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30 JanuaryYMarch & 2018

Hospital cultural competency as a systematic organizational intervention: Key findings from the national center for healthcare leadership diversity demonstration project

Robert Weech-Maldonado

Janice L. Dreachslin

Josué Patien Epané

Judith Gail

Shivani Gupta

Joyce Anne Wainio

Background: Cultural competency or the ongoing capacity of health care systems to provide for high-quality care to diverse patient populations (National Quality Forum, 2008) has been proposed as an organizational strategy to address disparities in quality of care, patient experience, and workforce representation. But far too many health care organizations still do not treat cultural competency as a business imperative and driver of strategy. Purposes: The aim of the study was to examine the impact of a systematic, multifaceted, and organizational level cultural competency initiative on hospital performance metrics at the organizational and individual levels. Methodology/Approach: This demonstration project employs a preYpost control group design. Two hospital systems participated in the study. Within each system, two hospitals were selected to serve as the intervention and control

Key words: cultural competency, diversity climate, diversity management

Robert Weech-Maldonado, MBA, PhD, is Professor and L.R. Jordan Endowed Chair, Department of Health Services Administration, University of Alabama at Birmingham. E-mail: [email protected]. Janice L. Dreachslin, PhD, is Professor Emerita of Health Policy and Administration, Penn State Great Valley School of Graduate Professional Studies, Malvern, Pennsylvania. Josué Patien Epané PhD, MBA, is Assistant Professor, Department of Health Care Administration and Policy, School of Community Health Sciences, University of Nevada, Las Vegas. Judith Gail, MSOD, is Owner and Principal, Gail Consulting LLC, Washington, DC. Shivani Gupta, PhD, is Assistant Professor, College for Public Health and Social Justice, Health Management and Policy, Saint Louis University, Missouri. Joyce Anne Wainio, MHA, Vice President, National Center for Healthcare Leadership, Chicago, Illionis.

This project was supported by the National Center for Healthcare Leadership (NCHL) with funding from Sodexo and member health systems. Dreachslin, Weech-Maldonado, Epané, and Gail were reimbursed by NCHL as consultants to the project.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

mailto:[email protected]

31 Findings From the NCHL Diversity Demonstration Project

Conceptual Framework

hospitals. Executive leadership (C-suite) and all staff at one general medical/surgical nursing unit at the intervention hospitals experienced a systematic, planned cultural competency intervention. Assessments and interventions focused on three organizational level competencies of cultural competency (diversity leadership, strategic human resource management, and patient cultural competency) and three individual level competencies (diversity attitudes, implicit bias, and racial/ethnic identity status). In addition, we evaluated the impact of the intervention on diversity climate and workforce diversity. Findings: Overall performance improvement was greater in each of the two intervention hospitals than in the control hospital within the same health care system. Both intervention hospitals experienced improvements in the organizational level competencies of diversity leadership and strategic human resource management. Similarly, improvements were observed in the individual level competencies for diversity attitudes and implicit bias for Blacks among the intervention hospitals. Furthermore, intervention hospitals outperformed their respective control hospitals with respect to diversity climate. Practice Implications: A focused and systematic approach to organizational change when coupled with interventions that encourage individual growth and development may be an effective approach to building culturally competent health care organizations.

The need for health care organizations to implement cultural competency practices is supported by demo- graphic trends and well-documented disparities,

not only in quality of care and patient experience but also in workforce career outcomes and perceptions of equity and opportunity in the workplace. The Agency for Healthcare Research and Quality continues to find disparities in health as well as in the care delivered to racial/ethnic minorities when compared to non-Hispanic Whites (Agency for Health- care Research and Quality, 2014). Similarly, the American College of Healthcare Executives (2008, 2012) has found that, despite some improvements, disparities in career ac- complishment persist even after controlling for human capi- tal variables, such as education and experience. Furthermore, racial/ethnic gaps in perceptions of workplace equity and opportunity remain, with non-Hispanic White men express- ing the most satisfaction with equity and opportunity in the workplace compared to racial/ethnic minorities.

Health care organizations_ policies and practices are among the most important factors influencing disparities in quality of care and workforce career outcomes (Meyers, 2007). As such, cultural competency has been proposed as an organizational strategy to address such disparities (Dreachslin, Gilbert, & Malone, 2013). Cultural compe- tency has been defined as the Bongoing capacity of health care systems[ to provide for high-quality care to diverse patient populations (National Quality Forum, 2009). Cul- tural competency is achieved through policies, learning processes, and structures by which organizations and indi- viduals develop the attitudes, behaviors, and systems that are needed for effective cross-cultural interactions (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Successful implementation of cultural competency requires an orga- nizational commitment toward a systems approach so that the health care organization_s complex structure of inter-

connected people, policies, and practices can work in con- cert to achieve the common goal of a culturally competent organization.

However, very few studies have examined the impact of systematic, organizational level cultural competency interven- tions on hospital performance metrics. Weech-Maldonado, Elliott, et al. (2012) found a positive relationship between hospital cultural competency, assessed as adherence to the Department of Health and Human Services Office of Minority Health_s cultural and linguistic appropriate ser- vices (CLAS) standards and inpatient experiences with care in California hospitals. This study makes a contribu- tion to the literature by using a preYpost intervention assess- ment to explore the impact of a systematic, multifaceted, and organizational level cultural competency initiative on performance metrics at the organizational and individual levels among two health systems.

