, and health equity” and can enact change to
improve BIPOC representation in leadership positions (Davenport et al., 2022, p. 62). Evidence
shows that the benefits of diversity include increased retention of BIPOC stakeholders among
faculty, staff, and students (Deas et al., 2012).
Deas et al. (2012) reported that the positive outcomes of implementing a successful
diversity plan from 2003 to 2012 were that BIPOC medical students’ rate increased from 11% to
21%, the retention rate for students increased to 98%, the percentage of BIPOC residents
increased from 3% to 7%, and the number of BIPOC faculty increased from 35 to 66. This study
found that a diversity strategy helped develop a diverse physician workforce (Deas et al., 2012).
Leadership diversity can complement different leadership styles and improve employee job
satisfaction and engagement. Today, healthcare employees are under much pressure, and
transformational leaders help increase employees’ job satisfaction and psychological well-being.
(Nielsen et al., 2009). Authentic leaders promote a positive working environment, enhance new
nurses’ confidence and occupational self-efficacy, reduce burnout, and improve new nurses’
mental health and well-being (Laschinger et al., 2015). Further, leadership diversity can optimize
patient care (Davenport et al., 2022).
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Improving Outcomes of Patient Care and Reducing Healthcare Disparities
Diversity of leadership improves patient care outcomes and reduces healthcare disparities
through multicultural awareness and effective communication. Multiple authors suggest that
diverse leadership can create a more diverse and culturally aware workforce; this, in turn, leads
to diverse faculty available to train newly recruited, diverse medical students and residents,
which ultimately helps eliminate racial/ethnic disparities in healthcare and improve patient care
outcomes (Hardy-Waller, 2015; LaVeist & Pierre, 2014). Diversity of leadership can promote a
diverse culture in healthcare (Beeler et al., 2019) and “foster an inclusive climate and show
appreciation for diverse contributions, which provides beneficial organizational outcomes around
creativity, innovation and performance” (Mor Barak et al., 2016, as cited in Vito & Sethi, 2020).
Healthcare employees’ performance directly impacts patient care outcomes, which include
timely diagnosis, appropriate care, knowledge, attitudes, and relationships with providers
(Chunara et al., 2021). Evidence shows that diversity improves healthcare access and patient
satisfaction while reducing disparities in patient care by developing cultural competence to
provide quality care to minority and underserved populations (Deas et al., 2012; Walsh et al.,
2016). In contrast, a lack of diverse leadership in AMCs hindered BIPOC populations from
receiving equitable patient care, and these vulnerable people still suffer from significant
healthcare disparities.
Furthermore, communication plays a pivotal role in healthcare outcomes and disparities
(Wright et al., 2012). Healthcare outcomes are based on patients’ self-reports, which are highly
related to their satisfaction (Chen et al., 2019; Randall et al., 2017). Patient satisfaction is a
complex metric that is not only affected by provider performance (Chen et al., 2019) but also by
effective communication, respect and dignity, and emotional support that relates to patients’
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expectations of care (Larson et al., 2019; Randell et al., 2017). Fenton et al. (2012) sampled
52,000 adult patients and found that patient-provider communication has a higher impact on
patients’ reporting than drug expenditure, inpatient admissions, and mortality (as cited in Anhang
Price et al., 2014; Fenton et al., 2012). Diversity indicates more culturally sensitive
communication, which impacts patient-provider interactions (Brooks et al., 2019), including
protecting patients’ dignity and providing them with emotional. Diverse clinicians can improve
patient-provider communication and information accuracy during diagnosis and treatment (Celik
et al., 2008; Betancourt et al., 2013, as cited in Brooks et al., 2019; Wright et al., 2012).
While the benefits of diverse leadership were well-addressed before COVID-19, as the
pandemic progressed, healthcare disparity became an area of glaring racial inequity and racist
vigilantism (Argueza et al., 2021). African Americans comprise 30% of the population but
represent 50% of COVID-19 cases and 70% of COVID mortality (Alcendor, 2020). Also, 19%
of Hispanics and 11.5% of African Americans were uninsured in 2020, while only 7.5% of
Whites had no insurance. Overall, 17.3% of individuals whose incomes were below the poverty
lacked healthcare coverage, while only 4.3% of those whose incomes were 400% of the federal
poverty line do (Artiga et al., 2020).
Disparities affecting BIPOC in terms of healthcare insurance coverage, outcomes, access,
and equity for in-person care are partially driven by the availability of clinicians and services
(Chunara et al., 2021). More diverse physicians and healthcare leadership enhance trust,
satisfaction, and equitable working environments, which drives better employee engagement,
ultimately improving patient care outcomes (Downey et al., 2015; Gomez & Bernet., 2019).
However, only 3.6% of medical school faculty physicians are African American, and 5.5% are
Hispanic/Latino, while 11% of healthcare leaders and 14% of hospital board members are racial
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and ethnic minorities (Wilkins et al., 2021). It is vital to examine the AMC leadership structure
systematically and accurately to discover the root causes that lead to a lack of diversity of
leadership at all levels in order to improve healthcare outcomes and reduce the disparities among
BIPOCs.
Causes of Lack of Diversity Among Leaders
Research shows there are four causes for the lack of diversity of leadership in academic
medicine: lack of accountable DEI leadership competency (Weech-Maldonado et al., 2018;
Wright et al., 2012), implicit bias in promotion procedures (Argueza et al., 2021; Rojek et al.,
2019; Teherani et al., 2018), a leaky leadership pipeline (Bingmer et al., 2020; Goode &
Landefeld, 2018; Teherani et al., 2018), and lack of top leadership sponsor (Vito & Sethi, 2020;
Walter et al., 2017). These causes were studied broadly in the past. This section will discuss
recent studies on these four causes by focusing on accountability for DEI culture competency,
implicit bias in promotion procedures, pipeline leaking, and lack of top leadership sponsors.
Accountability for DEI Cultural Competency
Healthcare leadership lacks accountability for DEI cultural competency. This cultural
competency has never been listed as a core competency for healthcare leaders in healthcare
organizations (Weech-Maldonado et al., 2018). The research found that the core competencies
for healthcare leadership typically relate to integrity, teamwork, critical thinking, emotional
intelligence, and the ability to provide selfless service (Hargett et al., 2017). Physicians and
leaders are “ill-equipped to dismantle systemic racism” in healthcare and academic medicine,
which led to a lack of cross-cultural competency (Argueza et al., 2021, p. 798). Medical school
leaders underlined the importance of DEI and often expected the BIPOC faculty and trainees to
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improve diversity without investing funds and time to take action on DEI (Argueza et al., 2021;
Mullin et al., 2021).
Mullin et al. (2021) argued that the pandemic and several recent high-profile anti-racism
events led to enhanced DEI needs in all healthcare organizations. However, these factors have
only reshaped healthcare leadership’s core competencies by embedding governance, mentorship,
and performance management through a DEI lens into the traditional leadership competencies
(Mullin et al., 2021). However, DEI has not been integrated as a measurable and accountable
leadership competency at most major healthcare facilities (Mullin et al., 2021). According to
Weech-Maldonado et al. (2018), there is no effective diversity training currently in place to
enhance top leaders’ cultural awareness and manage diversity attitudes, implicit biases, and
various ethnic identities. All core competencies in leadership frameworks need to be
strengthened and improved with DEI accountability for academic healthcare leadership (Mullin
et al., 2021). Developing cultural competency in healthcare needs to omit biases (Henderson et
al., 2018).
Implicit Bias in Promotion Procedures
Current evaluation and promotion procedures embedded with implicit biases impede
diverse BIPOC career advancement. The University of California, San Francisco’s Alpha Omega
Alpha society and evidence from many medical schools’ pipeline programs demonstrate a
holistic admission process and subjective evaluation criteria inhabited underrepresented medical
students from entering competitive residency programs and disadvantaged diverse medical
workers (Argueza et al., 2021; Rojek et al., 2019; Teherani et al., 2018). A diverse leadership
pool in academic medicine is shrunk by implicit biases across performance evaluation and
promotion procedures (Teherani et al., 2018).
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Although the development of diverse faculty and leadership is a critical element of the
agenda of diversifying the healthcare physician workforce (Nivet, 2010), the AAMC reported
that implicit and unconscious bias is embedded in the recruitment, evaluation, and promotion
procedures in healthcare (Rojek et al., 2019). Rojek et al. (2019) did a narrative evaluation study
among de-identification students in two medical schools, and they found that evaluations of
URM students were associated with fewer honors grades than non-URM students. Scholars have
noted that women and URM are not empowered in their roles, not valued for their work, and not
mentored for successful promotion (Mena & Vaccaro, 2017). Because of racial/ethnic biases,
underrepresented groups’ career pathways are rarely smooth, and their flow in the leadership
pipeline is stark (Carnes et al., 2008). However, few studies have focused on non-clinician and
middle-level leaders in the academic medical sector. Diversity leadership research should also
expand to middle-level managers to increase the leadership pipeline pool.
Pipeline Leaking
The leadership pipeline model is a core framework that helps business organizations
select, develop and assess specific work responsibilities at each leadership level (Charan et al.,
2010, p. viii). Cuofano (2021) defined the leadership pipeline model as having six levels in the
healthcare sector:
1. Step 1 is entry-level, from managing oneself to managing others. Some of this level’s
skills can be learned in early childhood, for example, in middle school. CDA-related
factual knowledge can be accumulated among different industries or sectors, such as
medical billing and medical research. Managing others also can be articulated through
similar job experiences.
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2. Step 2 is the manager level, from managing others to leading managers. This skill can
also be learned from related practices by leading a small group or a few team
members.
3. Step 3 is the senior manager level, starting with leading managers, such as the service
line director or CDA, who leads a subspecialty service line or a department.
4. Step 4 is the VP level as a functional manager, such as an ambulatory or hospital
CEO who runs a business unit under an AMC.
5. Step 5 is the senior VP level as a business manager, such as a medical school dean
and CEO of a healthcare group who supervises the ambulatory CEO and hospital
CEO within an AMC.
6. Step 6 is the C-suite level as group manager toward enterprise manager or board
member (p. 1).
Each step can be distinguished by “unique transitions, learning experiences, and personal
agency” (Baker et al., 2019; Hall & Chandler, 2005). This model can help AMC follow a
scrupulous roadmap (Dai et al., 2011) and identify the best candidate for specific leadership
roles.
Pipeline leaking at the entry and middle-level leadership pool causes a lack of diverse
healthcare leadership at AMCs. Pipeline leaking refers to the loss of potential candidates along
the leadership pipeline (Surawicz, 2016). For instance, although the pipeline of BIPOC
matriculants to medical schools is expanding thanks to the positive impact of BIPOC leaders in
the education field (Fuller & Young, 2022), the pipeline of BIPOC physicians from medical
school to competitive residencies and careers in academic medicine is leaking (Teherani et al.,
2018). While women make up 51% of the population and constitute 32% of surgeons and their
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representation increases at a rate of 0.4% per year, African Americans comprise 13% of the
population and 6% of surgeons, but their representation is decreasing at a rate of 0.1% annually
(Bingmer et al., 2020).
As Berlin et al. (2022) reported, the largest loss of potential BIPOC leaders occurs before
the SVP level. The difference in the percentage at the entry-level between White people and
people of color is 32%, but the disparity increases to 56% at the senior manager level (Berlin et
al., 2022). Research revealed that diversity in faculty after mid-career, such as department chairs,
declined in the leadership pipeline (Baker et al., 2019). Although research has shown that the
lack of diverse teachers in the pipeline significantly impacts racial imbalances in education
(Eddy & Easton-Brooks, 2011; Lomotey, 2019; López, 2016), little has been done to examine
the leadership pipeline gaps (Fuller & Yound, 2022) in the entry and middle levels. A study on
CDAs can help to understand why there is a lack of diversity among top-level leaders and shed
light on patching up the leaking pipeline to increase the number of BIPOC candidates in the
leadership pipeline pool for AMCs. However, research proved that a limited pipeline is not the
only cause of a lack of diversity (Beeler et al., 2019). Top leadership sponsors can enlarge
diverse advancement opportunities and increase visibility in the leadership pipeline.
Lack of Top Leadership Sponsor
The lack of top leadership sponsors directly impacts the lower-level leadership pool and
BIPOC career advancement. Sponsorship from top leaders who can influence decision-making
processes or structures significantly and actively advocate for, protect, and fight for BIPOC
career advancement is a more effective mechanism for improving BIPOC advancement
(Avakame et al., 2021; Ayyala et al., 2019; Raphael, 2019). The top leaders at medical schools
include a dean and hospital C-suite leaders who are in full control and demand performance from
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faculty and staff even though medical school leadership has evolved from a top-down to a more
collaborative approach (Sonnino, 2016). Entry-level BIPOC and HMMs usually need to work
their way up through their organization (Carlström, 2012).
Without sponsorship and inclusion from top leadership, BIPOCs who work in the
frontline as administrative staff are rarely invited to be involved in decision-making or have
access to high-profile information and resources (Travis et al., 2013). Top leaders with
traditional White values, norms, and organizational culture still perpetuate genderism and racism
(Vito & Sethi, 2020; Walter et al., 2017). White men who occupy top manager positions (62%)
and department chair positions (78%) lead to a lack of top leadership sponsorship for BIPOC in
many AMCs (AAMC, 2021; Berlin et al., 2019; Mullin et al., 2021). While 19% of men had
sponsorship during their advancement, only 13% of women had sponsorship (Travis et al.,
2013). Overall, men were 46% more likely to receive sponsorship than women (Travis et al.,
2013). The importance of sponsorship in minority career advancement is significant (Avakame et
al., 2021). The lack of diversity among top leadership exacerbated the lack of sponsorship from
top leadership, which further hindered medical schools from implementing action plans and
discouraging unequal promotions and microaggressions aimed at enlarging the BIPOC
leadership candidates pool to fill the healthcare leadership pipeline (Avakame et al., 2021;
Raphael, 2019; Travis et al., 2013). Constrained advancement opportunities, lack of sponsorship,
and a limited pipeline pool consequentially led to a lack of diversity among CDAs.
CDA Role and Required Competencies in AMC
To improve leaders’ diversity and expand the qualified BIPOC candidate pool, it is
essential to understand what knowledge and skills are necessary for each level of leadership (Dai
et al., 2011). Kaur and Kumar (2013) defined four major components of competency:
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knowledge, skills, personal attributes, and behavior (Kaur & Kumar, 2013). This section will
discuss the CDA’s scope of work and address its required knowledge and skills in reference to
healthcare leadership competency and the personal attributes and behaviors needed for this role.
CDA’s Scope of Work
The CDA role is a unique position in academic medicine. This position is under a
medical school usually associated with a high-profile and complex hospital and multiple satellite
clinics. As middle-level non-clinician leaders employed by a clinical department in a medical
school, CDAs directly work with faculty, students, and academic staff. Some are frequently
involved with clinic and hospital operations to ensure the AMC provides the best healthcare
services. A CDA is usually appointed by the clinical department chair and directly reports to the
chair. The department chair is akin to the CEO, and the CDA is akin to the CFO and COO in a
clinical department.
A CDA is responsible for their department’s accounting and financial analysis, budget,
operations, human resources, strategic business plan, facilities and equipment, safety and
compliance, fundraising, community relations, and anything related to its operational functions.
This person also works closely with their department chair to create the department budget, set
performance goals, provide financial analysis data to assist the department chair in developing
business strategy, and implement the standardizing process to facilitate faculty, trainees,
research, and administrative staff to strive for the tripartite mission of healthcare, education, and
research successfully. In addition, a CDA acts as the key liaison to coordinate patient care and
education between the hospital and clinical departments. A CDA is intimately involved in
negotiations with the hospital to acquire private clinics.
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Key Knowledge and Skills for CDA Role
Due to rapid transformation and development in healthcare, the importance of healthcare
leadership continues to grow, and the leadership model continues to evolve across all health
professions (Garman et al., 2020). According to the leadership pipeline model (Cuofano, 2021), a
CDA has gone through the leadership ladder of entry-level and manager before taking this role.
Different levels require different behaviors, skills, and competencies (Kaiser, 2011). Traditional
leadership roles for faculty in medicine require specific skill sets, including the ability to manage
finances, build strong teams, and have strong communication skills and emotional intelligence
(Sonnino, 2016). Due to healthcare’s dynamic and complex nature, leaders need multifaceted
specific skill sets for boundary-spanning goals and tasks (Popejoy, 2016).
In alignment with Sonnino’s (2016) findings, the Healthcare Leadership Alliance, a U.S.-
based healthcare management professional association, developed a five-domain model
communicating core competency domains for healthcare leadership (as cited in Garman et al.,
2020, Stefl, 2008). These are effective communication skills to manage relationships, efficient
leadership, integrity with professionalism, well-round knowledge of the academic medical
environment, and proficient business skills and knowledge (Hahn & Gil Lapetra, 2019), as well
as personal traits and behaviors. Although these skills encompass all healthcare leadership roles,
similar criteria could apply specifically to CDAs. The following section provides an overview of
these core competencies.
Business Strategy and Planning
Business strategy and planning is a core competency for the CDA role. Today’s
healthcare revenue model has shifted from volume-based to value-based care delivery (Kash et
al., 2014). In 2014, the HFMA National Institute found that many healthcare organizations are
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considering a broad-spectrum acquisition and various affiliation options beyond traditional
mergers and acquisitions (Landman, 2014). Middle managers must attain clearer insight into
management control, conflict management, and leadership (Carlström, 2012). Thus, CDAs’
business strategy can help their department expand healthcare services, reduce financial pressure,
and identify and facilitate business opportunities (Cuofano, 2021) for the AMC. The AMCs have
excellent faculty and staff members (Blumenthal & Meyer, 1993), and their tripartite mission is
crucial to national health (Valletta & Harkness, 2013). However, the cost of the education and
research mission has generally resulted in higher expenses in clinical departmental business
compared to community clinics.
Eighty-five percent of an AMC’s research and academic mission used to be covered by
its clinical revenue, and the other 15% was covered by research grants and fundraising (Valletta
& Harkness, 2013). Thus, AMCs have thrived under this economic model for a long time
(Valletta & Harkness, 2013). In the past decade, this traditional operating model has faced many
challenges in all aspects. The National Institute of Health (NIH) funding has declined,
community-based hospital development has increased, and these community hospitals have
taken over many lower-acuity cases that traditionally contributed significantly to an AMC’s
financial margins (Landman, 2014). All these factors caused revenue sources to change
significantly (Landman, 2014). The shifts in the economic model, the demographic changes in
the U.S. population, and a diverse workforce require diversity among healthcare leaders to
effectively manage conflicts in resource allocation among healthcare professionals, students, and
patients (Edwards et al., 2018; Stanford, 2020). Developing a feasible and compelling business
plan requires accounting and finance skills for properly processing and implementing a business
plan.
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Accounting and Finance
Skill in accounting and finance is one of the essential and core competencies for the CDA
role, which needs to be cultivated (Hargett et al., 2017) in the function manager period.
Accounting and finance skills can be accumulated through different working experiences, such
as healthcare, research, and education experience in AMCs. As HMMs in AMCs, CDAs are used
by the top management to communicate and implement “savings, personnel reductions,
redundancies and closures” during periods of fiscal constraints, which involves sliding out of
their role by sliding up in taking on governance roles and sliding down in taking on advocacy
roles (Carlström, 2012, p. 90). Healthcare finance is the most complex among all industries
(Popejoy, 2016) and has been increasingly pressuring CDAs over the last decade. Patient
expectations of high-quality care at a low cost are critical matrices for AMCs. Clinical operation
costs and salary support, especially faculty salaries, depend mainly on patient care revenue.
While CDAs help the leadership strive to balance demands from different stakeholders and the
financial constraints of providing high-quality, low-cost clinical services, they need an efficient
professional team to work with them and carry out the necessary tasks.
Human Resources and Teambuilding
Teambuilding is another core competency for the CDA role. Effective healthcare
leadership is defined as the ability to influence a team to provide the best healthcare to patients
(Hargett et al., 2017). Therefore, CDAs must be able to recruit and retain talented individuals,
cultivate collaboration, build trust, and develop a spirited team (Posner, 2016) to fulfill the
department’s tripartite mission. They are familiar with the frontline employees’ responsibilities
and have a store of knowledge based on their experiences (Carlström, 2012).
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Besides clinical service knowledge, CDAs need cultural competency to hire and train
diverse employees and build a dynamic and high-standard professional team to support clinical,
research, and education activities, manage finance and relationships, and process faculty affairs
and human resources (HR) tasks to fulfill departmental goals. Despite maintaining internal
relationships across departments and hospitals as well as external relationships with referral
doctors and communities, CDAs also directly influence four types of informal workplace
interprofessional interactions: socio-cultural practices, the physical environment, timing-related
factors, and organizational factors (King & Shaw, 2022). Research demonstrated that informal
interprofessional interactions enhanced communication, teamwork, research translation, and the
provision of safer care in the healthcare workplace (King & Shaw, 2022). Communication and
networking are important for building up an engaged professional team.
Communication and Networking
Valid and effective communication helps to implement policies and develop relationships
between employees and managers, superiors and subordinates, and colleagues by modifying
attitudes and behaviors to achieve shared goals and needs (Ejimabo, 2015). Knowledge sharing
among colleagues and students is essential for academic professionals to develop and contribute
to advancing knowledge in society (as cited in Ballesteros-Rodríguez et al., 2022, Hernaus et al.,
2019). In today’s academic environment, effective communication can provide sufficient
information and promote collaboration among team members to efficiently solve problems,
develop new ideas, or implement policies and processes (Wang & Noe, 2010, p. 117).
Communication is a key competency for leaders involved with their organizations’ business
negotiations and policy interpretation (Ejimabo, 2015).
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With excellent communication skills, it is easier for CDAs to collect sufficient
information for the best decision-making for their departments, deliver and clarify business
policies, and encourage the employees in their departments (van Diggele et al., 2020). Indeed,
effective communication can help the racial/ethnic candidates increase the underrepresented
group’s visibility and build a powerful network for advancement (Sherbin & Rashid, 2017). The
social and relational capabilities that facilitate the interaction among multiple organizational
members in healthcare have also been included in current leadership competency (Garman et al.,
2020; Leach et al., 2021). While competency plays a critical role in individuals performing their
job effectively (Elliot et al., 2018, p. 635), individuals’ characteristics affect the degree of
competency in learning and leadership.
Personal Attributes and Behavior for a CDA Role
Personal attributes and behavior will significantly impact the effectiveness of individuals’
knowledge and skills learning and job performance (Northouse, 2016, p. 21). Personal attributes
and behavior include intelligence, alertness, insight, responsibility, initiative, persistence, self-
confidence, and sociability (as cited in Northouse, 2016, p. 20; Stogdill, 1974), which impact the
demonstration of essential knowledge and skills. Most healthcare leadership studies have focused
on general leadership core competencies of “Acting with Personal Integrity,” “Communicating
Effectively,” and “Acting with Professional Ethical Values” (Hargett et al., 2017). There are
several subspecialties within the medical field, so CDAs must work closely with their
subspecialty to deepen their understanding of the subspecialty competency.
In addition to the aforementioned knowledge and skills, CDAs need to join their
subspecialty administrative associations to learn about their fields in greater depth. Self-learning
through their job may not be sufficient. To advance from team leader to functional manager, the
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CDA candidates should have authentic personal traits and relationship management skills to lead
and motivate their team to meet operational performance goals. Some of these skills can be
developed in the early stages of the pipeline or learned through sponsorship or mentorship.
Belasen (2021) also indicated that resilience is a critical competency that helps healthcare leaders
to identify strengths and weaknesses and develop sustainable business strategies (Belasen, 2021).
Although there is limited research, particularly on HMMs, this knowledge and skill set applies to
CDAs. The intervention aimed at CDA leadership competency is insufficient for promoting
diversity. There is consistent evidence for some challenges that impede BIPOC people from
acquiring the required competency effectively.
Challenges for CDAs, Especially Racial and Ethnic Minority CDAs
Although there has been little research on CDAs, some research on career advancement
challenges for faculty and nurse practitioners may apply to them. This section will address seven
core challenges that research has indicated as being impactful in improving diversity in
healthcare leadership. These include a lack of knowledge and skills training opportunities
(Sonnino, 2016), lack of sponsorship and mentorship (Chisholm-Burns et al., 2017), various
microaggressions (Franklin, 2016; Holder et al., 2015; Kalaitzi et al., 2017; Sue et al., 2019),
financial well-being (Surawicz, 2016), lack of networking and trustworthiness (Sherbin &
Rashid, 2017), and lack of self-efficacy and motivation to lead (Mascia et al., 2015).
Lack of Formal Professional and On-the-Job Training for CDA Role
One common challenge is the lack of formal and on-the-job training. Formal and on-the-
job training is essential for leadership development. Early formal leadership training is helpful
for individuals’ future leadership development, which sets the foundation for pursuing significant
leadership opportunities in their career advancement (Sonnino, 2016). However, there is no
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formal leadership training program available for CDAs. While evidence suggests some of the
healthcare leadership core competencies need to be formally taught or trained at an early career
stage, the available formal training for healthcare leadership is limited and usually focuses on
faculty, practitioners, or senior women leaders (Sonnino, 2016). Research demonstrated that
leadership development programs were valuable in enhancing individual capability and
confidence as well as in achieving individual advancement successfully (Mousa et al., 2021).
Formal training is the most effective and efficient way for individuals to gain the required
knowledge for a CDA role, yet there is a lack of comprehensive training programs for the middle
level of non-clinician leadership. Indeed, most healthcare administrators’ leadership career
pathways are not shaped by a specific type of degree that they obtain (Roskovensky & Grbic,
2012). Although 58.25% of current hospital administrators possess no technical or professional
healthcare training or a specific license, an academic degree is essential to acquiring leadership
ability, as 11.3% of healthcare leaders hold a doctoral degree, and 73% hold a master’s degree
(Matthews et al., 2013). Similar criteria can also be applied to the CDA.
Healthcare leaders need to be lifelong learners. Due to the rapidly changing context of
healthcare technology and environments, the complexity of challenges that AMC leaders face
has also increased significantly (Lieff et al., 2013). Physicians or nurses have various on-the-job
training programs to guide or support their career advancement. These programs can help
candidates become well-prepared and move up in the leadership pipeline. The rapid and dynamic
change in healthcare requires leaders to have stamina, integrity, courage, self-security,
accounting and finance skills, and strategic analysis while also being good at team building,
commitment, and willingness to be lifelong learners (Popejoy, 2016). Continuous learning is
essential for managers to maintain adaptability and reinvent their leadership styles to succeed at
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different levels (Kaiser, 2011). Research has found that learning opportunities heavily rely on
sponsoring and mentoring from their supervisor or senior managers (Chisholm-Burns et al.,
2017; Baker et al., 2019; Hewlett, 2013; Sherbin & Rashid, 2017; Surawicz, 2016).
Lack of Sponsorship and Mentorship for Minorities to Attain CDA Positions
There is a lack of mentorship and sponsorship opportunities for CDAs, particularly CDAs
of color. A sponsor from a top leader leverages their protégé’s visibility and advocates for key
assignments and promotions in a power system (Sherbin & Rashid, 2017). Mentors and sponsors
play an important role in motivating and guiding women to identify the right career advancement
pathway, particularly during their vital early career period (Chisholm-Burns et al., 2017).
However, HMMs, especially underrepresented HMMs, were expected to be self-taught and learn
while working for their leadership capacity and capability (Hartviksen et al., 2018).
Evidence has shown that sponsorship or mentorship is the most impactful method for
career advancement. Over the past 10 years, the percentage of women leaders has doubled
(AAMC, 2021) as formal leadership training sponsored by organizations and top leaders,
coaching, and mentoring have increased (Surawicz, 2016). Despite formal training to gain
knowledge, individuals can also accumulate the required financial, business, and HR knowledge
through their work experiences. Sponsorship is a fast track for people to make the most of their
talents and attain leadership positions (Hewlett, 2013). Baker et al. (2019) noted that mentoring
and coaching were strongly connected for middle-career faculty to holding a department head
role (Baker et al., 2019), which may apply to staff advancement.
Lack of mentorship or career advancement opportunities are the top two challenges for
BIPOC career advancement among all 21 categorized barriers in the academic sector and the 22
categorized barriers in the healthcare sector (Kalaitzi et al., 2017). Indeed, White perception and
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demographic dissimilarity hobbled sponsorship opportunities for BIPOC to gain training and
practice opportunities (Randel et al., 2021; Roberson et al., 2017). Research on sponsorship and
multicultural professionals shows that top BIPOC leaders generally hesitate to take sponsorship
action (Sherbin & Rashid, 2017). Only 18% of Asians, 21% of African Americans, and 25% of
Hispanics at senior levels are willing to sponsor employees of the same gender or ethnicity as
themselves, while 27% of Caucasians provide sponsorship (Hewlett et al., 2012).
Exposure to new leadership practices and opportunities helps leadership students deepen
their leadership competence and connect with leadership role models (as cited in Brue & Brue,
2018, Sinha & Hanuscin, 2017). The lack of diversity of clinical department chairs leads to a
lack of sponsors or mentors for BIPOC who work on the frontline and have difficulty being seen,
