The use of an analytic hierarchy process to promote equity, diversity and inclusion

The incorporation of equity, diversity and inclusion (EDI) in medicine is a moral imperative that can also improve patient care and the health care system. Although EDI directives are increasingly recognized in medicine, they increase the complexity of decision-making.

Several multicriteria decision-making methods are available, but the most straightforward and widely used technique is the mathematically based analytic hierarchy process. The analytic hierarchy process has been widely applied in medicine, science and business1 and was recently proposed to promote EDI in economic decisions.2 This process allows more rational decision-making when there are multiple, competing options, regardless of whether the decision criteria are qualitative or quantitative. The analytic hierarchy process uses pairwise comparisons of the designated criteria and eigenvector linear algebra to develop priority weightings for each criterion. For the process to yield correct results, the appropriate decision-making criteria must be identified, and their relative importance properly specified with the pairwise comparisons.3 The pairwise comparisons are ranked using a fundamental scale of relative importance from 1 to 9, where 1 is designated “equal importance,” 3 is “moderate importance,” 5 is “strong importance,” 7 is “very strong importance” and 9 represents “extreme importance.”1 An indication of the quality of the pairwise comparisons can be inferred from the consistency ratio, which should be less than 10%. An online calculator for the analytic hierarchy process is available.4

The analytic hierarchy process framework can incorporate EDI criteria into decisions regarding the recruitment, training, specialty selection, placement and retention with respect to underrepresented minorities, and help allocate medical care, research directives and medical resources to marginalized groups.5

The advantages of the analytic hierarchy process include intentionality for EDI, engagement from multiple stakeholders in group decision-making processes, enhancement of trust and the promotion of department morale in the attainment of diversity and inclusion excellence. The transparent use of an analytic hierarchy process may also help quell any concerns regarding reverse discrimination.

To illustrate the analytic hierarchy process, a framework for resident selection using the 8 Canadian Resident Matching Service (CaRMS) referee criteria,6 is presented, adding EDI as a criterion. If the 9 selection criteria are rated of equal importance, EDI considerations will receive a maximum score of 11.1%. If, hypothetically, a large residency program decides that working relationships between the residents and staff are of strong overriding importance (level 5 on the analytic hierarchy process scale) compared with the other criteria, but that EDI and “special qualities and unique contributions” are both slightly less important than the other criteria, then EDI receives a maximum weighting of 4.7% (Figure 1 and Figure 2). Each residency selection committee should perform its own pairwise comparisons to derive criterion weightings applicable to their program.

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Fig. 1

Hypothetical analytic hierarchy process (AHP) for resident selection, incorporating equity, diversity and inclusion with the referee criteria of the Canadian Resident Matching Service. Note: CR = consistency ratio; wrt AHP = numerical weight of the selection criterion.

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Fig. 2

Output of a hypothetical analytic hierarchy process for resident selection that incorporated equity, diversity and inclusion with the referee criteria of the Canadian Resident Matching Service.

• Accepted September 20, 2021.