The conceptual framework for this article draws from Burke and Litwin_s (1992) Model of Organizational Performance and Change and Cox_s (1994) Interactional Model of Cultural Diversity. The Model of Organizational Performance and Change posits that organizational change responds to the demands of the external environment and that orga- nizations can proactively facilitate the necessary change through leadership, management practices, structures, and policies. These factors can in turn influence work climate, which can ultimately affect organizational performance. The Interactional Model of Cultural Diversity highlights the importance of both organizational context factors (e.g., structures and human resource systems) and individual level factors (e.g., prejudice, stereotypes, and personal iden- tity) as determinants of diversity climate, whereas diversity

32 Health Care Management Review JanuaryYMarch & 2018

climate ultimately affects individual career outcomes and organizational outcomes. Using tenets from both models, we hypothesize that a systematic, multifaceted, and organi- zational level cultural competency/diversity intervention aimed at improving organizational and individual level com- petencies of diversity can positively affect diversity climate and workforce diversity (Figure 1).

Systematic Diversity Intervention

Two hospital systems participated in the study. Within each system, two hospitals were selected to serve as the intervention and control hospitals. Executive leadership (C-suite) and all staff at one general medical/surgical nursing unit at the intervention hospitals experienced a systematic, planned diversity intervention. The intervention was aimed at improving organizational level and individual level com- petencies as described in the following sections. Figure 2 summarizes the key steps in the intervention. First, a battery of preassessments was administered for both intervention and control hospitals. In addition to the survey instruments and other quantitative assessments, the project team con- ducted interviews, focus groups, and a website analysis of the intervention hospitals at baseline. A feedback report was developed for each intervention hospital document- ing the results of the quantitative and qualitative data analysis. Then, a diversity coach discussed the preassess- ment results with the CEO and leadership team of each intervention hospital. On the basis of this feedback, the

diversity coach in collaboration with the intervention hospital_s CEO and leadership team developed an organi- zational level action plan that determined the interventions in the next phase. Interventions included infrastructure development, executive coaching, training, individual level action plans, and other interventions determined by each intervention hospital. After the intervention phase, the quantitative assessment battery was repeated to determine preYpost intervention change.

Organizational Level Competencies

Organizations that follow a systems approach integrate cultural competency practices throughout their management and clinical subsystems. Three organizational level compe- tencies were the focus of the systematic change initiatives in the intervention hospitals: diversity leadership, strategic human resource management, and patient cultural com- petency. We hypothesize that the intervention hospitals will experience more improvement on each of the three organizational level competencies than their respective con- trol hospitals.

Diversity leadership is described as top management commitment toward cultural competency and includes (a) integrating cultural competency into strategic plan- ning and throughout all the management systems of the organization, (b) having dedicated staff and resources to achieve diversity goals, (c) implementing proactive human resources practices to ensure recruitment and retention of a

Figure 1

Conceptual framework

33 Findings From the NCHL Diversity Demonstration Project

Figure 2

Diversity demonstration project intervention flow diagram

diverse workforce, (d) diversity training, and (e) commu- nity engagement in decision-making (Weech-Maldonado, Dreachslin, et al., 2012).

Strategic human resource management represents a Bstrate- gic deployment of a highly committed and capable work- force[ using an array of personnel practices (Storey, 2001, p. 6). Strategic human resource management practices include (a) recruitment and selection (process of attract- ing and choosing candidates for employment), (b) job design/work systems (specification and allocation of tasks and responsibilities), (c) learning and development (edu- cational activities or learning experiences to enhance employee performance), (d) performance management (pro- cess used to define, measure, and provide feedback on strategic goals), (e) reward and recognition (formal or in- formal programs to acknowledge good performance or goal attainment), and (f) succession planning (formal pro- cess to identify and develop individuals to fill key leadership roles). Strategic human resource management practices are likely to result in a more diverse workforce, greater minority representation in leadership, and higher retention of minorities.

Patient cultural competency represents the processes of care aimed at delivering quality of care for diverse populations (Weech-Maldonado, Dreachslin, et al., 2012). This includes (a) patientYprovider communication (provision of inter- preter services and translated materials for limited English proficient patients) and (b) care delivery and supporting mechanisms (delivery of care, physical environment, and links to supportive services and providers).

Individual Level Competencies

Three individual level competencies were the focus of the systematic intervention: diversity attitudes, implicit biases, and racial/ethnic identity. We hypothesize that the inter- vention hospitals will experience more improvement on each of the three individual level competencies than their respective control hospitals.

Diversity attitudes, implicit bias, and racial/ethnic iden- tity status have been shown to influence behavior and decision-making (Carter, Helms, & Juby, 2004; Gawronski, Ehrenberg, Banse, Zukova, & Klauer, 2003; Richeson & Shelton, 2003). Therefore, a necessary goal of diversity

34 Health Care Management Review JanuaryYMarch & 2018

training and related strategic diversity management initia- tives is to move leadership, staff, and the organization to increasingly more evolved or sophisticated ways of experienc- ing diversity and to enhance their awareness of and ability to manage their own diversity attitudes, implicit biases, and racial/ethnic identity.

Greenwald and Banaji (1995) define attitudes as Bfavor- able or unfavorable dispositions toward social objects such as people, places, and policies.[ Attitudes toward diversity include four key constructs (Inscape Publishing, 1994): (a) knowledge (stereotypes and information about differences), (b) understanding (empathy), (c) acceptance (tolerance and respect), and (d) behavior (patterns of interactions, flexi- bility, and openness). Although explicit bias refers to the attitudes that individuals are consciously aware of, implicit bias consists of attitudes that operate outside of conscious awareness.