heard, and valued as equal participants (Randel et al., 2020). In addition, a lack of mentorship
leads to inequitable opportunities in the career advancement pipeline, which contributes to the
lack of top management competency and pipeline leaking (Surawicz, 2016). Sponsorship and
mentorship are coping strategies to overcome various microaggressions (Holder et al., 2015).
Microaggressions
Microaggression is another barrier for minority candidates to move up in the leadership
pipeline, yet it is ranked lower than the mentorship and sponsorship challenges (Kalaitzi et al.,
2017). Microaggressions are acts of aversive discrimination that intentionally or unintentionally
“communicate hostile, derogatory, or negative racial slights and insults to the target person or
group” through “brief and commonplace daily verbal, behavioral and environmental indignities”
(Holder et al., 2015, p. 165). Microaggression themes include environmental manifestations,
stereotypes about women and BIPOC groups (such as invisibility, glass ceiling, and feminine
modesty), perceived riskiness, and racial microaggressions. Microaggressions can have
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significant harmful and accumulative psychological impacts (Franklin, 1999, as cited in Holder
et al., 2015) on the target individual or group. The subsequent section discusses these
microaggressions and how they impact BIPOC career advancement.
Invisibility
Invisibility is a common form of environmental and professional microaggression
embedded deeply in the history of academic medicine (Mena & Vaccaro, 2017). Invisibility is
defined as conscious gender assumptions and male bias that marginalize women and people of
color by ignoring their identity and differences to their detriment, forcing them into other groups
as well as diminishing their qualifications and achievements (Harman, 2016; Hsieh & Kim,
2020) to give advantages to White males (Sue, 2004). Lack of visibility also leads to a lack of
information and resources for racial and ethnic minorities to learn skills that high-profile jobs
require.
Invisibility happens not only to women faculty and staff but to all women, especially
women of color who are leaders (Mena & Vaccaro, 2017). The career pathways for women and
people of color can be murky, as evidenced by Dr. Donna Strickland’s still being an associate
professor when she won the Nobel Prize in 2018 (Wijesingha & Robson, 2022). Although this
evidence may demonstrate that these women and people of color are quick and active learners,
able to adapt to different roles and accumulate different skills with limited resources and
guidance, these candidates are often invisible and/or devalued due to their race and/or gender
(Holder et al., 2015). Conspicuous invisibility was associated with feminist and gender blindness
during the Ebola crisis in global health governance (Harman, 2016). Although the glass ceiling
and feminine modesty are not visibility issues, both are invisible barriers that hinder the
advancement of women of color.
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Glass Ceiling and Feminine Modesty
The glass ceiling and feminine modesty are two subtle invisible barriers that prevent
women from advancing to top positions. The glass ceiling can be defined as a lack of women or
women of color being promoted to leadership positions, particularly to top decision-making
positions (Carnes et al., 2008; Cook & Glass, 2014; Wijesingha & Robson, 2022), which has
been legally identified as a barrier to the advancement of women and minorities (Carnes et al.,
2008). The glass ceiling, which is often referred to as the bamboo ceiling for Asian women (as
cited in Sanchez-Hucles & Davis, 2010; Hyun, 2005), is related to institutional culture and bias,
especially unconscious bias (Surawicz, 2016). This bias impacts all women, particularly women
of color.
For example, Chisholm-Burns et al. (2017) posited that women only hold 4% to 5% of
CEO positions, 25% of executive- and senior-level positions, and less than 20% of board seats
among Fortune 500 and S&P 500 companies. While women are overrepresented in entry-level
faculty positions (such as instructor or assistant professor positions) and compose over 80% of
healthcare occupations, they are underrepresented in senior-level and administrative positions,
such as associate professor, full professor, dean, and president (Chisholm-Burns et al., 2017).
Women of color still suffer from token status in elite leadership positions and lack role models in
academic medicine (Carnes et al., 2008). Although from 2005 to 2021, women chairs increased
from 10% to 22% and women deans from 11% to 22% in AMCs (AAMC, 2021), women of
color only occupied 4% of C-suite positions, and the glass ceiling for women of color starts as
early as the first promotion to manager (Berlin et al., 2019).
Feminine modesty can be defined as the tendency of women to deflect and minimize their
accomplishments (Jovanocic, 2019), which makes the gender bias floor even stickier and
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exacerbates the difficulties women and minorities face in entering into leadership positions. The
old axiom that “men take charge, women take care” is still persistent in academic medicine
(Surawicz, 2016, p. 1435). Research has found that feminine leadership styles add value to
leadership, and women comprise over 80% of occupations in healthcare (Cartwright, 2014, as
cited in Place & Vardeman-Winter, 2018). Nonetheless, women are still 30% less likely than
men to be promoted from entry-level to managerial-level positions (Chisholm-Burns et al., 2017)
and only account for 29% to 31% of C-suite and board positions (Berlin et al., 2022), which
severely underrepresents their proportion of the workforce. Leadership roles are overrepresented
by men, particularly at the senior levels and above, because leadership skills are defined as a
better fit for male traits (dominant, aggressive, independent) than female traits (being
affectionate, helpful, and nurturing) (Surawicz, 2016; Weiner et al., 2021). Women are more
likely to be associated with a lack of leadership skills and high perceived riskiness.
Perceived Risk
Perceived riskiness is another environmental microaggression with a mediating effect on
promotion decisions and salary offers between female and male candidates (van Esch et al.,
2018). Perceived riskiness is defined as “the degree of uncertainty and the significance of the
outcomes from the selection decision” for a leadership selection (van Esch et al., 2018, p. 915).
The selection of a leader usually requires an organization to invest an enormous amount of
money, time, and other resources, especially since the organizational success will greatly depend
on the new senior leader (van Esch et al., 2018). Although research found no significant
differences between men’s and women’s leadership qualities, leadership effectiveness, or
leadership preferences, women of color find it difficult to be promoted to leadership positions
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(Aldoory & Toth, 2004, Jin, 2010, Meng et al., 2012, as cited in Place & Vardeman-Winter,
2018) with the perceived risk.
To reduce the perceived risk of not aligning with leadership expectations, women have to
break either gender/race norms or leadership norms (Weiner et al., 2021). Since most chairs are
still predominately White men, it is not surprising that White women are more likely to break
gender norms and be appointed to an administrator role, such as a CDA position, than other
individuals from racial-ethnic groups. In 2013, only 20% of administrators were racial minorities
in the United States (Hill et al., 2016, as cited in Weiner et al., 2021).
Organizational support is critical for aspiring candidates to gain the multifaceted
knowledge required by the CDA role. More practical opportunities mean more experiences and
competencies that the candidates can attain. Although there is limited research pertaining to
healthcare middle management, there is a study on clinical department chairs that might apply to
CDAs. The study indicated that due to “the complexities and emotional burden of a clinical
department chair role, chairs must have a range of supports and capabilities to succeed in their
roles” (Lieff et al., 2013). Research also indicated that providing transitional support and
mentoring can enhance leadership effectiveness as well as facilitate the development of
communities of peers (Lieff et al., 2013). It demonstrated that workplace environmental
supporting factors could help to reduce these environmental microaggressions and individual
racial microaggressions.
Racial Microaggressions
As a modern-day aspect of racism, racial microaggressions significantly impede the
career advancement of women of color. A racial microaggression is a “subtle and common form
of modern-day racism” which is usually caused by “well-meaning individuals” (Minikel-
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Lacocque, 2013, p. 435). The subtle approach includes color-blindness and meritocracy, which
were indignities based on race (Franklin, 2016). Research showed that among 485 higher
education presidents in the US, 85.6% were White men (344) and White women (71), 10.7%
were African American, 1.6% were Hispanic, and 2.1% were others who needed an average of
32.5 years from their president’s terminal degree to their first presidency, which is significantly
longer than White women’s average of 22.8 years (Wallace et al., 2014).
Moreover, women of color need a much longer time to gain the same amount of
knowledge or to identify their career pathway than men or White women (Wijesingha & Robson,
2022) due to a shortage of sponsorship and mentorship. Women faculty had to wait one extra
year to be promoted to full professors compared with their male counterparts (as cited in
Wijesingha & Robson, 2022, Schirle, 2019). Research by Chen and Hune (2011) proved that
there are persistent disparities in gender and race in higher education leadership, and the pipeline
continues to shrink as they advance further along the pipeline (Chen & Hune, 2011). These
microaggressions further stifle racial/ethnic minority leaders’ advancement in AMCs. Racial
microaggressions are also associated with racial fatigue, racism-related stress, and racial trauma
(Franklin, 2016), which deeply affect women and BIPOC’s Well-Being financially and
physically.
Financial Well-Being
Financial well-being is another challenge for aspiring candidates pursuing CDA
competencies. It includes commitment and investment of time, money, and other resources that
are necessary for learning new skills. Acquiring the various skills required for the role takes a
significant amount of time, strong resilience, and motivation to accumulate the required
experiences and build up those skills. Women are not only perceived as lacking business skills
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but also are paid roughly 19% less than men in similar positions (Matthews et al., 2013). Women
usually were hired less frequently than men (Surawicz, 2016). While the average compensation
of male presidents in higher education was $558,153 in the private sector and $396,361 in the
public sector, the average compensation of female presidents was $454,079 in the private sector
and $386,442 in the public sector (Wallace et al., 2014). The financial gap between women and
men impeded women’s career advancement due to a lack of financial support for acquiring new
knowledge by pursuing additional advanced degrees or licenses.
Furthermore, due to family care needs, many women felt they were pushed off the ladder,
leading to missing out on opportunities (Sherbin & Rashid, 2017). Women of color who work on
the front lines usually do not have high-level networking. Female representation at a senior level
evidenced a positive impact on female representation at the feeder group of the senior
management (Gould et al., 2018). Lack of sponsorship and mentorship makes it even harder for
women or women of color to enact access to the networks for their advancement in both bottom-
up (increasing women or women of color representation at higher levels) and trickle-down
(advocate on behalf of women in lower levels and serve as role models) approaches (Gould et al.,
2018). Both sponsors and mentors enlarge the network and increase trust among the mentees.
Networking and Trustworthiness
Networking and trustworthiness are key determiners for career advancement. Despite
some talented BIPOC candidates possessing the required skills and being helpful to a department
chair for connecting multiple teams and improving departmental operational efficiency and
productivity under financial constraints, genderism and racism in the medical fields cause the
lack of diversity of senior healthcare leadership (Carr et al., 2018; Jagsi & Spector, 2020; Rojek
et al., 2019). Lack of diversity at the senior-level leadership trickles down to impact women’s
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informal networks and promotion (Gould et al., 2018), especially in recruiting, promoting, and
retaining them in HMM positions (Engle et al., 2017). The clinical department chair has a critical
impact on the CDA selection. The most important factor that impacts the chair’s decision is trust
in the individual’s ability to do the job. Due to the lack of a network in the leadership pipeline
and disparities in cultural values, women of color are not visible and even find it hard to gain
trust. In 2015, only 19% of first- and mid-level management positions were racial/ethnic
minorities (Wilkins et al., 2021). Women of color are often omitted from high-profile
assignments (Sherbin & Rashid, 2017). On the other hand, career advancement for BIPOC
women requires aspiring individuals to possess the self-efficacy and self-motivation to persist
along the journey.
Motivation Factors That Impact CDA Role
For BIPOC, learning behaviors and outcomes are heavily impacted by internal and
external motivations and environments. Social cognitive theory posits that an individual’s
knowledge and motivation impact each other, and motivation impacts their energization and
direction of behavior (Elliot et al., 2018). Motivation to lead (MTL) and self-efficacy are
motivational factors that influence an individual’s self-belief and confidence in their capacity to
execute and advance to leadership positions by controlling their motivation, behavior, and social
environment (Wong et al., 2012). The following section discusses MTL and self-efficacy, which
are two critical components of motivation.
Motivation to Lead
Besides the external motivation from sponsorship and mentorship, MTL plays a critical
role in an individual’s career advancement. Self-motivation is an individual’s intrinsic
motivation (Bandura & Schunk, 1981) which initiates their activities without supervision
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(Trolano, 2021) and allows them to persist in their efforts until achieving their goal (Bandura &
Schunk, 1981). An individual’s self-motivation comprises environmental settings, outcome
expectancies, valuing, and affect (Elliot et al., 2018). Self-motivation is equivalent to MTL in
career advancement toward leadership positions, especially where there is a lack of sponsors or
mentors. The organizational culture needs to accept and encourage women in their desire for
power. Motivation to lead is directly related to the power of valuing. Research scholars have
shown that the interplay between the organizational structure and the individual employee’s
characteristics affects that individual’s MTL, which is demonstrated by their persistence and the
efforts invested in their knowledge learning and career advancement (Mascia et al., 2015).
Research shows there is no gender difference in the motivation and inspiration of those
applying to a senior leadership role; however, 21.6% of women who applied to senior
management roles are unsuccessful, while the unsuccessful ratio of their male counterparts is
only 8.6% (Manfredi et al., 2014, as cited in Shepherd, 2017). Research often questioned if
qualified candidates had exerted enough effort and shown enough resilience to face challenges
such as personal discrimination based on gender and racial biases, injustice, lack of belonging,
and microaggressions (Elliot et al., 2018, p. 529). However, MTL was strongly determined by
“enjoyment- and challenge-based social norms” (Janus, 2014, p. 287). Studies have found that
the relationship with work impacts a physician’s MTL at an AMC (Janus, 2014). Although
motivation is difficult to measure, culture is a variable that helps understand individual and
group motivation under different contexts (Janus, 2014). More research needs to be conducted on
how aspiring BIPOC candidates’ motivation impacts their advancement to middle-level
leadership. From Bandura’s social cognitive perspective, “self-motivation through proximal goal
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setting serves as an effective mechanism for cultivating competencies” and perceived self-
efficacy (Bandura & Schunk, 1981, p. 586).
Self-Efficacy
Self-efficacy impacts leadership competency development and is positively related to an
individual’s MTL (Mascia et al., 2015). Self-efficacy is defined as “the degree of belief in the
individual abilities of personal organization and implementation of the desired tracks to achieve
the required result” (Abuzid & Abbas, 2016, p. 1978). Healthcare leadership models have
identified the essential competencies of healthcare leaders and highlighted that self-efficacy is
the critical factor for the effective development of leaders (as cited in Abuzid & Abbas, 2016,
Goldsmith, 2008). Self-efficacy, achievement motives and goals, personal values, and mindset
predict the outcome of an individual’s related knowledge learning. Research shows that nurses’
leadership self-efficacy affects their MTL and leadership experience, which, in turn, are
significantly influenced by mentorship and sponsorship (Cziraki et al., 2017).
Research conducted through an evaluation survey of self-perceived servant leadership
and leadership self-efficacy among 1,014 first-semester health professions students found that
additional leadership experience significantly correlated with leadership self-efficacy (Murphy et
al., 2020). Abuzid and Abbas (2016) measured the level of self-efficacy and the level of
performance test through random sampling from the health sector in Alkharj City in the central
region of Saudi Arabia, and this research also shows the effect of self-efficacy on leadership
capabilities development (as cited in Abuzid & Abbas, 2016, Anderson et al., 2008, Hannah et
al., 2008, Machida et al., 2012). The research based on 482 HMMs’ experiences published from
January 2005 through February 2019 found that their capacity for leadership development
depends on knowledge, trust, and confidence (Hartviksen et al., 2018). Although research has not
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been explicitly completed on HMMs, this conclusion may also apply to CDAs. Research shows
that self-efficacy impacts the cultivation of leadership competency. It is also necessary to
understand what shapes one’s self-efficacy.
Self-efficacy is carved out by personal experiences, culture, and values, which impact an
individual’s decisions about choice of activity, task persistence, level of effort devoted, and
resilience to achieve the goal of leadership advancement (Wong et al., 2012). Given the obstacles
to promotions that BIPOCs face, minority candidates have to spend much more time than
predominant groups to navigate and identify resources to promote diversity and advance their
careers in AMCs. The choice often heavily depends on individuals’ cost-effective motivation;
they must determine if it is worth it to pursue the CDA role, given that it requires much time and
effort. However, no studies have been conducted on how self-efficacy affects women,
particularly women of color, in overcoming those barriers to advancing middle-level non-
clinician healthcare leadership.
The absence of BIPOC leadership role models, which is a form of environmental
invisibility, impacts racial/ethnic individuals’ self-efficacy and hinders them from competing
with others to advance their careers in AMCs. The lack of role models causes some
underrepresented candidates not to believe that their effort and hard work can lead to career
advancement toward a CDA role. Proper environmental settings, such as more diverse leaders or
more training opportunities, not only help extend their perspectives of leadership knowledge but
also enhance the healthcare middle manager’s trust and confidence (Hartviksen et al., 2018).
“Trust and confidence are the key elements in building self-efficacy” (Wong et al., 2012, p. 2).
To aspiring leadership candidates in an AMC, environmental culture and settings as
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organizational factors can impact their self-motivation and self-efficacy significantly. It is
important to examine an AMC’s organizational factors that might affect diversity among CDAs.
Organizational Factors That Impact Diversity Among CDAs
Although explicit or implicit biases may cause the lack of diversity, increasing diversity
can only be achieved with “deliberate and systems-level decision” (Bingmer et al., 2020).
Academic medicine is described as a noncollaborative and biased environment (Surawicz, 2016)
that impacts the diversity of the middle manager role. Increasing diversity of leadership requires
organizational change. The organization can “act as a sponsor by leveraging its political capital
to advocate for individual career growth and advancement while promoting personal visibility
through networking” (Hardy-Waller, 2015, p. 26). Research has found that HR, organizational
culture and values, and leadership engagement significantly affect change initiatives (Kash et al.,
2014). Despite little research on the CDA role, related research on faculty or nurses should apply
to CDAs. The lack of women leaders can be exacerbated by multiple organizational factors
(Beeler et al., 2019). This section will review the literature on organizational factors that impact
leadership diversity, including the commitment of medical school top leaders and department
chairs, HR policies, culture, and values.
Top Leadership and Department Chairs’ Commitment
Top leadership commitment can determine if the goal of diverse leadership in the middle
and entry levels can be achieved (Chanland & Murphy, 2018; Ng & Wyrick, 2011). Top
leadership commitment is important for implementing strategies and delivering policies and
practices of diversity (Deas et al., 2012; Gould et al., 2018; Surawicz, 2016) through
organizational processes, awareness, engagement, mentoring, networking, training and
development, and organizational financial support (Mousa et al., 2021). While healthcare
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leadership faces financial pressures and a workforce shortage, it is essential to diversify the
clinical and academic workforce (LaVeist & Pierre, 2014) by attracting more BIPOC students
and a growing, diverse clinician workforce. Although academic culture believes that individuals
are responsible for managing their own career advancement (Coate et al., 2015, as cited in
Shepherd, 2017), research shows that commitment from the deans and acceptance from
department chairs are essential for improving diversity (Deas et al., 2012). Without leadership’s
efforts, implementing diversity is unlikely to increase. Most AMCs’ current settings still fail to
consider the non-White perspective.
Thus, top leaders’ commitment can provide vital support to diverse candidates, help them
cross hierarchical, departmental, and organizational boundaries, and minimize the challenges of
gender and racial biases in the career ladder (Chanland & Murphy, 2018). The slow progress of
women into leadership in academic medicine results from deeply embedded unconscious gender-
based biases and top leaders’ assumptions that underpin women’s stalled advancement in
knowledge and experience (Carnes et al., 2008). Diversity of leadership cannot be ignored. Top
leaders’ underlying biases allow institutional barriers to persist, which significantly impacts the
organization’s daily working environment and hinders the promotion of diversity and an
inclusionary culture for all employees (Gould et al., 2018). Evidence suggests that HMMs’
commitment is dramatically affected by top leadership’s support, including allocating HR,
training, funding, and implementing policies and practices (Birken et al., 2015). The lack of
diversity in faculty and leadership was compounded by a lack of effort that White leaders put
into recruiting, promoting, and retaining racial and ethnic minorities (Mena & Vaccaro, 2017).
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Human Resources Policies for Promotion, Recruitment, and Retention of BIPOC Leaders
Human resources policies on promoting, recruiting, and retaining diversity are essential
for solving the workforce shortage at all levels in medical schools. The persistent racial
disparities in education fields compel the reconsideration of strategies for recruiting, promoting,
and retaining BIPOC faculty and leaders (Bartanen & Grissom, 2019, Béteille et al., 2012, as
cited in Fuller & Young, 2022). The research predicted a healthcare leadership shortage 10 years
ago (Matthews et al., 2013). In addition, due to the demands for patient-centered care and
demographic trends in the United States, the healthcare workforce transformation has caused a
staffing shortage (Matthews et al., 2013) and a high turnover rate, as well as the crisis of burnout
in healthcare workers (Levine, 2021). There will be a 15-million-person health worker shortage
worldwide by 2030 (Liu et al., 2017). The World Health Organization (WTO) estimated the total
global shortage to be 4.3 million healthcare workers (Aluttis et al., 2014), which includes
physicians, nurses (Drennan & Ross, 2019), occupational therapy professionals (Lin et al., 2015)
and other professionals. The United States faced an estimated shortage of 91,500 doctors in
2020, which includes 45,400 primary care physicians and 46,100 medical specialists (Zhang et
al., 2020).
To change the current lack of faculty diversity, AMCs must specifically emphasize racial
and ethnic minorities’ advancement to leadership positions through promotional, recruitment,
and retention opportunities (Davenport et al., 2022). A study shows that strategic HR
management practices can promote a diverse workforce, increase minority representation in
leadership, and facilitate the retention of minorities (Weech-Maldonado et al., 2018). Therefore,
HR needs to attract and choose more BIPOC candidates and allocate more resources to provide
additional learning and practice opportunities, recognize and acknowledge the BIPOC’s
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contributions, and identify and promote more diverse candidates (Weech-Maldonado et al.,
2018). Organizational culture and values significantly impact organizational behaviors, including
HR policies and procedures to promote, recruit, and retain BIPOC in the entry-level workforce
and leadership at the middle or higher levels.
Medical School Culture and Values
Despite top leaders’ commitment and HR policies, a medical school’s culture and values
are also key elements that impact leaders’ diversity at all levels (Surawicz, 2016). The culture
and values of AMCs are reflected in available resources, rates of advancement, and recruitment
and retention, among other factors. The culture and values of diversity, equity, and inclusion in
an organization can help to attract and retain BIPOC faculty, students, and staff (Deas et al.,
2012). Cultural knowledge can help minority employees build rapport with colleagues, manage
diversity tensions, and improve BIPOC performance (Ely & Thomas, 2001, as cited in Vito &
Sethi, 2020). “Culture is a mechanism for sustainability and survival,” which has the “hidden
power to derail strategic change initiatives” (Browning et al., 2011, p. 11). The relationship
between the providers’ work environment’s culture, patient outcomes, and organizational
performance has been well documented, but the diversity has often not been integrated from all
levels of leadership and services rendered to diverse patient populations (Stanford et al., 2020).
Leadership is the most vital factor that impacts organizational culture (Edwards et al.,
2018). While BIPOC faculty in an AMC may suffer discrimination from their patients and
colleagues (Raphael, 2019), BIPOC non-clinician staff may face more derogatory experiences
from their clinician colleagues and have their concerns downplayed or face devaluing and
demeaning experiences compared with faculty (Sebalj et al., 2012). The high status of healthcare
providers combined with education and economic factors puts BIPOC CDAs in a challenging
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situation. They need to manage a high-standard professional team to support high-status
stakeholders (such as MDs) and balance these demands within financial constraints among high-
status stakeholders, especially in holding them accountable for meeting targets during budget
cuts and service changes (Edwards et al., 2018).
Research scholars argue that organizations and professions must strive for “a ‘well-
integrated, structurally egalitarian workplace,’ in which diversity equally shares power and
authority” (Jagsi & Spector, 2020, p. 1480). Although women of color performed much more
service activities than men, women usually were perceived as less competent and were offered a
lower salary than men (Surawicz, 2016). Sherbin and Rashid (2017) indicate that 37% of African
Americans and Hispanics and 45% of Asians say they need to compromise their authenticity to
conform to an organizational standard of demeanor or style (Sherbin & Rashid, 2017).
Research shows organizations take HMMs’ contributions for granted by letting the
HMMs take direction from top-level managers and implement the processes of day-to-day
activities (Birken et al., 2018). It is essential to set up regular support mechanisms for HMMs,
including CDAs. Structural solutions and wholesale cultural transformations are necessary to
change the systematic gender and racial inequity in academic medicine. To examine the
discourse from the standpoint of CDAs and achieve the desired diversity outcome, a conceptual
framework building on theories is essential for research.
Conceptual Framework
The majority of existing studies on healthcare leadership only focus on faculty, medical
students, residents, or C-suite leadership by gender identity or racial identity. Few researchers
have examined faculty, medical students, residents, or C-suite leadership by considering the
intersectionality of gender and race. There is a lack of research on the diversity of middle-level
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non-clinician leaders, such as the CDA role. Only two studies have examined the leadership
competencies or training of middle-level healthcare managers’ leadership capacity and capability
(Dearinger, 2011; Hartviksen et al., 2018). Past research used the leadership pipeline to examine
the lack of diversity of leadership by focusing on limited leadership positions, but there is no
specific reason to explain why women of color encounter more difficulties in their career
advancement (Berlin et al., 2019). Research on leadership diversity primarily focuses on
knowledge or organizational factors, and scholars seldom assess the gaps in combining
knowledge and skills, motivation influences, and organizational factors.
This research was guided by Clark and Estes’s (2008) gap analysis framework lens (akin
to KMO), along with the leadership pipeline and SCT to examine the required knowledge and
leadership skills, individual motivation influences, and organizational factors to identify the
reasons that cause the lack of diversity of leadership at the entry and middle levels of the
leadership pipeline. Once the impact factors are identified from the KMO aspects, SCT can be
applied to propose effective learning opportunities and improve organizational behavior for
BIPOC advancement.
Clark and Estes’s (2008) gap analysis framework diagnoses the organizational
performance gaps from three aspects: KMO factors. According to Clark and Estes, performance
problems result from a combination of gaps in KMO influences and organizational factors like
policies, procedures, and culture (Clark & Estes, 2008). The lack of diversity among CDAs is a
performance gap for an AMC. The gap analysis framework is a problem-solving model focused
on diagnosing an organization’s group performance issues (Clark & Estes, 2008). Therefore, a
gap analysis framework is appropriate to identify the root cause of a lack of diversity among
CDAs at medical schools and adopt proper strategies to fix this issue. The gap analysis model
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can provide clear advice and techniques on how to increase diversity among CDAs from aspects
of individual knowledge and motivational influences, as well as organizational factors. It can
help BIPOC and medical school top leaders to identify what changes are needed to achieve the
goal of diversity among CDAs and create an equitable and inclusionary environment. Using the
gap analysis framework, we can unpack a CDA’s experiences at the nexus of education, gender,
race/ethnicity, age, and other salient identities in the context of medical schools at AMCs.
Social cognitive theory (SCT) focuses on the reciprocal interactions among personal,
behavioral, and social/environmental factors (Bandura, 2001, as cited in Schunk & Usher, 2019).
The theory assumes that humans are social by nature. It is a widely applied theory to study the
personal cognitive factors that humans learn from social environments and how they exert
influence on an individual’s behaviors. It is an appropriate framework to explore how the
aspiring BIPOC candidate sets their goals through the self-evaluation process, understanding the
required leadership knowledge and skills for the CDA role, and determining their behavior
changes based on an individual’s beliefs, values, expected outcomes, and social comparisons that
they learned from their environment. These cognitive influences affect an individual candidate’s
desire, task choices, efforts, and achievements (Schunk & Usher, 2019) in advancing leadership
at each level of the leadership pipeline. Organizational factors such as the environment can
significantly influence BIPOC candidates’ learning and practice behavior and motivation.
Through the SCT lens, the top leaders in an AMC can apply the appropriate principles of SCT to
promote self-efficacy in a BIPOC group’s cognitive learning and create an effective motivational
environment to encourage the BIPOC group to pursue their career advancement in leadership
roles such as the CDA position.
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The pipeline model facilitates to guide aspiring BIPOC candidates to pursue proper
knowledge and skills at different levels. Figure 1 presents the conceptual framework developed
from the gap analysis framework, SCT, and pipeline model. Figure 2 shows how the literature
review and interview data helped to identify the CDA role’s knowledge and skills and how these
guide aspiring candidates in practice to promote diversity among CDAs. Table 1 depicts the key
knowledge and skills for a CDA role, the essential motivation (MTL and self-efficacy), and
AMC factors influencing BIPOC candidates’ advancement at the first and second levels of the
leadership pipeline. Based on this conceptual framework, the research aims to reveal the core
causes of a lack of diverse CDAs and propose practical solutions to improve the current
organizational settings.