Racial/ethnic identity development describes the process through which individuals become aware of and experience the social reality of their racial group identity and that of others (Helms, 1995). Helms_ model of racial identity de- velopment consists of a series of statuses, each of which is more emotionally, cognitively, and behaviorally sophisti- cated than the previous status. The maturation or develop- ment process that results in dominance and accessibility of increasingly more sophisticated statuses is driven by need, with new statuses evolving as the individual discovers that his or her current status is inadequate given what he or she knows and is experiencing now. Movement among statuses is indicative of a shift in worldview that occurs in response to experiences, self-reflection, and conscious decisions.

Organizational Outcomes

In this article, we focus on two organizational level out- comes for the intervention: diversity climate and workforce diversity. Diversity climate has been conceptualized as the perception of the value of diversity in a work environment (Kossek & Zonia, 1993); these include perceptions of organizational fairness and inclusion. Diversity climate has been associated with human resource outcomes (McKay et al., 2007). Leaders and organizations must provide a con- text in which diverse groups can realize their full potential.

Hospital staff and leadership at all levels of the orga- nization should reflect the community diversity (The Lewin Group, 2002). Racial/ethnic and language concordance between patient and provider has been associated with better patient experiences with care and satisfaction (Ngo- Metzger et al., 2006). Similarly, leadership diversity increases the likelihood that the needs of a diverse workforce and patient population are taken into account in organizational decision-making processes (Weech-Maldonado, Dreachslin, et al., 2012).

On the basis of our conceptual framework, we expect that the hypothesized greater improvement in organiza-

tional and individual competencies will result in greater improvement in organizational outcomes, such as diversity climate and workforce diversity for the intervention hospi- tals as compared to their respective control hospital.

Methods

Sample and Design

This study design consisted of pretestYposttest control group design, which allows for within-group pretestYposttest comparisons. A purposeful national sample of 25 hospital systems was invited by mail to participate in the National Center for Healthcare Leadership (NCHL) Diversity De- monstration Project. An overview of the project was included with the invitation, and follow-up calls were made to en- courage project participation. Two health systems located on the U.S. East Coast agreed to participate.

Within each system, two hospitals were selected to serve as the intervention and control hospitals. The intervention and their respective control hospital for each system served the same metropolitan area. The participating health sys- tems were located in similar metropolitan areas in terms of the population_s racial/ethnic and education profile, but one health system was located in a metropolitan area with lower unemployment rate and higher per capita income compared to the other. Assignment to intervention or control status was at random, with the executive leadership (C-suite) at each intervention hospital receiving the diver- sity interventions and the control not. In addition, a ver- tical slice of the intervention hospital_s staff, consisting of one general medical/surgical nursing unit, experienced the diversity intervention. This included support staff, direct caregivers, supervisors, managers, and directors. A matched nursing unit in the control hospital served as an additional control group and participated in selected preYpost assess- ments but did not experience the diversity interventions. See Table 1 for participant characteristics.

Preassessment interviews revealed that both interven- tion hospitals had diversity committees, limited diversity training, and racial and gender diversity in the leadership team. The project timeline consisted of approximately 6 months for preassessments, 2.5 years for the interven- tion phase, and 6 months for postassessments with comple- tion in December 2013. The study was approved by the Pennsylvania State University Institutional Review Board.

Measures

Preassessments and postassessments were completed by par- ticipants in both health systems. Both organizational and individual level measures were aggregated at the hospital level. Following is a description of how each competency and organizational outcome was operationalized and assessed.

35 Findings From the NCHL Diversity Demonstration Project

Table 1

Characteristics of study participants at baseline (N = 287)

Gender Male 13.2% Female 86.8%

Race/ethnicity White 67.7% Black 25.1% Hispanic 1.8% Other 5.4%

Career stage Early (G5 years) 30.6% Mid (5Y10 years) 18.1% Late (910 years) 51.2%

Education Some high school 2.1% High school or GED 11.5% Some college or 2-year degree 44.9% College graduate 28.9% Master_s or above 12.5%

Role in organization Nonclinical staff 6.7% Clinical support staff or licensed clinicians 12.9% Nursing 64.3% Medicine 1.6% Administration 14.5%

Organizational level competencies. 1. Diversity Leadership. Two survey instruments were used to assess the diversity leadership competency: NCHL Diversity Leadership and Cultural Competence Assessment and the Cultural Com- petency Assessment Tool for Hospitals (CCATH). The NCHL Diversity Leadership and Cultural Competence Assessment was completed online by executive leadership at each intervention and control hospital. The 68-item survey instrument was adapted from the Racial/Ethnic Diversity Management Survey (Dreachslin, 1998; Weech- Maldonado, Dreachslin, Dansky, De Souza, & Gatto, 2002). The instrument measures an organization_s alignment with diversity management best practices in five key areas: (a) Diversity Leadership (10 items): leadership_s commitment to cultural competence and diversity management; (b) Strategic Orientation (15 items): the role of cultural compe- tence and diversity management in determining the orga- nization_s strategy; (c) Diversity Infrastructure (14 items): an organization_s routine practices in support of cultural competence and diversity management; (d) Professional Development (14 items): organizational supports for training and development of a culturally competent workforce, of clinical and nonclinical staff at all levels; and (e) Culture/ Climate (15 items): the extent to which the organization_s image and behavior reflect a strong and visible commitment to diversity and cultural competence. Each survey item has

a 7-point response scale (1 = strongly disagree to 7 = strongly agree). Composite scores are obtained by averaging the item scores within each scale.

One CCATH survey was completed by each interven- tion and control hospital in consultation with the human resources team, nursing manager, and diversity leaders as needed. The CCATH has been shown to have adequate psychometric properties (Weech-Maldonado, Dreachslin, et al., 2012). The CCATH scales relevant to Diversity Leadership are Leadership and Strategic Planning (6 items), Data Collection on Inpatient Population (2 items), Data Collection on Service Area (7 items), Performance Manage- ment Systems and Quality Improvement (3 items), Human Resources Practices (8 items), Diversity Training (3 items), and Community Representation (2 items). Each item as- sesses the presence or absence of cultural competency prac- tices. CCATH composite mean scores were obtained by (a) linear transformation of each item to 0Y100 range and (b) averaging the items within each composite.

2. Strategic Human Resource Management. The NCHL Healthcare Leadership Questionnaire assessed the strategic human resource management practices of the organization and was completed by the CEO of each hospital and sub- mitted via e-mail. The survey questionnaire was developed based on empirical evidence and a review of current litera- ture. The questionnaire was used nationally in 2007 and 2010 for the purpose of developing a national health care leadership database (NCHL, 2011). Elements of the sur- vey include Recruitment and Selection (15 items), Job Design/Work Systems (4 items), Learning and Development (15 items), Performance Management (8 items), Reward and Recognition (3 items), Succession Planning (10 items), Governance (8 items), and Leadership (2 items) compe- tencies. Each item has a 7-point response scale (1 = not at all to 7 = a great deal). Composite scores are obtained by aver- aging the item scores within each scale.

3. Patient Cultural Competency. The CCATH referenced above was used to assess the two subdomains on patient cultural competency: patientYprovider communication, and care delivery and supporting mechanisms. The relevant CCATH scales were Availability of Interpreter Services (4 items), Interpreter Services Policies (4 items), Quality of Interpreter Services (3 items), Translation of Written Materials (6 items), and Clinical Cultural Competency Practices (4 items).

Individual level competencies 1. Diversity Attitudes. The Discovering Diversity Profile, which was completed by leadership and staff onsite, is an 80-item questionnaire that was used to assess four aspects of diversity attitudes: knowledge (stereotypes, information), understanding (aware- ness, empathy), acceptance (receptiveness, respect), and behavior (self-awareness, interpersonal skills). Items consist of a 4-point response option (1 = strongly disagree to 4 = strongly agree). Composite scores (range, 10Y40) for each

36 Health Care Management Review JanuaryYMarch & 2018

subscale were obtained by adding the individual item scores. Prior research has shown face/content validity and internal consistency of the scales (Mendez-Russell, Wilderson, & Tolbert, 1994; Moore & Frank, 2013).

2. Implicit Bias. Provided by Harvard_s Project Implicit, the Implicit Attitude Test (IAT) is a computer-based test that measures people_s unconscious attitudes, therefore addressing limitations related to social desirability of self- reported measures of bias (Greenwald, McGhee, & Schwartz, 1998; Nosek, Hawkins, & Frazier, 2011). The IAT, which was completed online by leadership and staff, measures the strength of associations between concepts (e.g., older people, Black people) and evaluations (e.g., good, bad) or stereotypes (e.g., athletic, clumsy). The IAT asks respon- dents to categorize two target concepts with an attribute, measures reaction time, and calculates a score accordingly. IAT scores range from no preference to a slight, moderate, or strong preference for one group versus the other (e.g., Whites vs. Blacks). Overall, the IAT has been shown to be both reliable and valid at detecting an individual_s level of implicit bias (Nosek et al., 2011). Three IATs are used in this project: Race, Gender/Having a Professional Career, and Age.

3. Racial/Ethnic Identity. The Black Racial Identity Attitude Scale (BRIAS) and the White Racial Identity Attitude Scale (WRIAS) were completed onsite by leaders and staff who self-identified themselves as Black or White, respec- tively (Helms, 1990). The BRIAS is a 60-item scale that measures five statuses of Black racial identity development: Conformity (17 items), Dissonance (8 items), Immersion (14 items), Emersion (8 items), and Internalization (13 items). The WRIAS is a 50-item scale and assesses six statuses of White racial identity development: Contact, Disintegration, Reintegration, Pseudoindependence, Immersion/Emersion, and Autonomy. Each item has a 5-point response scale (1 = strongly disagree to 5 = strongly agree), and there are 10 items in each subscale. Item scores are added to determine the subscale scores. Prior research has shown the validity of the scale, and the internal consistency estimates ranged from 0.55 to 0.74 for the subscales (Helms & Carter, 1990). Participants with other race/ethnicity completed the People of Color Racial Identity Attitudes Scale; however, given the small number of participants (n = 7 for postassessment), this group was excluded from the analysis.

Organizational outcomes. 1. Diversity Climate. The Diversity Perceptions Scale, which was completed online by leadership and staff, is a 16-item questionnaire that assesses employees_ perceptions about diversity climate (Barak, 2013). Each item in the scale uses a 6-point response option (1 = strongly disagree to 6 = strongly agree). The scale consists of two domains (organizational and personal dimen- sions) and has been found to have appropriate construct validity and adequate internal consistency (Barak, Cherin, & Berkman, 1998). We focus on the organizational dimen-

sion, which refers to perceptions of management_s policies, procedures, and practices affecting diversity. This dimension has two subscales: organizational fairness (Items 1Y6) and organizational inclusion (Items 7Y10). An average score was obtained for each subscale.