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Figure 1
A KMO Diagnosis Framework for Individual Advancement in the Leadership Pipeline

Note. This conceptual framework demonstrates the key knowledge and skills needed for a CDA
role and the core motivational and organizational influences on BIPOC advancement. The
knowledge and skills were based on literature by Carlström (2012), Garman et al. (2020),
Hargett et al. (2017), Kaiser (2011), Popejoy (2016), and Sonnino (2016). The motivation
influences were based on the literature by Abuzid and Abbas (2016), Ballesteros-Rodríguez et al.
(2022), Cziraki et al. (2017), and Mascia et al. (2015). The organizational factors were based on
Davenport et al. (2022) and Engle et al. (2017). The interactions between individuals’
motivation, behavior, and organizational factors were based on Elliot et al. (2018), Janus (2014),
Murphy et al. (2020), Schunk and Usher (2019), and Wong et al. (2012). The pipeline model was
mainly based on Cuofano (2021), Beeler et al. (2019), Dai et al. (2011), and Surawicz (2016).

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Figure 2
Process Diagram for Factual, Conceptual, Procedural, and Metacognitive Knowledge and Skills
for CDA Role

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Table 1
Influences for Knowledge, Motivation, and Organization in Conceptual Framework
Element Factors for Level 1 Factors for Level 2
Knowledge Accounting and finance
HR and teambuilding
Communication and networking
Personal attributes and behavior
Business strategy
Accounting and finance
HR and teambuilding
Communication and networking
Personal attributes and behavior
Motivation Self-efficacy
Motivation-to-lead
Self-efficacy
Motivation-to-lead
Organization Training opportunity
Human resources policies
Medical school culture and values
(invisibility, glass ceiling, feminine
modesty, perceived riskiness, and
racial microaggressions)
Diversity of chairs
Mentorship and sponsorship support
Formal training
Human resources policies
Medical school culture and values
(invisibility, glass ceiling, feminine
modesty, perceived riskiness, and
racial microaggressions)

Summary
Research on the diversity of medical faculty and top healthcare leadership revealed the
underpinnings of genderism and racism within both medical and academic environments. AMCs’
structural racism and implicit biases hindered the recruitment, retention, and promotion of people
of color and contributed to a lack of diversity of faculty and leadership. Considering the large
proportion of women in entry through middle-level leadership positions, women of color rarely
made progress to top-level leadership. From the literature review, diversity of leadership research
emphasized top healthcare leadership or clinician leadership by focusing on the intersectionality
of gender and leadership but ignoring the identity of race. Little research addressed the issue of
lack of diversity among middle managers. Predominant research focuses on the diversity of
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faculty or students in academic medicine. Little research has been conducted on the diversity of
staff in medical schools. There is a lack of research on diversity among middle-level and non-
clinician leadership. This dissertation focused on diversity among CDAs who are middle-level
and non-clinician leaders at AMCs. This research examines individual knowledge, motivation,
and organizational factors to unpack the reasons for the lack of diversity among CDAs. It hopes
to provide a roadmap for BIPOC career advancement and strategies for top leadership to
promote, recruit and retain diversity among CDAs in AMCs. This study also gave women of
color a voice to discuss the intrapersonal and interpersonal challenges they face and offered
strategies for AMCs to create more equitable spaces to support their leadership development.

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Chapter Three: Methodology
This chapter introduces the research methodology that was utilized during this study.
This chapter includes an overview of the research design as well as a description of the research
setting, data collection methods, and instrumentation approaches utilized. This study focused on
the CDA group in a single medical school within a private higher education university on the
west coast of the United States. The goal of the research was to identify the critical knowledge
and skills, motivational influences, and organizational factors that impact the career
advancement of BIPOC to the CDA role. The questions that guided the study are as follows:
1. What knowledge influences among clinical department leadership contribute to the
lack of diversity among CDAs?
2. What motivational influences among aspiring candidates contribute to the lack of
diversity among CDAs?
3. What organizational influences contribute to the successful promotion, recruitment,
and retention of women of color CDAs?
Overview of Research Design and Rationale
This research adopts a qualitative methodology. This study used the gap analysis
framework to identify the CDAs’ knowledge and skills, motivation influences, and
organizational factors that impact their role’s leadership development. I conducted semi-
structured interviews with a purposefully selected sample by inviting all available CDAs at one
medical school. This study was practical action research “focused on organizational change and
behalf of a particular subgroup” (Merriam & Tisdell, 2016, p. 55) of CDAs. I am an insider of
the particular CDA group at this organization. Given that there are about 15 CDAs in each
medical school, “typical, normal, and average” (Patton, 2014, p. 268) sampling was adopted by
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choosing a typical medical school and inviting all CDAs to participate in the study. The
purposive technique is the deliberate choice of a participant due to the qualities the participant
possesses (Etikan et al., 2016). The purposeful sample is a typical way to gather the information
that is particularly relevant to the research questions and “can’t be gotten as well as from other
choices” by deliberately selecting particular settings, persons, or activities (Maxwell, 2013, p.
97). In this research, the particular setting is a medical school, and the actors are CDAs. Table 2
presents the research methodology of the data sources.

Table 2
Data Sources
Research questions Interview
What knowledge influences among clinical
department leadership contribute to the lack
of diversity among CDAs?
X
What motivational influences among aspiring
candidates contribute to the lack of diversity
among CDAs?
X
What organizational influences contribute to
the successful promotion, recruitment, and
retention of women of color CDAs?
X

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Research Setting
The study was conducted in one private medical school on the west coast. Participants’
“selection decisions require considerable knowledge of the setting of the study” (Maxwell, 2013,
p. 99). This research sought to understand what contributes to the lack of diversity among CDAs
in medical schools. Therefore, the target population for the interview study was the CDAs from
whom “the most can be learned” (Merriam & Tisdell, 2016., p. 96), and the setting was the site
of the medical school. All the interviews were through Zoom meetings at my office during
weekdays. Three facets impact the research outcomes: selecting one medical school will help
control the conditions and understand the cause/effect (correlated) relationships among KMO
factors. The same organization has similar organizational factors, such as culture and values,
which would impact individuals’ knowledge, skills, and motivation influences. Culture is a key
context of organizational factors, which is attributed to “social events, behaviors, institutions, or
processes” (Geertz, 1973, as cited in Merriam & Tisdell, 2016, p. 30). Researchers must spend
more time with their study group to understand their culture (Merriam & Tisdell, 2016, p. 29).
Since I am a CDA in one clinical department, I adopted both purposeful and convenient
sampling strategies to select the medical school with which I am familiar. I have no authority or
power over any participants because all CDAs work independently in parallel positions and
report to their department chairs. However, I am familiar with this medical school’s settings,
persons, and activities and could collect the information relevant to the research questions
efficiently and effectively. In addition, this information is impossible to “be gotten so well” from
other medical schools (Maxwell, 2013, p. 97).
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The Researcher
As the researcher, I am a first-generation female immigrant currently employed as a
CDA. From my experience, the leadership pathway is never easy for women. It is particularly
hard for women of color, who are underrepresented in higher education, to advance to leadership
positions. Due to multiple factors, it took me more than 20 years to become a CDA. This study
reflects my perceptions of the leadership trajectory and practice associated with my identity as a
woman of color who grew up in a middle-class family and earned bachelor’s and master’s
degrees from top-tier universities. I worked at several universities before taking the CDA role.
As an underrepresented woman in a higher education administrative role, I faced not only
gender discrimination but also race and cultural discrimination, including stereotyping,
prejudice, and unjust treatment (Nguyen, 2020). Because of gender and racial discrimination, I
had been striving for the entry-level manager position for about 10 years before taking over the
CDA position despite the remarkable progress I contributed to the university. My core value was
shaped by the Asian cultural values of group orientation, resilience, strong work ethic, and
emphasis on excellence (Kawahara et al., 2013, p. 240), which I consider a merit resource that
led me to achieve my goal. I believe various cultural values bring worth to the community and
society, and I am rationally confident in my racial status (Nguyen, 2020). I want to spread more
positive messages to help more women of color fulfill their goals. I also hope to contribute my
efforts and work with women at similar organizations to establish diverse values and create a
better working environment for all women by eliminating discrimination related to gender, race,
and culture (Nguyen, 2020).
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Data Sources
The data were collected through individual interviews via Zoom meetings. This
phenomenological study involved conducting interviews (as cited in Creswell & Creswell, 2018,
Giorgi, 2009, Moustakas, 1994). In addition, as little research has been conducted on this topic,
the interviews were based on all CDAs’ lived experiences to get to their essence (Merriam &
Tisdell, 2016, p. 237).
Interview
Demarrais (2004, as cited in Merriam & Tisdell, 2016) defined a research interview as “a
process in which a researcher and participant engage in a conversation focused on questions
related to a research study” (p. 108). There are three types of interviews: structured, semi-
structured, and unstructured (Merriam & Tisdell, 2016, p. 110). This study used a semi-
structured interview approach through a recorded Zoom session. The 12 pre-written interview
questions (Appendix A) aligned with the research questions. Because I am a CDA who has built
rapport with other CDAs, semi-structured interviews were more flexibly worded for the same
open-ended questions to keep the participants engaged and so that I could use more probes to
follow up in-depth to collect more data.
This research utilized a transformative worldview with open-ended questions to examine
knowledge and skills and motivational and organizational influences related to a lack of diversity
among CDA leadership. Participants’ experiences are collected by using the narrative approach.
The narrative approach involves interviewing individuals at length to examine personal
experiences and identify existing gaps. (Creswell & Creswell, 2018, p. 17). When inviting the
participants, I provided an information sheet that included the purpose of the research, the
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interview information, and other pertinent information. Participation was voluntary, and
interviewees had the right to stop at any time during the research.
Participants
The idea behind qualitative research is to “purposefully select participants or sites that
will best help the researcher understand the problem and research questions” (Creswell &
Creswell, 2018, p. 165). With the limited number of sites or participants, the purposeful selection
is a considerable choice (Light et al., 1990, as cited in Maxwell, 2013, p. 97). In this study, the
site was one medical school, and the participants were all CDAs at this school, regardless of their
gender and racial identities. All CDAs at this school were invited to participate in the interviews,
which sought to “discover, understand and gain insight” (Merriam & Tisdell, 2016, p. 96) from
the interviewees as well as represent the “typicality of the settings, activities” (Maxwell, 2013, p.
98) among all medical schools. The goal of this research was to get all 16 CDAs to participate in
this study to gain knowledge about all perspectives, including those of people of different races
and genders.
Instrumentation
This study used semi-structured interviews to collect data from participants. Because
there is little research on the middle-level, especially non-clinician, healthcare leadership, and
this research “involves an understudied sample” of CDAs, “then it merits a qualitative approach”
(Creswell & Creswell, 2018, p. 19). The purpose of using a semi-structured interview is to
“gather information from key informants who have personal experiences, attitudes, perceptions,
and beliefs related to the topic of interest” (DeJonckheere & Vaughn, 2019, p. 2). I used a semi-
structured approach for the interview by asking each CDA the same open-ended questions
(Merriam & Tisdell, 2016, p. 110). Individuals’ responses can help understand their perspectives
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on the KMO factors that influenced their career advancement. Each interviewee had different
experiences or perspectives. However, the hope was to collect data on the three themes of
knowledge, motivation, and organizational influences that contributed to the lack of diversity
among CDAs to keep consistency and increase trustworthiness.
Semi-structured interviews allow us to ask the same open-ended questions and obtain
data to focus on answering the three research questions. The participants were familiar with me
and could have already answered some questions during a prior conversation. Therefore, some
questions could be flexibly worded, and the interview could be a mix of less structured questions
(Merriam & Tisdell, 2016), depending on the interviewee’s responses. I asked 12 questions
during the interview. These interview questions were distributed evenly among the research
questions, which means there are at least four interview questions associated with each research
question. Few questions covered more than one research question. The list of questions helped to
guide the interview, but the wording or order of the questions could not be determined ahead of
time to “[allow] the researcher to respond to the situation at hand, to the emerging worldview of
the respondent, and to new ideas on the topic” (Merriam & Tisdell, 2016, p. 111). All interviews
were recorded with a recorder, an iPhone, and Zoom recording and caption functions to make
sure all interview data were recorded properly and with extra backup to avoid technical glitches.
I used ATLAS to code and analyze these transcript data.
Data Collection Procedures
Each interview took 45 to 60 minutes. I set up a 1-hour Zoom meeting with each
interviewee. The interview protocol can be found in Appendix A, and the interviews were
conducted in individual formats. The interview involved semi-structured and “generally open-
ended questions … intended to elicit views and opinions from the participants” (Creswell &
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Creswell, 2018, p. 167). All interviews used Zoom live transcript with an additional recorder and
cellphone to make sure all data were captured properly. I also wrote short notes along with the
interview protocol. The Zoom meeting ensured the interview setting was consistent across all
participants and reduced other interferences. No incentive was offered to CDAs for completing
the interview. Follow-up reminder emails were sent to some CDAs as needed.
Data Analysis
I organized the recorded data by transcribing them within 1 or 2 days to capture the
details. The transcript data were organized by “bracketing chunks” and writing an expected
category code in the margins (Creswell & Creswell, 2018, pp. 193–195). The data that were
relevant to the research questions were coded into cluster categories by using axial coding to
identify the relationships between categories (Vollstedt & Rezat, 2019). ATLAS-ti software was
used for coding. A prior coding list was created based on the previous literature review. New
codes were added or emerged as needed during the data review and open coding process. I
thoroughly reviewed all transcripts multiple times to develop a complete list of core knowledge
and skills, motivation, and organizational influences before and after taking over CDA roles.
Then codes were grouped and exported to Excel sheets based on the knowledge and skills,
motivation, and organizational influences by critical words or sentences and consolidated based
on gender and ethnic groups.
I compared and analyzed the data between BIPOC and non-BIPOC and between White
women and women of color to identify the gaps among different subgroups. Inductive and
comparative analysis are the primary methods used widely throughout qualitative research to
generate findings (Charmaz, 2014, as cited in Merriam & Tisdell, 2016). “Data analysis is the
process of making sense out of the data,” which “involves consolidating, reducing, and
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interpreting what the participant has said” (Merriam & Tisdell, 2016, p. 202). The research based
on a healthcare leadership competency model (Garman et al., 2020; Stefl, 2008), competency
mapping (Kaur & Kumar, 2013), MTL and self-efficacy survey (Mascia et al., 2015) to identify
keywords for knowledge and skills, motivation, and organizational influences. Then, I
consolidated each participant’s interview transcription and converted all the keywords in Table
3.

Table 3
Keywords Related to KMO Categories
Category name Keywords related to the category
Knowledge and skills Finance, team, training staff, etc. (Hargett et al., 2017)
Coaching and training staff, providing resources and support (Engee et
al., 2017; Birken et al., 2012)
Motivation Behaviors: actively approach resources, target others who are slightly
better (Elliot et al., 2018, p. 193), etc.
Words or behaviors related to MTL (before taking the CDA role) and
Self-efficacy (after taking the CDA role) (Mascia et al., 2015)
Organization factors Mentor, sponsor, and leadership commitment (Engle et al., 2017;
Lukas et al., 2007), opportunities (autonomy/agency Elliot et al.,
2018, p. 371), strategic human resource and diversity leadership
(Baker et al., 2019), etc.

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Validity and Reliability
This study’s validity and reliability were guaranteed by multiple strategies, such as a
consistent approach and protocol, triangulation of data via cross-checking with all participants,
and member checking by repeating some of their responses during the interview. Qualitative
validity means that the researcher checks the accuracy of the findings by employing certain
procedures, whereas qualitative reliability indicates that the researcher’s approach is consistent
across different researchers and among different projects (as cited in Creswell & Creswell, 2018,
Gibbs, 2007). In this research, all the interviews followed the same interview protocol, and only
one interviewer conducted the interviews with the same list of questions. The selected medical
school has a diverse employee base, and all CDAs were invited to participate in this study.
Although I was the primary instrument for data collection and analysis, I triangulated the data by
using member checking during the interviews to determine the accuracy of the qualitative
findings (Creswell & Creswell, 2018, p. 200), “cross-check the data” and “shore up the internal
validity” (Merriam & Tisdell, 2016, pp. 244–245).
During data analysis, where there were multiple interpretations for certain content, I
asked the participant to clarify and confirm the interpretation. During the interview, I conducted
a pinpoint check with participants by reiterating or confirming their perspectives time by time.
This process helps to ensure the accuracy of the data interpretations and establish rigor and
validity. Since the interviewees and I are in a similar position and the entire CDA group has
fewer than 2000 people nationwide, we have attended many professional meetings together and
built up rapport in the past. Thus, I could “conduct a follow-up interview with the participants
and provide an opportunity for them to comment on the findings” (Creswell & Creswell, 2018, p.
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200) easily and consistently. Data triangulation helped to examine evidence and increase the
credibility and confirmability of the data.
In addition, all the research questions are designed from the CDA’s worldview and
alignment with the conceptual framework (Merriam & Tisdell, 2016, p. 254). Moreover, this
study used multiple theories, engaged all CDAs with adequate time (prolonged time was spent
getting to know all of them), clarified researcher biases and positionality, presented negative or
discrepant information that ran counter to the themes, and conducted member checks to validate
the data’s reliability (Creswell & Creswell, 2018; Merriam & Tisdell, 2016). All of those
strategies help maximize credibility and trustworthiness in this study.
Ethics
Ethical considerations are anticipated extensively and reflected throughout the research
process (Creswell & Creswell, 2018, p. 90). I considered the ethical needs during designing the
research plan, including the purposeful full-population sample, interview protocol, and
submitting an IRB by addressing all ethical issues before starting the data collection. I was aware
of the responsibility to keep all the information confidential and protect the participants’ privacy
during data analysis (Creswell & Creswell, 2018, p. 90). I introduced the research topic and
purpose, reiterated the confidentiality of the data to the participants, sought to “respect norms
and charters of Indigenous cultures” as well as the site and disrupt as little as possible, and asked
for permission to record the interview (Creswell & Creswell, 2018, pp. 92–94). The information
sheet provided with IRB approval states that this process is voluntary, confidential, and
anonymous. The results shared do not have names attached, and I assigned the school a
pseudonym to protect anonymity. I endeavored to report the findings honestly without falsifying
authorship, evidence, or findings, not plagiarizing, not disclosing information that could harm
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participants, and ensuring all data were saved in secure data storage (Creswell & Creswell, 2018,
pp. 95–96).

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Chapter Four: Results and Findings
The purpose of this research was to identify the KMO influences affecting aspiring
BIPOC candidates’ pursuit of career advancement toward a CDA role. Following a qualitative
design, this study utilized a conceptual framework (Figure 1) developed from the gap analysis
model, SCT, and leadership pipeline. In addition to Clark and Estes’ (2008) gap analysis model,
this chapter also adopted Bandura and Schunk’s (1981) SCT to understand what and how the
WMC could do to motivate and encourage BIPOC to learn and gain the knowledge and skills to
prepare for their career advancement toward a CDA role to promote diversity among CDAs in
their organization. This chapter outlines the following elements of the research: participating
stakeholders, interview results, and findings on a CDA role. As stated in the previous chapter,
three questions guided this study. Three questions guided this study:
1. What knowledge influences among clinical department leadership contribute to a lack
of diversity among CDAs?
2. What motivational influences among aspiring candidates contribute to the lack of
diversity among CDAs?
3. What organizational influences contribute to the successful promotion, recruitment,
and retention of women of color CDAs among clinical departments?
Participating Stakeholders
Fifteen interviewees participated in this study, 14 CDAs and one associate CDA. Among
the 14 CDAs, one participant was an interim CDA, and one was a floating CDA. The associated
CDA only managed the department’s clinical and research-related responsibilities but did not
manage finances or the budget. The participants’ experience ranged from 2 months to 32 years,
with nine years as the median. Among the 15 interviewees, 12 were female, three were male, and
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six were POC. However, not all races and ethnicities were represented. Eleven interviewees had
master’s degrees as their highest level of education, and two had doctorates. The majority who
took the CDA role in the past 15 years had certain degrees. A current qualification to be hired in
the role is to hold an MBA or MHA (see Table 4). Table 4 identifies the participants’ working
experience, education, and ethnicity.

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Table 4
Demographic Information of Participants
Participants
Working years
before current
CDA Role
Years of CDA at
WMC
Highest degree
completed
Ethnicity/gender

1 22 6–10 MBA Hispanic/male
2 22 6–10 MBA White/female
3 25 0–5 MBA White/female
4 12 0–5 MHA
Asian and Pacific
Islander/male
5 8 16–32
High school
diploma
Hispanic/female
6 20 10–15 MBA White/female
7 7 0–5 MHA, EdD
Asian and Pacific
Islander/female
8 10 0–5 EMBA White/female
9 10 6–10 MBA, MHA Hispanic/female
10 17 11–15 MPH White/female
11 12 0–5 Clinical master’s White/female
12 25 0–5 MBA
Asian and Pacific
Islander/female
13 15 10–15 DPH White/female
14 20 10–15 MBA White/male
15 44 10–15 BA White/female

Interview Results and Findings
I conducted 15 Zoom interviews with the participants. I coded and analyzed all interview
transcripts line by line in ATLAS-ti. The data analysis started with a priori codes derived from
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the literature review and open codes created during the coding process. Axial coding was used to
identify and cluster themes from the interview transcripts. I conducted the data analysis carefully
through multiple screens and reviews. This section presents the data analysis results and findings
related to the three research questions, which included results and findings of key knowledge and
skills, motivation, and organizational influence in a CDA role that contribute to a lack of
diversity among CDAs.
Results and Findings of Key Knowledge and Skills Influence Contribute to a Lack of
Diversity Among CDAs
Although the data show that a CDA performs different tasks, depending on their chair or
department needs, their fundamental knowledge and skills are similar. This section presents the
results and findings of the key factual knowledge and skills that influence CDAs’ job function
and discusses their procedural knowledge and skills by comparing the factual knowledge and
skills identified from this research with the conceptual knowledge and skills derived from the
literature review and presented in the conceptual framework in chapter two, which includes
finance, teambuilding, communication, networking, and business strategy planning. It aims to
answer the first research question by focusing on the key procedural knowledge and skills for the
role and whether there is a knowledge and skill gap between current POC CDAs, especially
women, and non-POC CDAs. The results can advise aspiring BIPOC women candidates to attain
the key procedural knowledge and skills as well as minimize the knowledge gap that hindered
their career advancement toward a CDA role and caused the lack of diversity among CDAs. The
knowledge and skills to be discussed include business strategy and planning, accounting, finance
and budget, HR management and teambuilding, communication and networking, and critical
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personal attributes. This section closes with a discussion of significant gaps that hinder obtaining
the knowledge and skills for the CDA role.
Key Knowledge and Skill in Business Strategy and Planning
Effectively managing business strategy and planning was the first key knowledge and
skills to emerge in data analysis. Among all 15 participants, 14 (93%) mentioned the business
strategy skill, and 12 (80%) indicated that business strategy skill was critical. A CDA helps the
clinical department chair run their department as a mini business unit. Not all department chairs
are business savvy, a good CDA should be able to assist the department chair to be a better
businessperson and facilitate the chair to be successful in his or her role.
To maintain a department’s sustainability and align its goal and mission with the AMC’s
goal and mission, exploring new opportunities, developing new collaboration, opening new
clinics, and expanding service lines happened frequently in a clinical department. A participant
said, “It’s like new businesses, all the time a new business that you never did before.” CDAs not
only need to handle daily tactical issues from internal and external but also need to decide the
best business strategy plan to ensure the department is running sustainably. As another
participant stated, the strategy can be “what do we do next to continue to grow, recruitment of
new faculty, the relationships with referring physicians? What other new hospitals are we trying
to develop contracts with?” Although two non-POC women participants admitted they were not
businesswise, nine participants (60%) had a business-related degree, and the other 3 (20%) had a
science-related degree. Twelve participants (80%) have at least one business- or science-related
degree. Table 5 shows direct quotes from three POC women CDAs and four non-POC CDAs on
how they use business strategy and planning to fulfill their tasks.

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Table 5
Direct Quotes of Business Strategy and Planning Influence
Participants Quotes
POC women Honestly, I think what has helped me the most is having a natural business.
We had to get creative. We needed to recruit faculty. We needed to make
sure that we had busy clinics. We needed to make sure that we had space.
I find that, in different organizations, they might not have a business
intelligence system set up. So, you kind of have to know. Okay, I need this
kind of information to be able to develop this analysis, to be able to make
this business decision. Strategy is important, and along with that is the
analytical experience.
Non-POC
women
I’ve always also been good at organizational problem-solving and structuring
wherever I worked. And it’s talking to those in the notes and trying to
figure out how can we make this work better. Now, basically the
department I’m in, the chair calls the shots on all of those, but he likes
inputs and ideas.
I mean, you have to have negotiation skills for sure. I mean, depending on
how deep you’re going to go into this, right? Because we negotiate call
contracts, we negotiate professional service agreements.
I think strategy, understanding of business, can be really helpful … very
strong critical thinking skills, very strong analytical skills, strategically
minded.
You have to be strategic because it’s all about how you get this money, and
that money you have to put together proposals. And if you can’t put flush
arguments together, they’re not going to buy it.

These quotes in Table 5 present insights into business strategy and planning, including
thinking critically, analyzing current data on status strategically, negotiating the support
agreement, and developing a meaningful plan as key skills. There was no significant gap in
business strategy and planning skills between POC women participants and others. While three
out of four (75%) women of color were business savvy, only four (57%) non-POC women CDAs
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indicated they are good at business strategy and planning. According to several participants, even
though business knowledge can be learned through an MBA program, they mainly gained it from
experience. One participant said,
I think having traveled a lot really helped me in terms of getting through difficult
positions or the difficult situations … So, I think that those are far more important to me
doing a good job at this than, say, getting my MBA.
Although there is no evidence proving who was excellent at business strategy before taking the
CDA role, seven participants had several years of experience in the business sector, including
manufacturing, bank, consulting firm, and pharmaceutical companies. CDAs recognized that
academic medicine evolved into more of a business because of the tighter financial resources,
which requires CDAs really have to think critically and be more strategic.
Key Knowledge and Skills in Accounting, Finance, and Budgeting
Another key knowledge and skill that emerged in data analysis was deeply understanding
accounting, being able to interpret the data, and managing the department’s finance. Fifteen
interviews agreed that accounting, finance, and budgeting are the most common knowledge and
skills that a CDA should obtain (see Table 6). One POC woman participant described, “The chair
is the CEO, and the CDA is the COO. You have to make sure your finance and budget are
running in good shape, inform the chairs.” Another non-POC interviewee also pointed out, “The
most effective CDAs that I’ve ever met have kind of this intuitive understanding of how to keep
the department in balance ... That requires keeping a lot of plates spinning at the same time.”
Table 6 presented other interviewees’ quotes sorted by POC and non-POC groups. It shows how
knowledge of accounting, finance, and budgeting is embedded in CDAs’ jobs.
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Table 6
Direct Quotes of Accounting, Finance, and Budgeting Influence
Participants Quotes
POC Finance is an important piece of CDA because you got to turn in a balanced
budget, and then every month, you review the budget and your actual thing
compared to where you are at and start figuring out if there are any
discrepancies or any variance to your budget.
I think fiscal management, budget management, and preparation are really
important in this role. Analytical skills of being able to pull reports or even
create reports from different data sets.
I was able to do P&Ls when I was 20. Working in the controller’s office, a lot of
the financials that we do today, I was doing 20 years ago.
Non-POC We are all responsible for budget, and we’re all responsible for invoicing
hospitals we work with.
You have to know the finances. You have to understand the revenue cycle
absolutely and utterly. You really need to know billing, and you need to be
really confident with the finances of the department.
I do think finance is someone you have to have. I think you have to know about
money. … I think you need to understand how to manage large budgets or have
had some experience in that.
You have to know how to read a balance sheet and understand P&L
If you’re doing finances in your role as a CDA, you need to understand that kind
of thing.