2. Workforce Diversity. Using data from the Equal Em- ployment Opportunity_s Employer Information Report (EEO-1), we compare workforce diversity for each interven- tion and control hospital pre- and postintervention. Di- versity is assessed in terms of percentage of women and percentage of non-White minorities and is reported for the following occupational categories: Executive/Senior Man- agement, First/Mid Managers, Professionals, Technicians, Administrative Support, and Service Workers.

Analysis

Descriptive statistics (means and standard deviations) were calculated for all the measures used in this study both pre- and postintervention. All hypotheses involving multiple observations were evaluated by conducting t tests and chi- square tests of the preYpost score differences and to test whether the preYpost change score was significantly different when comparing the intervention to the control hospital within each system. Hypotheses involving single observa- tions at the hospital level were evaluated descriptively by comparing the change scores (before and after the inter- vention) for intervention and control hospitals.

Findings

All eight hypotheses were supported or partially supported for Intervention Hospital X, but only six of eight were sup- ported or partially supported for Intervention Hospital Y. The intervention hospitals outperformed their respective control hospitals within each health system for change in diversity leadership, strategic human resource management, diversity climate, and all three individual level competen- cies: diversity attitudes, implicit bias, racial/ethnic iden- tity. Results were mixed for patient cultural competency and workforce diversity. Results by competency and organi- zational outcomes are presented in Table 2 and discussed below.

Organizational Level Competencies

Diversity Leadership (Hypothesis 1a). Differences were observed across the two systems in the NCHL Diversity Assessment scores. Intervention Hospital X experienced greater positive change in their total scores across all five dimensions, whereas Hospital Y experienced a decline in all five dimen- sions compared to the control hospitals. However, inter- vention hospitals at both systems experienced higher change scores in most CCATH diversity leadership dimensions, compared to their respective control hospitals.

37 Findings From the NCHL Diversity Demonstration Project

Table 2

Hypotheses and summary of findings

Hypotheses Measure Intervention

Hospital X vs. Control Intervention Hospital Y vs. Control

Hypothesis 1a: Intervention hospitals will experience an increase in diversity leadership compared to the control hospitals.

Hypothesis 1b: Intervention hospitals will experience an increase in strategic human resource management compared to the control hospitals.

Hypothesis 1c: Intervention hospitals will experience an increase in patient cultural competency compared to the control hospitals.

Hypothesis 2a: Participants in intervention hospitals will experience an improvement in diversity attitudes compared to participants in control hospitals.

Hypothesis 2b: Participants in intervention hospitals will experience a reduction in implicit bias compared to participants in control hospitals.

Hypothesis 2c: Participants in intervention hospitals will experience a greater development in their racial/ethnic identity status compared to participants in control hospitals.

NCHL Diversity Assessment

CCATH

NCHL Healthcare Leadership Index

CCATH

Discovering Diversity Assessment

IAT scores for age, gender, and race

WRIAS

Supported Increase in total scores that ranged from 1.0 (20.4%) for Diversity Infrastructure to 0.4 (8.3%) for Diversity Leadership.

Increase in three dimensions (out of 6): Data Collection on Service Area (14.3, 23.4%); Human Resources Practices (14.3, 20%); and Leadership and Strategic Planning (0.1, 8.5%)

Supported Increase in scores that ranged from 1.9 (41.3%) for Governance to 0.2 (4.9%) for Recruitment and Selection.

Partially supported Increase in four dimensions (out of 5): Clinical Cultural Competency Practices (75, 97.5%); Interpreter Services: Written Policies (50; 58.3%); Quality of Interpreter Services (33.3, 33.3%); and Translation Services (20, 28.6%). Decrease in availability of interpreter services (j30 point, j50%).

Supported Increase in seven dimensions ranging from 2.1 (7.4%) for Information to 0.25 (0.6%) for Respect.

Supported Greater reduction in the strong preference for both young and Whites. Significant shift from neutral toward preference for women with careers.

Partially supported Whites experienced deterioration

in their racial identity profile as evidenced by lower WRIAS scores in the higher-order dimensions (Immersion/ Emersion and Autonomy).

Partially supported Decrease in total scores that ranged from 1.3 (27.6%) for Strategic Orientation to 0.2 (3.4%) in Diversity Leadership.

Increase in four dimensions (out of 6): Leadership and Strategic Planning (33.3 points, 199%); Data Collection on Service Area (25, 25%); Performance Management Systems (25, 25%); and Human Resources Practices (14.3, 25%).

Supported Increase in scores that ranged from 3.0 (54.9%) for Recruitment and Selection to 0.2 (j5.0%) for Job Design/Work System.

Not supported Decrease in four dimensions (out of 5): Translation Services (j30, j40%); Interpreter Services: Written Policies (j25, j25%); Quality Of Interpreter Services (j33.4, j50.1%); and Availability of Interpreter Services (j10, j10%). Increase in one dimension (out of 5): Clinical Cultural Competency Practices (25, 33.3%).

Supported Increase in six dimensions ranging from 1.3 (4.6%) for Stereotypes to 0.3 (1.0%) for Self-Awareness.

Partially supported Improved scores only for race. Shift from preference for Whites to the neutral and preference for Blacks.

Shift toward greater preference for young and preference for men with career relative to the control.

Partially supported Whites experienced deterioration in their racial identity profile as evidenced by lower WRIAS scores in the higher-order dimensions (Immersion/Emersion and Autonomy).

(continues)

38 Health Care Management Review JanuaryYMarch & 2018

Table 2

Hypotheses and summary of findings, Continued

Hypotheses Measure Intervention

Hospital X vs. Control Intervention Hospital Y vs. Control

BRIAS Blacks experienced Blacks experienced improvements improvements in their in their racial identity profile racial identity profile postintervention, as evidenced by postintervention, as the shift in the BRIAS scores from evidenced by the shift in the the lower-order to higher-order BRIAS scores from the dimensions lower-order to higher-order dimensions

Hypothesis 3a: Intervention Supported Partially supported hospitals will experience Diversity Climate Positive increase in both Both intervention and control had greater improvement in Organizational Inclusion (0.4, negative change scores. However, diversity climate 8.9%) and Organizational intervention hospital experienced compared to the control Fairness (0.1, 2.2%). lower negative scores. hospitals.

Hypothesis 3b: Intervention Partially supported Not supported hospitals will experience Workforce Human Resources Outcomes: Human Resources Outcomes: a greater increase in the Diversity Increase in racial/ethnic diversity Slight increase in the diversity of diversity of their at the management level (for service workers (both intervention workforce compared to both intervention and control and control hospitals). the control hospitals. hospitals). Greater Decrease in the racial/ethnic diversity

improvement (16.4%) at at the management level (both the intervention hospital.

Percentage of women decreased, 44.8% for Management and 0.5%

intervention and control hospitals). Increase in percentage of women in the Administrative support category (4.0%).

among the Technicians. Increase in percentage of women among Service workers (3.3%), Professionals (2.7%) and Administrative support (1.1%).

Note. NCHL = National Center for Healthcare Leadership; CCATH = Cultural Competency Assessment Tool for Hospitals; WRIAS = White Racial Identity Attitude Scale; BRIAS = Black Racial Identity Attitude Scale.

Strategic Human Resource Management (Hypothesis 1b). Intervention hospitals at both systems experienced greater positive change scores across the dimensions of the Na- tional Healthcare Leadership Index, compared to their respective control hospitals.

Patient Cultural Competency (Hypothesis 1c). Differences were observed across the two systems in the CCATH patient cultural competency scores. Intervention Hospital X experienced higher positive change scores across four dimensions (out of five), whereas Hospital Y experienced a score decline in four CCATH dimensions, compared to their respective control hospitals.

Individual Level Competencies

Diversity Attitudes (Hypothesis 2a). Intervention hospitals at both systems experienced higher positive change scores in

most dimensions of the Discovering Diversity assessment, compared to their respective control hospitals.

Implicit Bias (Hypothesis 2b). Differences were observed across the two systems for the IAT scores for age, gender, and race. Compared to its control, Intervention Hospital X experienced greater reduction in the strong preference for both young and Whites. Similarly, Intervention Hospital X experienced a significant shift from neutral toward pref- erence for women with careers. On the other hand, Inter- vention Hospital Y experienced improved scores only for race relative to the control hospital. Intervention Hospital Y experienced a shift from preference for Whites to the neutral and preference for Blacks. However, there was a shift at Intervention Hospital Y toward greater preference for young and preference for men with career relative to the control.

39 Findings From the NCHL Diversity Demonstration Project

Racial/Ethnic Identity Status (Hypothesis 2c). Whites at the intervention hospitals at both systems experienced deterioration in their racial identity profile as evidenced by lower WRIAS scores in the higher-order dimensions (Immersion/Emersion and Autonomy) compared to their respective control hospitals postintervention. However, Blacks at the intervention hospitals at both systems expe- rienced improvements in their racial/ethnic identity pro- file postintervention, compared to their respective control hospitals.

Organizational Outcomes

Diversity Climate (Hypothesis 3a). Differences were observed across the two systems in the Diversity Perceptions scores. Compared to its control, Intervention Hospital X experi- enced more positive change for both Organizational Inclu- sion and Organizational Fairness. In the case of Health System Y, both intervention and control hospitals had negative change scores; however, Intervention Hospital Y experienced lower negative scores than the control hospital.

Workforce Diversity (Hypothesis 3b). Findings were mixed with respect to the recruitment of non-White minorities. Both control and intervention hospitals in Health System X experienced increased racial/ethnic diversity at the man- agement level, although Intervention Hospital X had a greater improvement (16.7%) compared to its control. Both control and intervention hospitals in Health System Y ex- perienced a decrease in the racial/ethnic diversity at the management level; however, there was a slight increase in the diversity of service workers at both hospitals. With respect to percentage of women, there was a decrease in the interven- tion hospitals at both systems, particularly at the manage- ment level, compared to their respective control hospitals.

Practice Implications and Discussion

Results of the demonstration project contribute to the evidence base for adoption of the systems approach to sustainable change in diversity and cultural competence practices in hospitals. Overall performance improvement was greater in each of the two intervention hospitals than in the control hospital within the same health care system. Both intervention hospitals experienced improvements in the organizational level competencies of diversity leader- ship and strategic human resource management. Similarly, improvements were observed in the individual level com- petencies for diversity attitudes and implicit bias for Blacks among the intervention hospitals. Furthermore, interven- tion hospitals outperformed their respective control hospitals with respect to diversity climate. As such, results suggest that a focused and systematic approach to organizational change when coupled with interventions that encourage individual growth and development may be an effective approach to building culturally competent health care organizations.