Table 6 shows that knowledge and skills in accounting, finance, and budgeting are
important for a CDA role. There is no difference between POC women participants and other
participants. Twelve (80%) interviewees were very confident with their finance and budget
management responsibilities. Several participants commented that this knowledge and skills are
learnable in the early career stages. A POC interviewee indicated, “I got my first job as a student
worker at business services at the university. I worked on purchasing, disbursement control,
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accounts payable, and travel management.” Although this is a trainable skill, 12 (80%)
interviewees had finance and budget experience before they took the CDA role, and five (33%)
were well-trained or good at numbers. In an AMC, the money is “usually flowing from us [the
clinical departments] to the medical school in the form of a tax,” as a participant shared. The
medical school operation heavily relies on the clinical departments; as an interviewee stated,
“NIH dollars are shrinking. GME dollars are not enough. So, really, our only currency of the
realm is clinical dollars.”
Given that WMC contributed almost 40% of the university’s revenues and the shrinking
funds of the grants and gifts, the hospital and the medical school put more financial pressure on
all CDAs who were responsible for their department finance and managing their provider’s
clinical productivity. Clinical departments’ financial status impacts not only their department and
hospitals but also the medical school as well as the entire university. Accounting, finance, and
budgeting are the knowledge and skill to deal with all kinds of data related to different revenues
and/or expenses. This knowledge and skill help a CDA to understand the numbers in depth,
interpret the available data meaningfully, use their resources wisely, and advocate for their
department effectively and strategically. As one interviewee said: “Data is our friend.” In order
to consolidate and interpret the financial reports generated from different systems and present
meaningful data to their chair and faculty, a good CDA needs to be excellent in data analysis and
be proficient in Excel. A participant said,
Physicians … have different needs and desires for their careers. Sometimes it doesn’t
match the business strategy for a department or a unit. So, it’s working with them to get
to where they want to be but make sure that it fits within the business strategy. So, that’s
where data is very important with physicians, and it has to be accurate.
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There is no difference in the ability to acquire financial skills by gender or race. Four
POC participants, as well as non-POC participants, demonstrated excellent finance and budget
knowledge and skills in managing their departments. CDAs must understand the numbers and
context and monitor the department’s financial status. Because CDAs usually started their roles
by figuring out “how to bring the department from a deficit situation to a profitable situation” an
interviewee said, “A financial certificate program for people that will want to become CDA role
is very important.” If a clinical department is big enough, the CDA may hire a financial analyst
to be in charge of daily finance and budget task. However, it required a CDA to have a good
judgment in hiring and excellent teambuilding skills. An interviewee said, “If you can manage
research grants and a lot of dollars, … and you can figure out how to staff and hire those people.
… It’s sort of like a mini business officer, in a way.” Business, finance, and HR knowledge and
skills are integrated and connected for CDAs.
Key Knowledge and Skills of Human Resources Management and Teambuilding
The interview data also proved that HR management knowledge and teambuilding skills
emerged as important components in a CDA role. Twelve interviewees learned HR and
teambuilding during prior professional experiences. Managing people became more challenging
due to the pandemic. The knowledge and skill of having high expectations for the team that
works with you and building a good and strong foundation for your team is a must for a CDA.
Without this knowledge and skill, it is impossible to fulfill the role successfully. Table 7 below
presents more direct quotes from nine participants that demonstrated how the knowledge and
skill of HR and Teambuilding impact the function of the role and how the CDAs’ perspective
impacted employee hiring, which directly impacts the diversity of employees and departmental
culture.
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Table 7
Direct Quotes of HR and Teambuilding Skill and Influence
Participants Quotes
POC You do have some stellar employees, but then, at the same time, you also have
difficult employees and address those issues in a timely manner. Because if
you let it build up, then it gets out of hand, and then it becomes very difficult
to work, especially with other employees.
I realized the people skills you have to manage your faculty and staff especially.
I feel like, as a manager, with wellness and requiring diversity and valuing
everybody. I think it’s more difficult to manage. So, I think management skills
and people skills are more important than ever.
Human resources and hiring onboarding, sometimes having to downsize, and
having to terminate employees that might not be working well. Knowing how
to do outreach.
When I look for an employee, I don’t look for someone who has the experience.
… What I look for are more of the qualities that I can’t teach, right? I can’t
teach someone to be respectful. I can’t teach someone to have a good work
ethic.
If this is a good person or a good quality employee, how do I give them tools or
different tasks so that we can maximize them, make them successful, and also
maximize what we need as an organization?
You have to build your team whom you can trust. And that team doesn’t just
happen. You have to invest your time and your energy to build a team who
can support you through your career.
Non-POC Being the one to say, “How come you’re not showing up at work.”
we hopefully don’t have much of that because we choose the right people. But
you have to be willing to deal with that when the time comes. … You have to
be able to calmly meet with people, give them the facts, tell them their
options, let’s ask them what they think.
Well, I think you have to understand all the different pieces of work that your
staff does, even if you can’t do it yourself. It’s important to understand what
they’re doing and why they’re doing it. … If I didn’t know what my people
were doing, I couldn’t be as strong of a leader.
The third is building a team. I hired talent, fully expecting them to move on, but
I hope that I’m able to create a kind of trajectory of development and
opportunities within the department. When I hit the end of the road, then I
find opportunities for them some places else.
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Participants Quotes
I’m interested in people that have a wide berth of experiences. I said the stuff
that we do here, I can teach most people how to do. What I can’t teach them
are the experiences they have. So, I was looking for people that were
multilingual, had traveled, and had done something other than just go through
school and punch the ticket.

Although HR and teambuilding skills are unavoidable practices for CDAs, this skill is
difficult to teach. Clinical department sizes and needs are different. The smallest may only have
dozens of employees, and the largest may have several hundred. Despite the size, as one
participant indicated, a clinical department has “a lot of moving parts and relationships that need
to be cultivated.” Although not all participants were good at HR and teambuilding, all divulged
this knowledge and skills for a CDA role. However, HR and staffing are challenging, as three
non-POC participants admitted that HR-related factors are challenging and bothersome.
In contrast, except for a new POC CDA, all other five POC CDAs are very confident in
HR and teambuilding. One participant said, “the broader the CDA’s experience, the better they
are at sort of getting along in this multiple cultures, different people, different education levels.”
This knowledge and skill gap between POC and non-POC groups demonstrated that POC CDAs’
multicultural backgrounds helped them understand multicultural relationships easily and handle
HR and teambuilding effectively in diversified environments. More diversity among CDAs can
reduce racial disparities and promote the diversity of employees in AMC. Excellent
communication and networking skills are important supplements for building positive
relationships, creating a satisfying working environment, and lining up people for the
teambuilding in any department.
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Key Knowledge and Skills of Communication and Networking
The fourth key knowledge and skill that emerged in the data analysis is communication
and networking. Excellent communication skill is a tool for networking. A non-POC participant
said, “When you’re at a department, communications are with the dean, hospitals, and other
entities. … Relationships with your partners, the hospital, the county, and the dean’s office are so
important.” One POC participant also stated that building up relationships with other CDAs, the
hospitals, and the dean’s office could help individual CDAs “bounce ideas off and figure out
what the best practices are.” Communication and networking skills help people to understand
each other and interact with physicians, the dean’s office, and hospital administrators to make
sure people realize they “have to work together and have to have common goals and common
strategies for either one of them to be successful,” as indicated by another participant.
Excellent communication and networking skill also help in fundraising activities. One
participant mentioned, “If we don’t have donors, we can’t be afforded certain things that we
want to do in research or the clinical space, or in anything that we do” in academic medicine.
According to several other participants, CDAs need to be politically savvy, have strong
interpersonal skills, and be able to build trust and relationships. These proved that
communication and networking were critical skills for a CDA role. A total of 13 interviewees
(87%) pointed this skill was important for a CDA role. Table 8 shows some direct quotes related
to communication and network skill sets from both POC and non-POC CDAs that can further
confirm there was no difference in terms of the importance of this knowledge and skill.

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Table 8
Direct Quotes of Communication and Networking Skill and Influence
Participants Quotes
POC I think, definitely, ability to communicate in written and verbal skills. … We
know we have a lot of HR needs to manage staff and faculty.
Having that collaboration with faculty affairs and HR and having good
partners in those areas will help you achieve everything that you need to get
approved.
It’s because of that network of emotional, intelligent individuals that we all
created that we can rely on each other. It really makes us successful. [If] you
don’t have that, you may not be successful in this role.
When I have challenges, I gather people gather my team and ask for their help.
Non-POC It makes a difference in those kinds of conversations, not in the nice, positive
conversations, but in the tense meetings, or when you’re dealing with, trying
to get a deal done and negotiating, and you need to be super clear. You try
and make opportunities without offending people.
Building those relationships with those clinic managers is pivotal.
No matter what role you’re in, I think being part of a good partner is always
the way that you kind of get people on board
You have to have good written and oral communication skills because you’re
talking to people at all levels, from a patient to C-suite physicians.
You have to have that capacity to build relationships and build trust among a
very wide range of people, from the lowest-level staff to the highest-level
sort of executive in an institution.
The single most important skill set … is the ability to communicate a message.
… We had to build our practices in the community, and so that means going
out into the community, building relationships with referring physicians, and
helping our physicians that don’t really understand how business works.
Those are all kinds of relationship and psychology-type processes where you
sit down, have dinners, and convince people that you’re the right one to take
care of their patients and get them to refer [their patients to our physicians].
I had to pay my dues for a couple of years and establish relationships with
people such that they could trust what we were talking about.

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Although the interviewees applied communication and networking skills on various
occasions and at different levels, they all indicated that it is a necessary skill for a CDA to
achieve their goals and fulfill their job functions. Three interviewees (20%), including two
POCs, are excellent at this skill; two are not good at it, and 10 (67%) are average or slightly
above average. Even though this is a trainable skill, it is also associated with sociability, which
should be developed before taking the CDA role for career advancement. Networking helped two
POC interviewees accumulate finance knowledge and build broad networking during their early
careers. Communication helped them reach their positions without knowing their chairs
beforehand. A participant advised being “honest, transparent, and communicating changes in a
way that’s best for the business, the department, and the institution.” POC and non-POC also
have no significant gap in this key skill, but 60% of POC participants are below the average
level. This is the only key skill in which POC participants seem weaker than the non-POC group.
Personal Attributes Influence
The data analysis also revealed that personal attributes have a significant influence on
individuals’ relationships with colleagues, staff, and supervisors. An interviewee indicated, “One
big area I didn’t mention is personality to get along with the chair.” Personal traits affect
networking and the outcome of business strategy, finance and budgeting, and team building.
Interactions with colleagues and supervisors directly affect knowledge and skills learning. One
participant mentioned that her previous boss told her, “I’m thinking you need to get inside my
head,” which basically requires her to “think ahead and to anticipate what might be needed so
that when I approach something, I’m ready. I’m not blindsided.” This participant also explained
that although one “may not know what the person is thinking,” one already has “that kind
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mindset” and “that really has helped being anticipated” and train people to be thoughtfulness and
proactive in duties.
In addition, three participants (20%) had a demanding boss early in their careers who had
high expectations. The challenging experience trains individuals to be alert with details in
knowledge and skills of accounting, finance, and budgeting, to be responsible and work hard to
prepare for different scenarios proactively and build intelligence in the knowledge of business
strategy planning, to be persistent and confident with challenges to build up self-efficacy for
their career advancement, which is aligned with Belasen (2021) research. As an interviewee said,
I think that is what has brought me other opportunities because it motivates me. Not to
prove people wrong but just to show them that I can do the job. You know that, and you
know my hard work, and it’s what motivates me to do better in my career.
The trait of hard work also sets an example for the staff. As an interviewee stated,
If they see that their leader is also chipping in and doing the work, too, then it’s a team
effort. It comes from the top showing that you’re willing to be a part of the team, and
you’re not just gonna sit back and just sit on meetings, but rather you’re gonna
participate, even if it means working off hours.
According to several participants, the personal attributes of humility, respect, honesty,
and appreciation glue the team together as well as build up a high-standard professional network.
This is evidenced by statements like “the minute you start to show arrogance, then you start
building enemies” and “How do you get to know their true colors? My strategy was also to be
very honest and transparent with everybody” Other participants stated, “We’ve been able to
manage with a lean staff just through having that team atmosphere and just also recognizing and
thanking them” and “it’s an example of how goodwill connections can help you get into a role
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and meet people throughout the university.” Table 9 presents the direct quotes related to these
personal attributes that the interviewees indicated and related to a CDA role.

Table 9
Direct Quotes of Personal Attributes and Influence
Personal attributes Quotes
Alertness,
intelligence
And would someone trust you and listen to you? Then, you measure your
words more carefully because you know that [they] are going to be
acted upon. So, you will be very careful with what you say.
You know, there have been times when I’ve been the only female in the
room. … And I have to sort of understand that I can read the room, and
when I can speak, or when I don’t need to speak.
Leader by
example, hard-
working
You get by being on the ground, right, as opposed to just looking at it
from a distance. … I think that if they see that their leader is also
chipping in and doing the work, too, then it’s a team effort. It comes
from the top showing that you’re willing to be a part of the team, and
you’re not just gonna sit back and just sit on meetings, but rather you’re
gonna participate, even if it means working off hours.
I think you have to lead by example. I’m not somebody who just
delegates and leaves it to somebody else. I am actively involved, and I
think that’s how you get a staff that appreciates you because you treat
them well. … I set an example.
So, that notion of getting, I got this job. No, I worked hard to get this job,
you know.
Responsibility We’re all different, and it just depends on how seriously you take your
job. I’m certain that all the other CDAs have similar responsibilities.
In an institution, these roles matter, and the others will follow suit.
If you know you have the skill, and you see somebody who needs the
skill, then you help them. … If somebody needs help, you go help
them. … I feel like It’s our duty. If you have the skill to do something,
then you should do it. You don’t keep it to yourself, right?
Persistence You learn the process and be patient. You need a lot of patience in this
role.
I think pretty much my approach has been hit up against something, and
it’s no. To me, that is not no. It’s finding another way.
Self-confidence If I can get straight As, that means I’m not dumb. So, I should pursue
that, take advantage of this, and do whatever I can with my brain.
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Personal attributes Quotes
I was once told by a high school teacher that I had two strikes against me.
One, I was a woman, and two, I was a woman of color. … I said I don’t
think those are strikes against me because I think that what you’re
doing is you’re underestimating my capability. If you think those are
strikes against me, I’m going to use those strikes to my advantage.
Appreciating I think I enjoy what I do, and there are a lot of people that help me along
the way, and I’m very grateful for that.
Even if it’s just like a lunch or a Starbucks or something to say, “Thank
you.” And sending emails where I copy the department chair or the
division chief to say thank you so much for going above and beyond.
Humility, Respect,
Honesty
I make sure I voicemail my opposition politely.
My strategy was also to be very honest and transparent with everybody.
Have your facts right, and if you don’t know all the facts, admit that you
don’t know all the facts, and come with an open mind. But you have to
be respectful.
Being cordial and respectful is the best way to maintain those
relationships with key departments.
I’ve been successful because I’m a very good listener. I have a great deal
of empathy. I’m very humble. I am not afraid to be wrong. I am not
afraid to admit it. When I’ve screwed up, or if I’m late in getting
something done, I take full responsibility.

As a participant stated broadly that CDAs must work hard to “remove the impediments at
a university or a health system.” However, among the four CDAs who indicated they were hard
workers, three were POC. Only POC pointed out appreciating others, possibly due to the
organizational expectation influence or their POC’s cultures and self-identification influence.
There may be a recognition gap that needs further study. Table 9 also shows that self-confidence
helped them to overcome gender and race biases. There are no significant gender or race gaps
among the other attributes.
Regardless of personal traits, a CDA must treat everybody with respect to build a highly
productive professional team. They have to be team players and respect other people’s opinions,
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points of view, and perspectives. Being cordial, respectful, and honest can make the career go a
long way. As some participants indicated, some moral characteristics, such as respect and
honesty, are difficult to teach. Martimianakis et al. (2015) addressed the premed student’s moral
character as a hidden or informal curriculum, which can significantly influence the students and
the clinical professionals they will become. That is why the MCAT and other medical school
admissions requirements changed to focus more on humanities and ethical reasoning since 2015
to increase future physicians’ success (Geller et al., 2018). The cognitive and neurosciences have
unfolded moral development, which implicated that ethical education is only applicable “in
select slices of life” (Narvaez & Bock, 2014, p. 19). Therefore, the earlier the ethical education
training, the better the outcome.
Synthesis of Knowledge Findings: Lack of On-the-Job Training
Although this research identified the factual knowledge and skills of a CDA role, which
fully align with the conceptual knowledge and skills listed in the conceptual framework and
literature review, no CDA participants were found to have all the essential knowledge and skills,
especially procedural knowledge and skills crossing clinical, educational, and research fields
when they accepted their role. Three (20%) of them were more financial-oriented, nine (60%)
were more clinical-oriented, and three (20%) were more clinical research-oriented. After taking
over the CDA role, all participants needed to learn additional procedural knowledge and skills to
fulfill the tripartite mission. As one POC said, “Even after 17 years at [WMC], I still don’t know
everything. I don’t think anybody knows everything because it’s always little pieces here and
there.” However, WMC does not have formal or continuing on-the-job training for CDAs, either
before or after they take the role. An interviewee said, “People just get kind of thrown into their
new role, and they’re expected to figure it out.” Thirteen (87%) participants mentioned that the
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only available internal organization support or resource for CDAs is coming from the CDA peer
group. Six also indicated the internal peer group and external administrative association were the
only support they had. The useful external resource consists of CDAs at other AMCs or their
national administrative meetings.
Ten (67%) interviewees stated that WMC did not provide any on-the-job training to
CDAs. One interviewee said the hospital “had kind of leadership training, retreat things which
we don’t have at all.” Another interviewee also mentioned, “It will be nice if there was a little
more resource on educating [CDAs].” Interviewees thought refreshing CDAs’ skills was critical
and were happy to see more resources on CDA education, whether on software, challenges, or
management skills. Many of them are willing to advocate for more of that in hindsight. The POC
participants were more focused on self-reflection and self-learning, and non-POC participants
were more active in providing suggestions. The majority of participants, especially women, felt
there was a lack of orientation and on-the-job training. Table 10 shows more direct quotes from
POC and non-POC participants that demonstrate a high demand for formal on-the-job training.

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Table 10
Direct Quotes of Lack of On-the-Job Training
Participants Quotes
POC As far as the training, I think it’s all internally from the people that are
in each department, in each area, to bring you up to speed and then
also networking with the other CDAs.
I don’t feel like there are a lot of resources. I’m glad that we have our
group, our CDA administration meeting,
Non-POC Was there a job description? Yes, but with just the job description
alone, like there was no additional training just for a CDA.
I don’t feel like there are a lot of like programs for the CDAs here, if
anything.
Why don’t we have something like that? Chairs go off, and they have
chair training, right? Like, there is training to become a chair that
probably would be really valuable to preparatory CDA.

While there is no significant knowledge and skills gap in business strategy, finance, HR,
and teambuilding between POC and non-POC participants, 60% of POC women participants
were slightly below the average in communication and networking compared with non-POC
participants. This small influence contributed to the lack of diversity. Table 10 shows that WMC
did not provide adequate training to support the new and established CDAs in learning the
knowledge and skills needed for their jobs, and the participants became the best resources for
each other and the aspiring candidates. Given that there were only six POC CDAs, including four
women of color, it will limit exposure to the CDA role for BIPOC in the initial stages of the
leadership pipeline. Due to a lack of on-the-job training, it is even hard for aspiring candidates to
find the opportunity to gain experience in the key knowledge and skills that are critical to a CDA
role. Consequently, there was less opportunity for BIPOC to build up self-efficacy to trigger their
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motivation to lead in their career advancement toward a CDA position. Except for personal traits,
communication and networking, lacking on-the-job training is a critical knowledge-related
influence that caused the knowledge gap among CDAs, especially women of color.
Results and Findings of Motivational Influences Contributed to a Lack of Diversity Among
CDAs
Self-efficacy and MTL can influence an individual’s behavior profoundly and enduringly
(Abuzid & Abbas, 2016; Bandura & Schunk, 1981; Elliot et al., 2018; Mascia et al., 2015).
According to the interview data on individuals’ knowledge and skill learning experience and
their motivation to pursue a CDA role collected through the open-end questions, this section will
discuss the data analysis findings on how sponsorship, mentorship, and training influence self-
efficacy and trigger MTL, which leads a prospect to pursue a CDA role. This section closes with
a discussion of the lack of formal sponsorship and mentorship program that influence motivation
on CDAs’ career advancement and contribute to the lack of diversity among CDAs. It aims to
provide the answer to the second research question.
Motivation Influence of Self-Efficacy and Motivation to Lead in CDA’s Career Advancement
The data analysis shows that 11 (73%) interviewees indicated that their successful
learning and working experience helped them build their self-efficacy before applying for the
CDA positions. One interviewee said, “If I can get straight As, that means I’m not dumb. So, I
should pursue that. Take advantage of this and do whatever I can with my brain.” Self-efficacy
motivated them to pursue their career advancement and eventually reach a CDA position.
Interviewees’ career pathways in Table 11 demonstrate that sponsorship, mentorship, and CDA-
related training in the early career stage could trigger their learning interests and guide their
career advancement more effectively. These interests transferred to self-motivation enhanced
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them to learn more new knowledge and skills that pertain to a CDA role. A POC interviewee
indicated that she “was paired with a mentor who was already doing the job,” and she “got to
shadow her and got to really experience what it is” for about a year of CDA mentorship training
during her earlier career. When she “went back to the office and figured ‘this is what I want to
do. This is the path that I want to take at the time.’” She applied for a clinical research program
administrator job immediately after her CDA mentorship training because she wanted to look for
advancing opportunities and build up the new skills that a CDA role needs. She “did not see real
opportunities that I could pursue” in her previous organization and “think this department thing I
would love to do it.” With her successful learning experience and more knowledge and skills
under her belt, her self-efficacy was built up. Along with her mentor and supervisor telling her,
“I think you can run the department,” her self-efficacy and self-confidence triggered her MTL.
Eventually, her MTL led her to decide to advance her career and apply for a CDA role in another
medical school about a year later.

Table 11
Direct Quotes Related to Sponsorship/Mentorship/Training
Quotes (sponsorship/mentorship) Working
experience
before CDA
Quotes (self-efficacy,
motivation to lead)
POC The company will pay for all of
everything, so you just have to
go take the class and stuff! So,
he’s actually the one who
encouraged me to [get an
MBA]. He actually mentored
me and taught me a lot,
especially here at the
university.
22 years in
accounting
manager and
business
controller
positions

I want to say that I probably
would have anyway
because I was looking for
something a little bit more
challenging.

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Quotes (sponsorship/mentorship) Working
experience
before CDA
Quotes (self-efficacy,
motivation to lead)
POC I think mentoring is really
important. My administrator …
was my mentor. … I thought
she had such an impact on me.
Eight years in
clinical office
staff
I just want to learn from
moving up in the ranks. I
tried to help out
everybody, and I helped
out with the payroll. I
helped with the billing.
POC He wanted to give me the
opportunity, and he mentored
me.
Seven years in
division
administrator
and clinical
director
positions
I got a master’s degree, but
it’s nothing like the
practical experience of
managing people. … I
really thought this is my
niche. I enjoyed the
interactions, and I excelled
in them.
POC My mentor introduced me to
what it was to oversee a
department, what the medical
aspects of education were, the
clinical aspects of the research,
the three pillars that we
actually use.
Eight years as
clinical trial
coordinator
and research
administrator
Everybody has the first
time. Right? That’s how I
see it. And I was like, just
give me a chance.
Non-POC This was a number of years
before I applied for this job,
and she mentioned this job. All
as a place to aim for.
22 years in a
finance staff
position
I kind of knew about it, and
it was always in the back
of my mind and looking at
[a CDA role].
Non-POC He was a great mentor to me. He
taught me a lot about patients
… about how to be
compassionate.
17 years in
medical staff
positions and
division
administrator
positions
I realized that I liked the
job, and I was good at it,
and then I could have a
career in it, you know,
because before, it was just
a job, right? It was never
considered a career.
Non-POC I did the leadership academy at
the … system. That was
another opportunity that was
given. The more I think about
it, they have so many
opportunities there for training
for people to move on.
12 years in
clinic
manager and
clinical
director
positions
I came up here, and I
interviewed for two
different jobs, and I had
seven interviews.
Non-POC I have a mentor that is used to be
the CEO and dean at the
University of [ ] School of
Medicine.
12 years as a
clinical
project
manager

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The data analysis emerged that the CDA mentorship training during the candidate’s early
career stage was particularly effective for POCs. Three (50%) of the six POC participants who
had CDA mentorship or sponsorship pursued their roles successfully with less than ten years of
working experience, a much shorter time than other non-POC CDAs in the group (see Table 11).
It proved that the earlier a prospect was exposed to the CDA role, the sooner they could identify
their career pathway and achieve that goal. Table 11 also lists the direct quotes related to
sponsorship, mentorship, and CDA-related training and how their mentorship or training
triggered their MTL. The top four are from POC participants, and the bottom four are from non-
POC participants.
The reciprocal determinism concept in Bandura and Schunk’s SCT proved that human
behavior of knowledge and skills learning, their motivation (including motivation to lead), and
environmental factors (such as organizational settings, culture, HR policies, etc.) have a
reciprocal impact on each other (Bandura & Schunk, 1981). One POC interviewee mentioned,
“My education triggered me to go down this path.” Knowledge and skills also can be learned
through practice. Experience in a leadership position helped them gain more knowledge and
develop leadership skills, which created a positive circulation for their career advancement.
Another interviewee indicated, “I kind of worked up off the chain. It was not from education. It
was from just experience I worked for.” It proved that knowledge could impact a person’s
motivation and result in career advancement.
The data analysis also revealed that individuals’ MTL could reciprocally impact their
knowledge and skill learning, such as in team building and organizational culture. This is
evidenced by “one of the things I learned on this job was as a leader, my main job is to develop
other people’s skills,” “how do you galvanize people to do more than they think they can do,”
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and “if we are a good leader and a good colleague, or respectful of one another, everything else
falls in place.” Among the interviewees, eight (57%) interviewees (four POC and four non-POC)
indicated at least one instrumental person or training that significantly influenced their career
advancement toward the CDA position. Table 11 also demonstrates that sponsorship,
mentorship, and CDA-related training were effective factors that triggered self-motivation to
learn and attain the CDA role.
Synthesis of Motivation Findings
Despite the vital role that sponsorship, mentorship, or training played in motivating eight
participating CDAs to pursue their career advancement (see Table 11), the majority of these
activities of the participating CDAs happened before they took over the CDA role at WMC.
Overall, female participants set the CDA as their career goal more clearly than male CDAs,
especially two POC female participants who pursued the CDA role assertively before the
opportunity came up. The lack of a formal continuing training program at WMC caused a lack of
incentive for CDAs to keep up their motivation for career advancement. Only one POC
participant mentioned that WMC contacted her and would like to sponsor her to attend
leadership training recently. However, she said, “I think it’s just one or two people from the
entire university that they sponsor to go to an academic leadership training for females in
academic.” As most other interviewees confirmed, “I had other CDAs who mentored me and
helped me along and answered my questions. But I had no formal training.” There is a lack of
formal mentorship or sponsorship program at WMC.
The only informal sponsorship for a CDA role at WMC is from the clinical department
chair. All participants indicated that the clinical department chair had a significant influence on
the role. Table 12 lists some direct quotes from the participants. Given the current WMC
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leadership structure in that CDAs have no dotted-line report to the dean’s office, the CDAs’
contributions were also mostly unrecognized by any top leadership in the dean’s office besides
their chairs. Some CDAs pointed out that “there is no infrastructure, and there’s no respect for
good operations.” Among the participants, 12 (86%) were recommended for the CDA role by
their department chairs. Only two participants did not know their chairs before they took over the
CDA role, which means that the department chair’s sponsorship is critical in motivating people
toward a CDA position in an AMC.
Lack of formal training, mentorship, and sponsorship led to a lack of opportunities to
build up self-efficacy and trigger the MTL at WMC. Although Table 12 shows that the chair’s
sponsorship is the most important factor for a CDA role, as some CDAs pointed out, “We are so
unique in that we’ve created informal things. I would love to see a formal process or a formal
mentorship program for all of us” and “I think they really should have a program, and maybe
give people an opportunity to grow into these roles.” Although 13 (87%) participants
demonstrated strong self-efficacy and all 15 (100%) participants were motivated when they took
the CDA role, data analysis revealed a lack of formal sponsorship and mentorship program,
especially from the department chairs or CDAs, to help aspiring candidates build up self-efficacy
and trigger their motivation in their career advancement.

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Table 12
Direct Quotes of Department Chair Support and Influence
Participants Quotes
POC Another important person you have is the support of your supervisor or the
department chair in our case.
If you don’t get along with your chair as a CDA, your job is not possible to do
so.
You know the chair is the decision-maker, and we are the advisor. We advise
him, and he makes a decision.
Non-POC If the chair isn’t going to support it, it’s not going to happen.
You have to have the ability to establish a fundamentally trusting relationship
with your chair.
I came because he was here because of the really good working relationship
that we had.

Results and Findings of Organizational Influence Contributed to a Lack of Diversity
among CDAs
Research has proved that organizational settings and culture influence employees’
behaviors and motivation (Elliot et al., 2018). This study aimed to reveal the organizational
influences on CDAs’ career trajectories and the lack of diversity among them. This section
discusses the operational settings, including the operational structure and data report system, HR
policies and hiring process for promotion, recruitment, retention and/or recognition, and
organizational culture. This section closes with the synthesis of findings on the lack of prompt
organizational support and resources to promote diversity, including school support, resources,
and standard HR processes and policies.
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Operational Settings: Burnout caused by Inefficient Operational Structure, Lack of
Transparency, Poor Data Report System
The data analysis showed that WMC’s operational structure is inefficient. An interviewee
indicated, “There was no independent decision-making until you got to the top right. The staff
wasn’t empowered to manage and to make decisions.” Although the CDAs are willing to
implement more things and be more efficient, the reality is that CDAs felt they did not have any
authority to change the process, despite having to manage it and being accountable for it. Eight
interviewees confessed it is very difficult to complete their tasks at WMC, as evidenced by one
interview’s statement, “We have to go back to square one with these people and get the building
blocks.” Ten interviewees felt frustrated at the ineffective system and hoped the organization was
interested in working with the CDAs constructively to streamline the process and keep things
moving quickly. One participant pointed out that “we don’t solve problems very well joined. We
don’t. We don’t have the toolkit to talk honestly about this is a problem.” Fourteen participants
felt WMC lacks an effective administrative process and needs to reform the operational structure
to consolidate many administration processes.
The data analysis also proved that the organization needs more transparency. Many
participants found that it is difficult to collaborate with the dean’s office due to a lack of
transparency. Although the dean’s office organized monthly administrator meetings, the
participants felt it was just very top-down stealing out information. One participant petitioned the
dean’s office:
Give us the data. I mean, we should be able to know the data behind our IDC
distributions. We should know how the funds flow through the Dean’s office, where the
money goes, and where it comes from. We should know how much downstream we
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generate. We should know all these things so that we can help improve them. If you
cannot give me money, I should be able to understand why.
However, WMC has not addressed the inefficient operational structure and the transparent issue
at the school level. Interviewees felt there was no administrative support from the dean’s office.
There is also no effective data reporting system to provide CDAs with the necessary
information resources. As the CDAs indicated, “data is our friend” because clinical revenue is
the primary funding resource for clinical department operations, especially for surgical
departments. However, it was very challenging to learn all the different systems at WMC
because the systems and processes were archaic and backward in the 1960s. One CDA described
this as “flying a 747 over the mountains. I have no idea of my altitude [or] my airspeed for my
pitch because I’ve got no data.” Seven interviewees pointed out that they have to pull multiple
reports from multiple systems and combine several reports into one that goes to the faculty every
month. One participant said, “It’s almost like a treasure hunt to try to put everything in one
place.” It is even more difficult since COVID. One CDA indicated, “Right now, because I’m
short-staffed. I’m sure a lot of us are dealing with that. I’m kind of hands-on with everything.”
Large departments may be able to afford one dedicated financial staff to take care of the data.
However, CDAs in small or medium-sized departments spend more time on reports to
understand their department’s finances and follow up on the status of processes on top of their
routine duties due to WMC’s dysfunctional operation. One interviewee said they wanted “a
system that’s more automated that can let us know exactly where things stand to avoid because it
all does create a lot more work.” This represented many CDAs’ expectations.
Many interviewees felt they wasted much time trying to reinvent processes. They called
for more standards to follow instead of everyone being on their own, which can also avoid
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mistakes and backlogs caused by staff turnover. Most participants considered it essential to
implement a standard workflow process to improve operational efficiency. However, many
CDAs confessed they do not have time to develop new workflows on top of busy routine
schedules. This is evidenced by participants’ statements like “I don’t know where I would find
the time or even look at our data a little bit closer” and “We’re so busy that it is challenging to do
that. I’m busy trying to keep my head above water.” Eight (53%) felt overwhelmed by their
workloads. The dysfunctional operational structure caused burnout for CDAs. Table 13 shows
evidence of burnout, highlighting that participants lack time to reflect on their careers to mentor
or sponsor aspiring candidates.

Table 13
Direct Quotes on Lack of Burnout
Participants Quotes
POC I just don’t feel like we have time to do these things. I think that administrators
get caught up in the day-to-day stuff, and I think that we also could be
helping.
I think a lot of times, we don’t have time to reflect upon our own careers.
Non-POC I haven’t had the time to be honest with you just because the job has been 24/7.
It’s pretty intense.
From the moment I woke up, it started at 6:15 am this morning until I go to
sleep, and I kind of turned it off. I mean, that’s bad. I don’t have a good
work-life balance.

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Human Resource Policies and Hiring Process for Promotion, Recruitment, and
Retention/Recognition
Although more women of color were appointed to the CDA role by the clinic department
chairs, there is no formal HR policy to guide department chairs in selecting the best-fit candidate
for a CDA role from a diversified pool. There is no standardized process for recruiting,
promoting, and retaining diverse CDAs. The only requirement is a master’s degree. One
interviewee stated, “It is kind of the concept of getting your ticket punched. If you want to get
into this position, you are probably going to have to have a master’s degree, either in healthcare,
administration, or MBA.” Due to economic inequalities, this could cause a financial burden on
some BIPOCs who do not have economic or sponsorship privileges and cannot afford expensive
graduate education (Mineo, 2021).
In addition, “having an MBA or an MHA does not make you a leader. In fact, it is
probably the furthest thing from the truth,” indicated an interviewee. The new CDAs felt they
were “given the role,” but “there is no process” and “no system support.” They hope to “have
kind of like an operations improvement team or project management resources that different
departments could tap into.” They noted, “It would be really nice to have like standard CDA
checklist” and “would be good to like in-service of some sort.” Even the experienced CDAs are
not familiar with HR policies on dealing with some HR issues they encounter. They pointed out
that they “feel like we have a lot of processes we manage, and we do not get a lot of guidance.
You will see it is not organized, whether it is credentialing, whether it’s onboarding, promotion,
or appointments.” One senior CDA provided an example:
One employee just recently was complaining that it wasn’t fair that they’re not getting to
work hybrid [work remotely and in person] because they needed a hybrid work as a gift.
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It is an opportunity. It is not a guarantee but what we had new staff was complaining
about unfairness. … I just feel like, nowadays, the HR piece is so complicated.
These statements imply that HR needs a well-established hiring process to recruit the best-fit
candidate who could manage the CDA tasks to support the department chair. There also needs to
be an effective onboarding process or continuing training for CDAs to help them fulfill their role
successfully.
There is also lack of opportunity or HR guidance for CDAs to advance their career. Nine
interviewees have been in their CDA role for 9 to 32 years. Many wondered what their next step
should be and felt a career crisis. One participant said, “I think there’s only so far you can go
without being a physician.” Another participant stated,
All the chairs find their CDA as a good partner, the partner to help them manage the
department. So, CDA is also at risk, and when there is a department chair change, you
may or may not have your job. And how do we mentally prepare for when we face that
day? [Do] we have a good skill set for our next career opportunity?
There is no HR policy to guide or retain the CDAs in terms of changing department chairs. One
of the interviewees lost her job during this study due to her chair stepping down. No
announcement recognized her contributions, and CDAs received no official notification. A
second interviewee said, “When the change in leadership, then it’s always a challenge to figure
them out. If I felt that I was stagnating, I would be done.” A third participant also expressed, “I
honestly don’t think that the school had a formal organization at all. I think we had an informal
organization.” Many CDAs felt lost spinning up opportunities after serving in the CDA role and
worried about the next step of their careers, especially these CDAs who have served in this role
for more than five years. The term “spinning up” was used up by two participants during the
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interviews. I will continue to use this term to describe the action of CDAs continuing to learn
new knowledge and skills and striving to overcome difficulties to advance their careers. One
non-POC interviewee affirmed that “If there were something that was to be more growth-
oriented or background oriented in terms of things we should know. That would help us to
advance or awareness of opportunities,” and another non-POC participant felt “we’ve sort of
capped out in terms of our being able to rise any higher, in terms of our positions on the
professional side.” This evidence showed that WMC lacks a mechanism to retain current POC
and non-POC CDAs and a plan to promote and recruit Black and Indian CDAs.
The department chair’s sponsorship and mentorship are the main determinants for
promoting and recruiting a CDA. An interviewee indicated, “It’s up to the department chair to
hire you because you’re going to be working closely with that department chair. You got to make
sure you have a connection with the interview process before they offer me the position.”
However, HR did not have much influence on CDAs’ promotion, recruitment, or retention
because there are no standard hiring processes to guide recruitment. Due to the perceived risk,
most chairs hire someone they trust to reduce the risk of uncertainty (van Esch et al., 2018).
Lacking the department chair’s sponsorship is a significant influence contributing to the lack of
diversity among CDAs.
Organizational Culture
There are many aspects to examine an organizational culture. This study focused on
WMC’s diverse atmosphere of CDAs. The interview data show that 80% of the interviewees are
female, and 40% are POC, but there are no Black or Indian CDAs at WMC. This section will
discuss gender bias and race bias factors that influence CDAs’ career advancement.
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Genderism/Glass Ceiling. Although Table 4 presented that 12 out of 15 (80%)
interviewees were female, they indicated they still felt gender bias at WMC. As an interviewee
mentioned, “There is still a glass ceiling for a lot of roles in a lot of places.” Thirty-three percent
of female CDAs indicated that they had experienced gender bias in their workplaces. Below is a
quote from one female participant.
We still are in this inequitable position, and in a meeting, you know, there still happens
where you say your opinion and your idea. And then 10 minutes later, a man enhances
that same idea. And then they’re like, “Oh, that’s a great idea.”
Another female CDA mentioned that gender disparity existed, especially in higher-level
leadership at WMC. She indicated,
Because we’re considered to be middle management, and the males are at the next levels
up, right? … Because when you look at the upper, the upward Z. They are mostly males!
There are a few females, but they are mostly males, and this level seems to be female.
The above three quotes were from three non-POC CDAs who have more than ten years of
working experience in their CDA roles. According to interview data, female participants stated
that the gender disparity at WMC has improved significantly in recent years, especially in
middle-level leadership. However, many females who demonstrated excellence in required
leadership knowledge and skills still encountered difficulties being promoted to higher-level
leadership positions due to gender bias. This status aligns with Berlin et al.’s (2022) findings. A
female interviewee explained, “If you want to be up there playing with the big boys. I guess you
are going to be aggressive.
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Previously, the institution did not consider the CDA role important, and males only
started to take it on over the past decades when it became a real career. One interviewee
described her observation and experience:
I noticed around the late 90s that when I would go to administrator meetings and look
around the room, it used to be all women, and we were pretty much-glorified secretaries.
And then, as the job got bigger and more important and more relevant and more
recognized, I started seeing more men in the room.
This statement explains why there are more female than male CDAs. It also reflects the gender
disparity in non-clinician leadership in academic medicine. Among 12 females, five (about 42%)
indicated that they encountered gender bias in their careers. They felt males were heard more.
That demonstrated that genderism is still a significant challenge to female CDAs in the male-
dominated healthcare field even though the number of female CDAs has been much more than
male CDAs compared with other leadership positions. Interestingly, the participants who are
aware of gender bias are the females who have been CDAs for more than five years. This
awareness might occur because the status of gender bias at WMC was better than five years prior
to this study. In terms of the literature review, racial discrimination was found to be more severe
than gender bias in AMCs.
Racial Disparity/Invisibility. Despite six (47%) interviewees being POC, there are no
Black and Indian CDAs. Two of the six POC CDAs indicated they faced racial bias in their
career advancement. One POC CDA said, “I think some more people with different races were
being given up opportunities that I wasn’t given.” Another POC CDA told a story that she
experienced,
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One patient asked to speak with the manager onsite, and our clinic manager was not
around. I happened to be in the clinic at the time... So, I went out, and the patient said,
“No, I want to speak to the manager.” And I said, “I am actually the department’s
administrator. How can I help?” And his response was, “You cannot be the department’s
administrator, you’re a girl, and you’re a girl of color.”
Racism may exist anywhere in CDA’s working environment. Most of the time, it is presented as
microaggressions but not as obvious as in this case. As one of the other POC interviewees said,
“People don’t know what I am. So, you just think I’m White or Irish like that? … And people are
always surprised when I tell them I am Hispanic, and they are like, ‘Oh, you are kidding.’” These
statements are evidence that racism exists internally in the AMC and in the community, which
directly affects self-efficacy and satisfaction with the working environment. These biases can
influence POC’s self-efficacy and MTL and enhance their career advancement. Although WMC
had reduced gender bias slightly, gender and race biases still evidently hindered BIPOC’s career
advancement.
Synthesis of Organizational Influence Findings: Lack of School and University Support and
Resources due to Inefficient Structure and Poor Data Report System
Although gender and racial biases directly impacted diversity among CDAs, it is not the
only influence contributing to the lack of diversity among CDAs at WMC. CDA’s burnout and
lack of HR policies and standard hiring processes to recruit, promote, and retain the diversity of
employees are also impacting the lack of diversity among CDAs. The lack of HR policies and a
standard HR hiring process gives racial bias a boundless influence on CDA’s recruitment,
promotion, and retention, which hampered bringing different perspectives and lived experiences
for a diverse pool and directly hindered BIPOC’s career advancement at WMC. Due to a lack of
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school support to improve the inefficient operational structure and the poor data reporting
system, CDAs, especially those of color, are burned out and lack time to inspire other BIPOCs or
mentor candidates, exacerbating the lack of diversity among CDAs. COVID doubled the
healthcare challenges that CDAs had to face. However, WMC did not provide any additional
resources to support CDAs.
While CDAs can count on their chairs’ support when needed, most interviewees felt
isolated and the lack of school and university support, especially from the medical school dean’s
office. This is evidenced by statements like “I don’t think that our university provides enough
support for policies and procedures. I feel like everybody has to keep doing this on their own”
and “I just don’t see this environment as a lot of resources.” When struggling, interviewees asked
themselves, “Am I the only one going through this? Is everybody else seems to be just fine?”
because “most CDAs would not really talk about the stuff that exposes them and makes them
feel vulnerable” publicly. Before COVID, there was an internal monthly brown bag meeting for
CDAs to meet in person and discuss their unique issues. Since COVID, this meeting has been
stopped, and CDAs “are not getting together on a routine basis.”
Given the medical school’s unique tripartite mission, CDAs faced threefold challenges,
which were much more than other middle-level managers who might have similar authority and
resources granted by the dean’s office but without clinical duties. However, the dean’s office
never realized that and did not provide additional support to CDAs compared with education-
oriented or research-oriented department administrators. There is no recognition of CDAs’
contributions from the dean’s office or top leadership. Table 14 presents quotes related to the
lack of school support and resources for CDA career development, asserted by both POC and
non-POC interviewees. It demonstrated a significant gap in the organization’s support for CDAs.
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The data analysis revealed that the key contributor to the lack of diversity was that organizational
support, resources, HR policies, and a standard hiring process were missing.