The hypothesized evolution in racial/ethnic identity status for individual respondents in the intervention hos- pitals as compared to the control hospitals was evident only for Black respondents. In fact, White respondents_ racial identity status devolved to less developed statuses. Blacks may have responded to the change to a more diversity-focused context in the intervention hospitals with personal growth, which may help explain these findings. The early stages of a diversity initiative may produce back- lash among Whites, which could explain the devolution to lower-order White racial identity statuses observed in this study postintervention.

Intervention Hospital X experienced an increase in the racial/ethnic diversity of its management compared to the control hospital; however, female representation in lead- ership declined. This may have been a result of turnover and male minorities being recruited to leadership positions that were previously occupied by White women.

Intervention Hospital X had stronger performance im- provement than Intervention Hospital Y across most metrics of the study. Although both hospitals experi- enced the same intervention, contextual differences may have impacted the implementation of the intervention. For example, qualitative analysis shows that Hospital X was more successful than Hospital Y in the implemen- tation of their organizational action plan as part of the intervention. Postassessment interviews suggest that health system factors, such as Hospital X having more direct con- trol over the planning domains compared to Hospital Y, may have impacted the implementation of the action plans.

The relatively long intervention period of over 2 years may have limited the potential impact of the project in the two participating hospitals. A shorter, more focused inter- vention period may have produced better outcomes but was precluded by competing priorities in the health system. A strategic diversity initiative needs to be actively aligned with other hospital and health system initiatives for it to be effective.

One limitation of this study is that change in individual level competencies was compared at the hospital level because of turnover from pre- to postassessment. The percentage of respondents who completed both the pre- and postassessment ranged from a low of 7% to a high of 24%, so that specific individual_s preYpost intervention change scores were not calculated. Anecdotal evidence from leadership team postintervention group interviews and observations by the diversity coach, however, indicates that some of the turnover was due to the project itself, which resulted in some departures by individuals who were not supportive of the enhanced organizational focus on diversity as well as the addition of new staff who joined the hospital because of the diversity focus. As such, the preYpost improvement in diversity attitudes and preYpost reduction in implicit bias at both intervention hospitals, relative to their control hospital,

40 Health Care Management Review JanuaryYMarch & 2018

may be indicative of a more culturally competent workforce postintervention.

Another study limitation is that the original demon- stration project design called for preYpost collection of additional outcomes measures. These included hospital- level operating and total profit margins and nursing unit level readmissions and mortality data. However, one health system_s data were only available at the system level, not at the hospital level, and patient outcomes data, including HCAHPS, were not available at the nursing unit level in either health system. As a consequence, although results do lend support to the systems approach as a strategy to implement best practices in diversity management as well as build cultural competence in hospitals, no clear connection can be drawn as to the impact of improved diversity man- agement practices and cultural competence on financial or patient outcomes.

The demonstration project involved control hospitals and assessed change on a wide array of measures at the organizational and individual levels. Despite these positive aspects of the study design, only two health systems par- ticipated in the project, and this small sample limits the generalizability of the findings. Future research that also employs a preYpost design with an intervention and control hospital but involves more health systems and analyzes additional outcome measures is needed to build on the demonstration project_s findings.

In summary, far too many health care organizations still do not treat diversity management as a business imperative and driver of strategy, and we have yet to achieve full inclusion in the health care workplace and amelioration of disparities in health and health care. The current focus on population health calls for a strategic approach to diversity management and organizational cultural competency. Sys- tematic, multifaceted, and organizational level cultural com- petency initiatives show promise in improving diversity performance metrics and in aligning health care organiza- tions with the opportunities and challenges of an increas- ingly diverse population. However, these initiatives should be aligned with other health system strategic priorities for them to be effective.

References

Agency for Healthcare Research and Quality. (2014). 2014 National healthcare quality & disparities report. Washington, DC: Author. Retrieved from http://www.ahrq.gov/research/findings/ nhqrdr/nhqdr14/exsumm.html

American College of Healthcare Executives. (2008). A racial/ ethnic comparison of career attainments in healthcare manage- ment. Retrieved from http://www.ache.org/PUBS/research/ ReportTables.pdf

American College of Healthcare Executives. (2012). A comparison of the career attainments of men and women healthcare executives. Retrieved from https://www.ache.org/pubs/research/2012- Gender-Report-FINAL.pdf

Barak, M. E. (2013). Managing diversity: Toward a globally inclusive workplace. Thousand Oaks, CA: Sage.

Barak, M. E. M., Cherin, D. A., & Berkman, S. (1998). Organi- zational and personal dimensions in diversity climate: Ethnic and gender differences in employee perceptions. The Journal of Applied Behavioral Science, 34(1), 82Y104.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh- Firempong, O. 2nd. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118(4), 293Y302.

Burke, W. W., & Litwin, G. H. (1992). A causal model of orga- nizational performance and change. Journal of Management, 18(3), 523Y545.

Carter, R., Helms, J., & Juby, H. (2004). The relationship between racism and racial identity for White Americans: A profile analysis. Journal of Multicultural Counseling and Development, 32, 2Y17.

Cox, T. (1994). Cultural diversity in organizations: Theory, research and practice. San Francisco: Berrett-Koehler Publishers.

Dreachslin, J. L. (1998). Diversity leadership and organizational transformation: Performance indicators for health services orga- nizations. Journal of Healthcare Management, 44(6), 427Y439.

Dreachslin, J. L., Gilbert, M. J., & Malone, B. (2013). Diversity and cultural competence in health care: A systems approach. San Francisco: John Wiley & Sons.

Gawronski, B., Ehrenberg, K., Banse, R., Zukova, J., & Klauer, C. (2003). It_s in the mind of the beholder: The impact of stereotypic associations on category-based and individuating impression formation. Journal of Experimental Social Psychology, 39(1), 16Y30.

Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychological Review, 102(1), 4Y27.

Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring individual differences in implicit cognition: The implicit association test. Journal of Personality and Social Psychology, 74(6), 1464Y1480.

Helms, J. (1995). An update of Helm_s White and people of color racial identity models. In Ponterotto, G., Casas, M., Suzuki, A., & Alexander, M. (Eds.), Handbook of multicultural counseling (pp. 181Y198). Thousand Oaks, CA: Sage Publications.

Helms, J. E. (1990). Black and White racial identity: Theory, research, and practice. New York: Greenwood Press.

Helms, J. E., & Carter, R. T. (1990). Development of the White racial identity inventory. Black and White Racial Identity: Theory, Research, and Practice, 5, 66Y80.

Inscape Publishing. (1994). The Discovering Diversity ProfileA

research report. Retrieved from http://www.employee-training- programs.com/Inscape-Publishing/Discovering-Diversity- Profile-Research-Report.pdf

Kossek, E. E., & Zonia, S. C. (1993). Assessing diversity climate: A field study of reactions to employer efforts to promote diversity. Journal of Organizational Behavior, 14(1), 61Y81.

McKay, P. F., Avery, D. R., Tonidandel, S., Morris, M. A., Hernandez, M., & Hebl, M. R. (2007). Racial differences in employee retention: Are diversity climate perceptions the key? Personnel Psychology, 60(1), 35Y62.

Mendez-Russell, A., Wilderson, F. Jr., & Tolbert, A. (1994). Discov- ering diversity profile. Minneapolis, MI: Inscape Publishing, Inc.

Meyers, K. (2007). Racial and ethnic health disparities: influences, actors, and policy opportunities. Oakland, CA: Kaiser Permanente Institute for Health Policy.

http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/exsumm.html

http://www.ache.org/PUBS/research/ReportTables.pdf

http://www.employee-training-programs.com/Inscape-Publishing/Discovering-Diversity-Profile-Research-Report.pdf

https://www.ache.org/pubs/research/2012

41 Findings From the NCHL Diversity Demonstration Project

Moore, R. R., & Frank, C. (2013). Blended learning solutions for military soft skills training. Journal of Applied Learning Technology, 3(3).

National Center for Healthcare Leadership. (2011). National health- care leadership survey implementation of best practices. Chicago, IL: Author. Retrieved from http://www.nchl.org/Documents/ Ctrl_Hyperlink/doccopy5321_uid11420131046251.pdf

National Quality Forum. (2009). A comprehensive framework and preferred practices for measuring and reporting cultural competency. Retrieved from http://www.qualityforum.org/ Publications/2009/04/A_Comprehensive_Framework_ and_Preferred_Practices_for_Measuring_and_Reporting_ Cultural_Competency.aspx

Ngo-Metzger, Q., Telfair, J., Sorkin, D. L., Weidmer, B., Weech- Maldonado, R., Hurtado, M., & Hays, R. D. (2006). Cultural competency and quality of care: Obtaining the patient_s perspective. New York, NY: The Commonwealth Fund.

Nosek, B. A., Hawkins, C. B., & Frazier, R. S. (2011). Implicit social cognition: From measures to mechanisms. Trends in Cognitive Sciences, 15(4), 152Y159.

Richeson, J. A., & Shelton, J. N. (2003). When prejudice does

not pay: Effects of interracial contact on executive function. Psychological Science, 14(3), 287Y290.

Storey, J. (2001). Human resource management today: an assessment. In Storey J. (Ed.), Human resource management: A critical text. London, UK: Thomson Learning.

The Lewin Group. (2002). Indicators of cultural competence in health care delivery organizations. Retrieved from http://www. hrsa.gov/culturalcompetence/healthdlvr.pdf

Weech-Maldonado, R., Dreachslin, J. L., Brown, J., Pradhan, R., Rubin, K. L., Schiller, C., & Hays, R. D. (2012). Cultural competency assessment tool for hospitals: Evaluating hospi- tals_ adherence to the culturally and linguistically appropriate services standards. Health Care Management Review, 37(1), 54Y66.

Weech-Maldonado, R., Dreachslin, J. L., Dansky, K. H., De Souza, G., & Gatto, M. (2002). Racial/ethnic diversity man- agement and cultural competency: The case of Pennsylvania hospitals. Journal of Healthcare Management, 47, 111Y126.

Weech-Maldonado, R., Elliott, M., Pradhan, R., Schiller, C., Hall, A., & Hays, R. D. (2012). Can hospital cultural com- petency reduce disparities in patient experiences with care? Medical Care, 50, S48YS55.

http://www.nchl.org/Documents/Ctrl_Hyperlink/doccopy5321_uid11420131046251.pdf

http://www.qualityforum.org/Publications/2009/04/A_Comprehensive_Framework_and_Preferred_Practices_for_Measuring_and_Reporting_Cultural_Competency.aspx

http://www.hrsa.gov/culturalcompetence/healthdlvr.pdf