Table 14
Direct Quotes of Lack of School Support and Resources for Career Development
Participants Quotes
POC Most of the support came internally, not necessarily from the school.
I don’t feel like there are a lot of resources. I’m glad that we have our
group, our CDA administration meeting,
Non-POC I don’t feel like there are a lot of like programs for the CDAs here, if
anything.
That’s the culture of very centralized, very top-down. So, that was
very, very hard to break that.
Now the Dean gave a town hall, which I think is great. She had a
whole two tables worth of reserved people that she considered her
leaders. And I’ve been here 11 years, and there were people there
that I’ve never seen in my life. I don’t know who they were. So, if
that’s your leaders, and your department managers don’t have any
clue who they are, that’s a problem.

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Summary
This chapter presented the results and findings of the qualitative interviews related to the
three research questions. The interview data identified the key knowledge and skills, motivation,
and organizational influences that corresponded to the literature review and conceptual
framework and revealed the gaps in CDAs’ career advancement caused by these factors,
particularly for women of color. The data indicated a lack of formal on-the-job training caused a
knowledge and skills gap. Data analysis also revealed a lack of formal sponsorship or mentorship
program to inspire and motivate BIPOC staff to develop their self-efficacy and trigger their MTL
for career advancement.
Data analysis also divulged burnout among participants caused by a lack of medical
school support, a poor data reporting system, and a dysfunctional operation structure. This
finding aligns with Levine’s (2021) study. Burnout further disrupted the mentorship and
sponsorship opportunities for aspiring BIPOC women candidates and caused a lack of diverse
candidates in the leadership pipeline. It is urgent to provide formal and continuing knowledge
and skill training for CDAs, organize formal sponsorship and mentorship program to support
diversity among CDAs, and promote health and mental wellness for CDAs by providing
sufficient support and resources, including improving operational efficiency. Chapter Five will
discuss the solutions and offer recommendations based on the research results and findings.

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Chapter Five: Recommendations
Chapter Four presented the research results and findings from the data collected through
interviews in an effort to answer the three research questions, identifying the KMO influences
that contributed to the lack of diversity among CDAs based on the conceptual framework
developed from Clark and Estes (2008) gap analysis framework along with SCT. These results
and findings not only considered the KMO frameworks but also reflected SCT and the lens of the
leadership pipeline. Although the results and findings were categorized into KMO factors, the
categories interacted to influence the CDA trajectory pathway. This chapter discusses the key
findings, posits three recommendations for practice based on the validated needs, and proposes
implementation and evaluation plans for the recommendations. Finally, this chapter declares the
limitations and delimitations of the study and presents recommendations for future research.
Discussion of Findings
There are 16 CDAs at WMC, 14 of whom (87.5%) participated in this study. If more than
50% of the interviewees reported any influencing factor, it was categorized as a significant
influence on their role. This section discusses the key findings related to KMO influences on
career advancement, especially for BIPOC. This study identified that the key knowledge and
skills influencing a CDA role were business strategy, finance, team building, communication,
and networking, coinciding with the literature review in Chapter Two (see Table 15). Regarding
knowledge of finance and HR, all participants indicated these were critical to their role. Thirteen
(87%) participants confirmed that communication and networking were essential skills.
Comparing HR and communication and networking skills, whether POC or non-POC,
knowledge of finance must be taught formally in school or informally on the job. Therefore,
training opportunities became critical for aspiring candidates’ career advancement.
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In addition, 93% of participants mentioned business strategy knowledge and skill, and 13
(87%) had MBA or MHA degrees related to the healthcare business, meaning that business
knowledge and skill also significantly influence a CDA role. Many interviewees indicated that
they were good at business strategy and planning. While there is no significant gap in business
strategy and planning skills between POC women and other participants, 75% of women of color
are business savvy, which is much higher than non-POC women (57%). This difference might
mean that only business-savvy women of color had the opportunity to be selected for the CDA
role.
Although participants who are women of color had a higher business-savvy ratio than
non-POC women, the White participants were more confident and firmer when they talked about
evolving business strategy planning. It could be because their business partners were more often
Whites, and BIPOCs usually were the minority in these business occasions. Therefore, business
strategy and planning skills could be a key knowledge influence on CDAs who are women of
color. Given that an MBA or MHA became the most effective ticket for a CDA role and the high
cost of an MBA degree, the MHA seems a better option from the angle of a cost-effective point
of view. However, MHA is still an enormous financial burden to many BIPOCs who face the
wealth gap (Mineo, 2021). This challenge aligns with the literature on financial well-being but is
not limited to women of color. All participants who obtained an MBA or MHA did so while
working full-time, and 60% of the POC participants’ MBA degrees were sponsored by their
employers. At least one POC participant (20%) would not get his MBA without sponsorship and
mentorship. Therefore, despite the research proving that formal higher education and on-the-job
training for CDA-related knowledge and skill training is critical to BIPOC’s career advancement
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toward a CDA role, organizational sponsorship and mentorship are essential factors that facilitate
BIPOC to obtain this key knowledge and skills.
In this research, four out of six POC (67%) confirmed that the significant impact on their
career advancement came from their mentors, compared with only 40% of non-POC who made
the same comments. This indicated that sponsorship, mentorship, and formal training were more
critical to the POC group than the non-POC group. Formal sponsorship and mentorship were
important for BIPOC to trigger their learning interests, build self-efficacy, and convert it to self-
motivation to guide their career direction and endure their career advancement.
There are 141 AMCs in the United States, and each AMC has only about 15 CDAs.
Given the low number of CDA roles, BIPOCs were rarely aware of this career pathway due to a
lack of knowledge and connections. This study found that three out of six POC participants
(50%) found their path mainly because of sponsorship and mentorship. This influence is much
more significant than in the non-POC group. Although sponsorship and mentorship also
accelerated non-POC CDAs’ career development and shortened the duration of achieving their
career goal, it did not change non-POC’s career direction. This study revealed that 83% of the
early career sponsorship and mentorship happened before the CDAs joined WMC. This research
found that formal sponsorship and mentorship in early career development was significant,
especially to the BIPOC group. This study also revealed, as the vital factor of sponsorship for a
CDA role, the department chairs played a crucial role in promoting diversity among CDAs.
Among six departments that have POC CDAs, four of these department chairs are not Whites. It
proved that diverse sponsorship and mentorship from clinical department chairs are crucial to
promoting the diversity of CDA in AMC, which is aligned with the trickle-down effect research
conducted by Gould et al. (2018)
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A more specific factor compared with other healthcare leadership positions is the
personal attributes of hard work and humility/respect. This demonstrated that a CDA was a
leader and an actor who needed to create a business strategy and implement the plan to achieve
the goal. A CDA has many leadership responsibilities but is not entitled to clinical, research, and
education faculty. Therefore, their traits contribute to fulfilling CDAs’ performance. This also
compounds burnout. As the study identified, the primary support and resources for a CDA were
their peers and department chair, but there is a lack of organizational support. CDAs were under
pressure due to the responsibilities assigned by their organization, but the organization did not
provide support resources or efficient tools for them to complete these tasks. They tried to
improve the department’s productivity but encountered roadblocks they could not overcome.
Eighty-seven percent of interviewees (12 female and one male) felt there is a lack of
organizational support and resources for CDAs who are women and women of color, given that
there are no Black and Indian CDAs at all. Although there is a high demand for support and
resources in current CDA groups, the school and HR have yet to present any agenda or actions to
minimize this gap. The CDAs need to find their resources or support themselves, as there was no
clear onboarding guidance or organizational structures, on paper or online, for reference. It was
especially difficult for a new CDA who had never worked at WMC, which currently has two
interim CDAs and two senior CDAs planning to retire soon. Thus, four out of 16 (25%) CDA
roles might be changed shortly at WMC, which is a high turnover rate at one institution. This
also showed that the healthcare workforce shortage significantly influenced the healthcare field,
especially after COVID, as indicated in the literature review. This also proved that promoting
diversity among CDAs is urgently needed.
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This research also revealed that WMC lacks a proper organizational setting to support
CDAs and has neither an efficient administrative operation structure nor an effective data
reporting system. The parallel reporting systems of the hospital and medical school did not share
information. Although a new leadership position, senior vice president for health affairs, was
recently created to supervise the hospital CEO and school dean, the underlying structures
remained the same. The two worlds had not been integrated at all. There needs to be more
effective communication between the two parties at each corresponding leadership level. The
clinical staff and service director ran the clinic’s operational parts, but the department ran the
administrative components for the providers. However, the clinic service director had no dotted-
line reporting responsibility to department chairs or CDAs. Department chairs and CDAs were
entitled to be responsible for the tripartite mission. They can influence the clinical operation
through the providers but cannot effectively control the clinical portion and align clinical
operations with the academic and research mission. This operational structure hampered CDAs’
achievements which reciprocated their self-efficacy and MTL and indirectly hampered diversity.
Although 40% of the POC CDA ratio at WMC is much higher than the 21% of the
middle-level BIPOC manager ratio (Berlin et al., 2022), racial bias was still severe, as there were
no Black or Indian CDAs, and eight out of 14 (57.14%) are White. Among the participating
CDA groups, 29.45% of WMC employees are White, 25.21% are Asian (including South Asian),
6% are African American, and 12.8% are Hispanic/Latino, showing that Whites are
overrepresented at WMC. Given that 40% of participants were POC and 33% of POC CDAs
were male, although 30.09% of WMC employees were male, the POC male CDAs were 2.91%
overrepresented. In contrast, the 66.67% of CDAs who are women of color is 2.91% less than the
69.58% of female employees at WMC. These data demonstrate a need to promote diversity.
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While gender bias is not as severe at the CDA level, WMC lacks HR policies to address racial
bias, a standard process to implement HR policies, and a strategy to recruit, promote, and retain
diverse employees to reduce racial disparities. These actions include creating formal on-the-job
training to enlarge the qualified candidate pool, setting up a formal sponsorship and mentorship
program to fill the entry-level leadership pipeline, providing organizational support to increase
BIPOC self-efficacy, and opening the move-up channel to motivate them to pursue career
advancement.
In general, most of the results and findings align with the conceptual factors attained
from the literature review and presented in the conceptual frameworks. Table 15 lists the
findings regarding key knowledge and skills and motivational and organizational influences, and
the factors and challenges in the literature review and conceptual framework. It shows the
knowledge and skills aligned with the literature review. However, the challenge at WMC is a
lack of on-the-job training for CDAs to be well-rounded for their jobs’ needs. The motivational
factors also matched the literature review. The challenges are a lack of formal training to build
self-efficacy and sufficient mentorship and sponsorship to trigger BIPOC prospects’ MTL and
inspire them to pursue a CDA role. Regarding organizational influence, WMC lacks school
support and resources for CDAs and HR policy and guidance for recruiting, promoting, and
retaining diverse CDAs. In particular, WMC lacks an efficient structure and system, causing
burnout for CDAs and disrupting mentorship resources for BIPOC women. Some challenges in
the literature review, such as feminine modesty and perceived riskiness, were not discovered at
WMC. Overall, the gender and race disparity at the CDA level is better than senior-level
leadership and better than other industry sectors. However, gender bias, including invisibility and
the glass ceiling, and racial bias persist and must be addressed continuously.
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Table 15
Comparison of Knowledge, Motivation, and Organizational Results and Findings With
Literature Review Factors
Type Factors in literature review Findings of influences
Knowledge Business strategy
Accounting and finance
HR and teambuilding
Communication and networking
Personal attributes and behavior
Business strategy and planning
Accounting, finance, and budgeting
HR and teambuilding
Communication and networking
Personal attributes
Motivation Self-efficacy

Motivation-to-lead
Self-efficacy (lack of knowledge and
skills training)
Motivation-to-CDA (lack of
mentorship and sponsorship)
Organization Top leadership and department
chairs’ commitment

Human resources policies

Medical school culture and values
(invisibility, glass ceiling, feminine
modesty, perceived riskiness, racial
microaggressions)
Organizational settings: inefficient
structure, ineffective report system,
lack of top leadership recognition
and support, burnout
Lack of HR hiring process to guide
department chair for CDA
recruitment
WMC culture (invisibility, glass
ceiling, and racial bias are
improved and much better than 5
years ago)

Focusing on diverse prospects’ knowledge and skill development is the first step to
increasing diversity. Schunk and Usher (2019) found that purposefully creating organizational
support programs and resources to motivate prospects to be interested in learning the knowledge
and skills for the CDA role is vital to enlarge the CDA feeder group with more aspiring BIPOC
candidates to promote diversity. It is essential to tie the long-standing organizational interest in
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the tripartite mission with diversity among CDAs. This research data analysis identified the
barriers that caused the lack of diversity. As an important step in changing the status quo as the
unfreezing stage in Kurt Lewin’s organizational change model, the research initiated an open
discussion (Hussain et al., 2018) on the lack of diversity among CDAs. In order to stimulate the
changes, three implementing recommendations are proposed below.
Recommendations for Practice
Based on the validated key knowledge and skills, motivation, and organizational
influences, this section presents three recommendations to increase diversity among CDAs at
WMC. These are to create formal on-the-job training, set up formal sponsorship and mentorship
program, and provide consolidated support and resources from the dean’s office. These three
recommendations align with the three components of the conceptual frameworks and with
solving the issues found. Most of these issues matched the challenges for BIPOC leadership in
the literature review, and only some problems of the organizational support and resources
particularly pertain to WMC. Since these three recommendations influence each other,
implementing the three proposed recommendations together can systematically leverage
diversity among CDAs and achieve the best outcomes at WMC.
Recommendation 1: Create an On-the-Job Training Program for CDA Role
Although there was no significant knowledge gap in terms of different genders or races,
none of the participants had well-round procedural knowledge and skills that met the tripartite
mission needs in healthcare, research, and education before they took the CDA role. Forty-six
percent were only good at healthcare-related knowledge and skills, and 64% were good at
healthcare and research combined knowledge and skills. Most interviewees indicated that the key
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knowledge and skills for a CDA role came from experiences rather than education and degrees,
yet continued learning is necessary for any leadership position.
Creating on-the-job training and opening this opportunity to diverse administrative staff
is critical. This on-the-job training can help BIPOC identify their knowledge gaps and inspire
them to learn and practice the key knowledge and skills to build their self-efficacy. It can also
help new CDAs be well-rounded for their jobs and set up a successful example for followers to
motivate more BIPOC to enlarge the entry-level leadership pool. In addition, healthcare policy
changes and technology develop very quickly, so on-the-job training can help current CDAs
keep up with their knowledge and skills alongside the healthcare development needs. It creates a
diverse learning environment, develops a positive learning climate, and enhances the possibility
of recruiting qualified diverse prospects to achieve diversity among CDAs at WMC. This on-the-
job training can be set up as professional training onsite for a few hours every month and two
levels of sessions: one entry-level and one advanced level. Each class can focus on one item of
key knowledge and skills, such as Excel in finance, medical data analysis, HR policies and hiring
process, communication, or business strategy planning, which pertain to a specific practical
topic.
Senior CDAs can teach entry-level classes. The advanced courses should invite some
experts or senior hospital and school leaders to be trainers or guest speakers. The topic can be
gathered through a survey among current CDAs and prospects or from department chairs and top
leadership. The entry-level class should be open to all aspiring candidates. Each class should
follow up with a hands-on practice session or a practical assignment to examine outcomes and
identify potential candidates to encourage them to follow through with the advanced program.
People can choose the class they are interested in or need to sharpen their skills. Opening this
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training to diverse administrative staff can increase the utilization of the resources, enlarge the
entry-level applicant pool, and help the organization prepare more people for the healthcare field
to remedy the workforce shortage. Promoting well-trained internal prospects can increase
employee satisfaction and belonging, attract and retain more diverse and competent employees,
make the leadership transition smooth, and increase the probability of success to achieve
diversity among CDAs. This recommendation focuses on the knowledge and skills component of
the conceptual frameworks. The entry-level on-the-job training aligns with the knowledge
component in the Level 1 leadership pipeline, and the advanced level aligns with the knowledge
component in the Level 2 leadership pipeline.
Implementing this on-the-job training to enhance the procedural knowledge and skills
among diverse candidates can base on the New World Kirkpatrick Model as displayed in Figure
3, which includes four testament levels according to today’s modern practice of training: Level 1
Reaction, Level 2 Learning, Level 3 Behavior, and Level 4 Results (Kirkpatrick & Kirkpatrick,
2016). This framework is presented backward to ensure the results align with the original goal to
maximize the implementation effectiveness and outcomes. Level 4 is the degree to which
knowledge and skills were transferred to implementations as a result of training. Level 3 is the
behavior that trainees turn what they learned during training into application actions. Level 2 is
confidence leading to behavior change. Level 1 is the participant’s engagement. Organizations
can use this framework to help employees improve their knowledge and skill capacity and build
the foundation of self-efficacy and MTL by applying the training knowledge and skills in their
career advancement. The four levels of implementing the CDA’s on-the-job training are
delineated here:
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4. Results: According to the expected outcomes of promoting diversity among CDAs,
WMC needs to develop a series of formal internal on-the-job training sessions for
aspiring BIPOCs and CDAs to obtain the critical procedural knowledge and skills for
a CDA role, enhance their leadership competencies and boost their career prospects
through continuous professional learning. It is essential to use personalized career
targets as leading indicators for CDAs’ on-the-job training sessions. The participants’
satisfaction survey and self-reflection reports after each session, the percentage of
returning/continuing participants in other on-the-job training activities, and the
employee participating ratio can be used as the metric(s) and method (s) to evaluate
the outcomes of the on-the-job training.
3. Behaviors: Critical behaviors must be identified for each designed on-the-job training
session, and drivers of reinforcing, encouraging, rewarding, and monitoring can be
applied accordingly. Individuals use the knowledge and skills that they learned from
the training and cohort’s experiences to improve their daily workflow and job
efficiency, such as creating new working processes or checklists, designing a
professional teambuilding event, initiating new networking activities, etc. Through
the practical exercises, participants can evaluate their procedural knowledge and
skills. Metric(s), method(s), and timing can be pinpointed according to a specific
training session. Organizational support is necessary for providing training location,
tutoring material, commitments of the guest speakers, etc.
2. Learning: Every on-the-job training session can be designed based on the CDAs’
need or required procedural knowledge and skills for a CDA role. In each training
session, after the knowledge and skill tutorial, individuals discuss related practical
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issues they encountered in their job and bounce ideas among the group by applying
the knowledge and skills they learned. Evaluation tools can be various based on the
training contents.
1. Reaction: Create a learning environment and ensure CDAs and aspiring BIPOCs
participate in on-the-job training. Individuals can choose different sessions based on
individual’s knowledge and skill gaps by comparing current performance with the
required knowledge and skills. Since the participating and aspiring CDAs are self-
motivated and eager to participate in on-the-job training, engagement should not be
an issue. However, the trainer/organizer must obtain feedback through formative
evaluation and adjust the program content to facilitate CDAs to gain their desired
procedural knowledge and skills and help improve other sessions of on-the-job
training.
Figure 3 illustrates how to apply the Kirkpatrick model. More implementation details can be
constructed based on the details listed in the Kirkpatrick model for each session of CDA’s on-
the-job training to address gaps that surfaced in this study. This on-the-job training can help
CDAs, department chairs, and top leaders identify potential BIPOC talents who need mentorship
and sponsorship.

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Figure 3
Applying the New World Kirkpatrick Model to CDA’s On-the-Job Training

Recommendation 2: Set Up a Formal Sponsorship and Mentorship Program
The research indicated a need for formal sponsorship and mentorship programs for
CDAs. To keep the current CDAs “spinning up”, promote diversity, and help BIPOC talents
obtain hands-on experience on these key knowledge and skills and get a punching ticket, the
school should sponsor more BIPOC candidates to pursue a degree by providing some
scholarships to reduce financial burdens and set up a formal mentorship program. This formal
sponsorship and mentorship program can pair aspiring BIPOC candidates with current CDAs and
let the candidates shadow the mentor. It also motivates the current CDAs to share their
experiences with diverse aspiring candidates, helps them find more capable employees to
facilitate team building and maintain professional integrity, and creates a positive employee flow
at the organization. The current CDAs and department chairs can sponsor aspiring BIPOC
candidates to work on small projects. It is hard for a skilled employee to stay on one track.
Sponsorship and mentorship can help BIPOCs build up self-efficacy, motivate them to learn new
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knowledge, and create more opportunities for BIPOCs to broaden their networks and open the
move-up channel. The percentage of BIPOC participants in pairing mentorship can be used as
one of the metrics to measure the success of sponsorship and mentorship program.
The sponsorship and mentorship program also can pair experienced CDAs with new ones
and organize quarterly seminars by inviting a top leader from either school or hospital. Even if
these top leaders provide general information and industry trends or policy updates, they will
help create a learning atmosphere for CDAs to keep “spinning up,” improve the organizational
structure and increase collaboration and productivity. The formal sponsorship and mentorship
program can also help open the move-up channel for CDAs to move from small to medium-sized
departments or medium-sized to large departments by cross-training. It also could be organized
as an annual retreat for CDAs to be away from their offices which allows the focus to be on
learning and promotes their sense of wellness.
The top leaders from the hospital side can share more information with CDAs from a
different perspective, such as how CDAs can work better to align their work with the hospital or
introduce the changes of workflow and structure in the hospital that the CDAs perform routinely
in different scenarios. It can ensure that all information and policies are shared with the entire
group and not limited to specific people or individuals. Doing so will reinforce the knowledge
and skills learned in recommendation 1 and create positive circulation among different levels and
groups to promote mutual understanding and a respectful working environment and integrate
multi-culturalism into the team to facilitate BIPOC career advancement. This recommendation
focuses on the component of building self-efficacy and triggering self-motivation in both level 1
and level 2 of the conceptual frameworks.
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Recommendation 3: Change the Organization Setting and Set Up HR Standard Recruiting
Process
This study found that the WMC lacked a proper organizational setting, an efficient
operation structure, an effective data reporting system, and a standard HR process for CDA
recruitment, especially for women of color. These organizational factors caused a lack of
diversity and burnout, which exacerbated administrative inefficiency. Changing WMC’s
organizational setting and creating a more efficient operational structure requires sharing
information and integrating clinical and academic resources and support, given the financial
constraints and labor shortages after COVID. The dean’s office should initiate two major
changes.
One of the most cost-effective changes in the organizational setting to support CDAs is
having the dean’s office provide more data access authority to clinical departments to improve
transparency and efficiency and decentralize some faculty affairs authority to large and medium-
sized departments. Therefore, the faculty affairs office can allocate its limited resources to
critical tasks and avoid delays in faculty hiring and promotion processes to improve operational
efficiency. Meanwhile, CDAs should have a formal dotted-line reporting relationship with the
dean’s office at the top of the current solid-line reporting relationship with the clinical
department chair. The dean’s office should sponsor/organize formal on-the-job training and
formal sponsorship and mentorship programs collaboratively with hospital leadership and
facilitate the CDAs to work with the hospital leadership team instead of letting the CDAs
approach the hospital leadership individually.
At many AMCs, the funds usually flow from the hospital to medical school. At WMC,
the funds flowed from the hospital directly to the clinical department. In terms of clinical
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practice, the hospital has no transparent support mechanism. Every CDA had to negotiate with
the hospital leadership independently. No clear business strategy was shared between the
hospital leadership and clinical department CDAs. Although there were some involvements with
the dean’s office regarding the other two legs of the educational and the research components,
there is no standard process and policies for CDAs to follow through and achieve goals aligned
with the healthcare part. The formal sponsorship or mentorship program can fill this gap by
inviting the hospital leadership. The dot-line report structure will help integrate the hospital and
the medical school and increase the transparency and efficiency of the entire WMC. This will
improve the utilization of limited resources, reduce the frustration caused by bottlenecks, and
create more autonomy to improve operational efficiencies. The CDA roles were so unique and
had such a mix of many different aspects that there was no one stream of influence. It is easy to
cause burnout without efficient system support and practical resources. Reducing CDAs’ burnout
can increase mentorship opportunities for aspiring BIPOC talents.
Another critical step is that the medical school HR should set up a standard process to
recruit, promote, and retain talented BIPOC employees, which includes creating a checklist and a
series of checkpoints. Promoting diversity should be more than just infused into symbolic
activities or policies in recruiting, admissions, hiring, and administrative structures and practices
(Williams et al., 2005). HR can use the above findings of key conceptual knowledge and skills to
guide the clinical department chairs for CDA recruitment instead of only based on their intuitive
judgment. The dean’s office should also continue promoting diversity among clinical department
chairs, which will provide more diverse sponsorship and mentorship and lead to more diversity
among CDAs. Due to COVID, staff shortages became more severe. Therefore, it is urgent to
bring people out as quickly as possible. With a professional teamwork atmosphere supported by
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faculty affairs and HR, CDAs will manage with a lean staff and bring clinicians on board on
time.
The dean’s office and the hospital’s top leadership should also recognize and retain these
skillful and critical frontline members, including CDAs. The recognition goes a long way in
making sure that skilled CDAs can stay afloat during difficult times. Although it is hard for an
institution to hire more CDAs due to these positions being few and CDAs’ turnovers being
minimal, the dean’s office should work with HR to create assistant or associate CDA positions in
medium-sized or large-sized departments. This can help more people explore the CDA role, gain
more hands-on experience, and expand the leadership pool and pipeline for BIPOC talents.
These assistant or associate candidates were provided opportunities to get the CDA job or a job
like it somewhere else. CDAs can have someone to share the responsibility and workload to
reduce their burnout risk and increase their wellness. In the meantime, these assistant and
associate CDAs can also be an excellent resource to mentor more BIPOC interested in entry-
level on-the-job training and provide more internships and job shadowing opportunities for those
interested in gaining experience. The medical school will also have a more diverse caliber for
backing up workforce shortages and creating more stability for the leadership team. This solution
is a win-win for all parties and will significantly improve the lack of diversity among CDAs in
all AMCs.
Due to the significant operational issues in the current organizational structure, there is an
urgency to call the top leaders’ attention and implement recommendation 3. Kotter’s eight-step
change model (Kotter, 2022) could be utilized to fix this issue. Because Kotter’s Eight Step
process for leading change focused on building a sense of urgency, which is critical for WMC
top leaders to understand CDAs’ burnout and the lack of diversity among CDAs, and be willing
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to provide the resources and support to CDAs through improving the administrative structure’s
efficiency by decentralizing some authority, improving the data transparency, building up the
dotted-line reporting relationship between CDAs and the dean’s office, and setting up standard
HR policies and hiring process. The eight steps for implementing these changes are explained
here:
Step 1: Create a sense of urgency. Articulating a compelling rationale to persuade
stakeholders to understand and agree to support the change, and in this case, communicating the
research findings with the top leaders, which includes the vice president for health affairs, school
dean, and Healthcare CEO, to gain buy-in from them for the urgency of improving the
operational efficiency and effectiveness and CDAs’ wellbeing.
Step 2: Build a guiding coalition. Forming a collective group from the dean’s office,
clinical department chairs, CDAs, and aspiring BIPOC candidates and working together to
encourage and persuade others to support the changes. The coalition should interact well with the
organization’s current leading groups on DEI and well-being movements.
Step 3: Form a strategic vision and initiatives. Creating a feasible strategic plan by
influential participants and decision-makers to guide implementation decisions and activities. It
should identify the outcomes clearly and prioritize the relative actions cohesively among
stakeholders regarding increasing data transparency, improving the system efficiency and
employee wellbeing, and initiating the dotted-line reporting relationship.
Step 4: Enlist a volunteer army. This is a process to ensure all stakeholders, including
CDAs and aspiring BIPOCs, are included. It is an opportunity for CDAs to contribute their
perspectives in increasing data transparency and improving the efficiency of administrative
workflows or processes to reduce CDAs’ burnout. This can help CDAs increase their bandwidth
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to mentor aspiring BIPOCs. The dotted-line reporting relationship enhances the linkage between
the school and the departments. It helps to provide regular updates on on-the-job training and
mentorship program to the dean’s office.
Step 5: Enable action by removing barriers. Gaining commitment from the top leaders to
remove obstacles to desired outcomes and smooth and speed the occurrence of change actions.
Step 6: Generate short-term wins. Communicating the progress and recognizing any
achievement often among CDAs and other stakeholders, including any successful efforts to
improve data transparency, complete on-the-job training, decentralize operational authority, and
initiate the dotted-line reporting relationship. This step can incorporate into recommendation 1.
Employees who accomplish a series of on-the-job training sessions will receive a certificate and
recognition. The certificate can be a prerequisite for promotion to specific jobs or positions. This
will encourage more employees to participate in on-the-job training and increase the possibility
of holding individuals accountable for their job, maintaining higher professional standards, and
improving operational efficiency.
Step 7: Sustain acceleration. Consolidating the prior achievements and keeping up change
momentum by continuously improving the dotted-line reporting relationship and operational
structure, launching more on-the-job training and sponsorship/mentorship opportunities, and
completing the standard HR hiring process for recruiting, promoting, and retaining BIPOC
talents to leadership roles. The dotted-line reporting relationship can maintain the sustainability
of support from the dean’s office and ensure information exchange accuracy across different
areas. The program certificate and standard HR hiring process can trigger employees’ learning
motivation and improve operational efficiency in the long term.
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Step 8: Institute change. Promoting changes as the status quo. Actively dismantling
dysfunctional processes and instilling innovation and learning behavior into the culture, ensuring
sustainability by setting up new workflows, building new working relationships, investing more
job opportunities on career advancement, and anchoring new approaches to increase the
representation of BIPOC in CDA and other senior leadership roles.
Figure 4 adapts Kotter’s eight-step change model (Kotter, 2023) to depict how the eight-step
process leads to more support and resources for CDAs and aspiring BIPOCs that promote
diversity among CDAs in WMC. It also incorporates recommendations 1 and 2. Implementing
recommendation 3 ensures the feasibility and sustainability of setting up on-the-job training and
mentorship/sponsorship program to achieve the best outcomes in promoting diversity among
CDAs in the long run. Although some contents in this agenda are particular for WMC, and
different AMCs may have different rubrics and operational statuses, Kotter’s eight-step change
model can be applied to leading any organizational change to promote diversity among CDAs in
any AMC.

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Figure 4
Applying Kotter’s Change Model to Enable Organizational Transformation and Promote
Diversity among CDAs

Limitations and Delimitations
Although this study discovered some significant gaps that impacted diversity among
CDAs, this study had several limitations that were out of my control (Theofanidis & Fountouki,
2018). Academic medicine is a very complex and dynamic field, and due to the limited time,
resources, and participants, some dynamic organizational factors may have yet to be captured.
While there is no power issue at play because all CDAs work independently at the same level as
me, this study may be impacted by my identity or bias due to my identity as a woman of color
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CDA. This study invited all of one medical school’s CDAs, of different genders and ethnicities,
to avoid assumptions, maximize variation among participants, minimize bias, and identify
influences (Merriam & Tisdell, 2016, p. 259). Moreover, the research also includes positionality
and reflexivity, which are strategies to promote validity and reliability. Therefore, the
researcher’s critical self-reflection regarding assumptions, worldview, biases, and positionality
can be appropriately addressed (Merriam & Tisdell, 2016, p. 259).
There were several delimitations in this study which were set by my decisions
(Theofanidis & Fountouki, 2018). Although there are about 141 AMCs in the United States, this
work is derived from one AMC and has a limited sample of data. Each medical school may have
different challenges due to its demographics, geography, and operational structure. Some of this
research’s findings may not be generalized. In addition, this study only adopted interviews as a
research methodology. Other nuances might not be captured at other AMCs or through other
research methodologies. Moreover, this research only examined aspects related to the questions,
so not all aspects or issues were measured or covered. More aspects can be added in further
research or constitute more new research in more medical schools across all regions.
Furthermore, the data was collected through interviews and self-reports regarding the
participants’ prior experiences, which may not cover all competencies and challenges. Further
understanding of challenges and the development of CDA competencies is needed.
Recommendations for Future Research
This research focused on CDA’s self-report of the KMO influences on the CDA career
trajectory pathway. Due to the time limitations, clinical department chairs for the CDAs were not
interviewed. There is a need to conduct qualitative research on the focus group of clinical
department chairs and collect data regarding the CDA role from the department chairs’
133

perspective. It will help to get the full picture of influences on a CDA’s career advancement and
reexamine the key knowledge and skills, motivation, and organizational factors that impacted the
CDA’s career development.
Furthermore, similar research at multiple AMCs should further investigate the influences
and examine whether there are differences in the key knowledge and skills, motivation, and
organizational factors that shaped the CDA career pathway. That research could inspect if any
results and findings in this study apply to other AMCs. More research will call BIPOC’s
attention to this role and lead to more diversity among CDAs. Quantitative research, in addition
to qualitative research, will provide data related to organizational culture and settings from the
same entry-level BIPOC administrative staff at medical schools. That research would yield an in-
depth understanding of the organizational culture and settings that influence diversity.
Conclusion
These research findings at WMC aligned closely with the literature review and
conceptual framework, especially in the knowledge and motivation influences. The results
indicated that the KMO gaps hindered the BIPOC women’s career advancement toward a CDA
role. The knowledge gap was caused by a lack of formal on-the-job training, as CDAs were
assigned the role without guidance or checklists. This lack also contributed to the motivation
gap, which was the lack of a formal sponsorship and mentorship program. The organizational
gaps were a lack of standard HR policy and hiring procedures to promote, recruit, and retain
diverse CDAs; a lack of dean’s office support and information transparency; and a lack of
efficient administrative structure and an effective data reporting system. This study found that
WMC has no formal professional training programs to trigger self-motivation and build self-
efficacy, does not have a professional hiring and onboarding process to promote and recruit
134

diversity, and lacks a well-functioning administrative structure and an effective and transparent
data reporting system to support diversity.
All these findings contributed to the lack of diversity among CDAs. If the KMO gaps are
not addressed, they will continue to hinder diversity. According to research, 57% of
administrators have been in their positions for over 20 years and will retire in the next decade
(Matthews et al., 2013). There will be a significant shortage of qualified CDAs, who usually
require multiple experiences and soft skills to fulfill the tripartite missions of AMCs. Promoting
diversity is necessary due to the brain drain at AMCs. This study confirmed that WMC had two
unfilled CDA positions and two will be empty soon because of retirement (25% of total CDA
positions). This study found that enhancing employee training and establishing organizational
support was necessary to promote diversity. WMC has improved gender and race equity, as
evidenced by interviews and the number of POC CDAs. However, WMC benefits from putting
more effort into articulating formal training, sponsorship, and mentorship programs for BIPOC
women, creating promotion and recruitment opportunities, and setting standard hiring processes
and retention policies to advance their careers. This study provided insights into a non-clinician
role that research scholars have not adequately addressed, which significantly impacted the
diversifying workforce at the entry and middle levels in the healthcare leadership pipeline.
Promoting diversity among CDAs can help reverse the sharp decline that women of color
experienced from manager to senior manager in the healthcare leadership pipeline and embark a
positive ripple effect on reducing disparity among genders and races, promoting diversity,
equity, and inclusion, and improving employee satisfaction and healthcare treatment outcomes in
AMCs. It is time to encourage and support BIPOC talent, especially women of color, to pursue
the CDA role by redefining AMC’s notions, norms, and assumptions and holding the top
135

leadership accountable for promoting diverse representation in the healthcare leadership
structure.
136

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161

Appendix A: Interview Protocol
Introduction to the interview:
Good morning/afternoon! Thanks so much for agreeing to talk to me today. Your
knowledge and experiences of the CDA role are very valuable to the study of CDAs’ trajectory
pathway. This study tries to find the key components that contribute to CDA career
advancement. I will ask you about how you achieved and fulfilled a CDA role. I will take some
notes while we are talking so I can ensure to capture your perspectives and refer to them
appropriately. I would also like to record if that’s OK with you. The purpose of the recording is
to ensure I capture your perspectives accurately. Only I can hear the recording. This is just a way
for me to go back to what you’ve said to ensure I’m capturing your perspectives. Would that be
OK with you? Do you have any questions before we start the interview?

Table A1
Interview Protocol
Interview questions Potential probes RQ
addressed
Key concept
addressed
Q type
(Patton)
Tell me how you
learned about being
CDA before you took
the role.
How did this trigger you to
pursue your CDA career
pathway? Do you have any
mentor or learning model? Did
you participate in any related
pieces of training?
1,2,3 Knowledge, motivation,
organizational
resources
Knowledge, background
Can you please tell me
about your experiences
that impacted your
career advancement
before you took the
CDA role?
Tell me more about any
experiences that are related to
academic or medical fields.
How do these benefit your
CDA role?
1 Knowledge Experience
In general, what type of
knowledge and skills
does a CDA need?

What makes you see this? 1 Knowledge Opinion
How did you learn those
knowledge/competenci
es that a CDA role
needs?
How did you find this
opportunity? What did you
learn from those activities?
How many years of related
experience did you have before
you took over the CDA role?
1, 3 Knowledge Experience
162

Interview questions Potential probes RQ
addressed
Key concept
addressed
Q type
(Patton)
Tell me about your
routine day: What kind
of tools or strategies
are you using for your
tasks?
Do you use any job aids to
facilitate you? What do you see
as the result?
1 Knowledge Behavior
What kinds of
experiences
shaped/guided/prepare
d you for your CDA
role?
What is your approach to
pursuing your career in the
academic medical
administrative field? What did
you perceive to be a CDA?
2 Motivation Experience, values
Tell me about a time
when you felt
challenged to achieve
the goal of being a
CDA.
How did you approach this
situation? What makes you
continue on this journey? Have
you ever thought to change
your career or give up your
career goal? Did you have or
expect any organizational
support?
2 Motivation Experience
Could you tell me what
led you to the CDA
role?
What do you believe are the
reasons for you to be a CDA?
How valuable does the CDA
mean to you? How confident
are you about your ability to be
a CDA? Can you please tell me
some examples?
1, 2 Knowledge, motivation Values
163

Interview questions Potential probes RQ
addressed
Key concept
addressed
Q type
(Patton)
Tell me how you
approached the CDA
role successfully.
How many years have you
served in your current role?
What kind of support did you
have that facilitated you to be a
CDA?
1, 2, 3 Knowledge, motivation,
organization
Behavior, values,
experience
Can you please describe
what type of
organizational
resources would help
you fulfill the CDA
role?
Were you being recruited
internally or externally? Tell
me about your interview and
hiring process for the CDA
role. Do you have some
examples that your supervisor,
chair, or school supported you
in your career advancement?
3 Organizational culture
and setting
Experience, opinion
What would you advise
women of color who
are aspiring to pursue
their career toward a
CDA role?
Do you have any suggestions that
you would like to provide to
them for their career
advancement?
3 Knowledge, org culture Behavior, opinion
How do you identify
your ethnicity?
Does your identification impact
your career advancement? How
do you describe your career
pathway (progress smoothly or
murky)?
2,3 Motivation, Org culture
and setting
Background,
demographic,
experience

164

Abstract (if available)

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Asset Metadata

Creator Hu, Jianhong (author)

Core Title Creating support infrastructure for women of color advancing toward clinical department administrator role

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 04/25/2023

Defense Date 03/21/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag clinical department administrator,healthcare administration,healthcare leadership,OAI-PMH Harvest,women of color

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Ott, Maria G (committee chair), Kim, Esther C (committee member), Tobey, Patricia E (committee member)

Creator Email hujenny@usc.edu,jennyhulu@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113078003

Unique identifier UC113078003

Identifier etd-HuJianhong-11708.pdf (filename)

Legacy Identifier etd-HuJianhong-11708

Document Type Dissertation

Format theses (aat)

Rights Hu, Jianhong

Internet Media Type application/pdf

Type texts

Source 20230425-usctheses-batch-1030 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu