DQ4-42

WORKFORCE DIVERSITY

Rupert M. Evans, Sr., DHA, FACHE

CHAPTER

6

145

Learning Objectives

After completing this chapter, the reader should be able to

• understand how proactive use of diversity principles can transform the organization’s culture;

• understand the business case for diversity and inclusion in healthcare organizations;

• work toward creating an inclusive organizational culture; • define the roles that healthcare providers, management, and governance

play in building a business imperative for diversity within the organization; and

• discuss how healthcare leaders can develop a diversity program in their organizations.

Introduction

When you hear the term “diversity,” what comes to mind? To some, the word means the differences between human beings related to race or ethnicity. To others, it means the uniqueness of each individual. A few people still may jump up to argue that diversity is just a code word for affirmative action.

Healthcare organizations across the United States are beginning to move toward embracing and fostering workforce diversity. This cultural change means adopting new values that are inclusive and appropriately man- aging a diverse workforce. In the future, diversity will drive the business prac- tices of hospitals and other healthcare organizations, and this dynamic will re- quire strong leadership. This change will take time, but in the words of Reverend Jesse Jackson, “Time is neutral and does not change things. With courage and initiative, leaders change things.”

In this chapter, we provide a definition of diversity and a framework for understanding the different ways people view the term. In addition, we high- light several studies and legal issues pertaining to this topic and enumerate methods for building a case for and establishing a diversity program.

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A Definition of Diversity

People define diversity in many ways, depending on the way they live in and view society. In his book, The 10 Lenses: Your Guide to Living and Working in a Multicultural World, author Mark Williams (2001) discusses the framework that explains the way people see the world:

1. The assimilationist wants to conform and fit in with the group to which he or she belongs.

2. The colorblind ignores race, color, ethnicity, and other cultural factors. 3. The cultural centrist seeks to improve the welfare of his or her cultural

group by accentuating its history and identity. 4. The elitist believes in the superiority of the upper class and embraces

the importance of family roots, wealth, and social status. 5. The integrationist supports breaking down all barriers between racial

groups by merging people of different cultures together in communities and in the workplace.

6. The meritocratist lives by the adage, “cream rises to the top”—the belief that hard work, personal merit, and winning a competition determine one’s success.

7. The multiculturist celebrates the diversity of cultures, seeking to retain the native customs, languages, and ideas of people from other countries.

8. The seclusionist protects himself or herself from racial, cultural, and/or ethnic groups in fear that they may diminish the character and quality of his or her group’s experiences within society.

9. The transcendent focuses on the human spirit and people’s universal connection and shared humanity.

10. The victim/caretaker views liberation from societal barriers as a crucial goal and sees oppression as not only historical but also contemporary.

With this framework in mind, it is easier to understand why so many interpretations of the same idea exist. For our purposes, we describe diversity in the context of three key dimensions: (1) human diversity, (2) cultural di- versity, and (3) systems diversity. Each dimension needs to be understood and managed in the healthcare workplace.

Human diversity includes the attributes that make a human being who he or she is, such as race, ethnicity, age, gender, family status (single, married, divorced, widowed, with or without children), sexual orientation, physical abilities, and so on. These traits are what frequently come to mind first when individuals consider the differences in people. Human diversity is a core di- mension because it defines who we are as individuals. This dimension is with us throughout every stage of our lives, guiding how we define ourselves and

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how we are perceived by others. A workplace definition of diversity includes human diversity as a minimum.

Cultural diversity encompasses a person’s beliefs, values, family struc- ture practice (nuclear or extended family, independent living), and mind-set as a result of his or her cultural, community, and environmental experiences. This dimension includes language, social class, learning style, ethics or moral compass, religion, lifestyle, work style, global perspectives, and military views. Cultural diversity is a secondary dimension, but it can have a powerful impact on how a person behaves in the workplace. The cultural norms vary from one culture to another and influence how individuals interact with their work en- vironments. For example, some religious groups are forbidden from working on the Sabbath, and this exemption has an impact on work scheduling and even hiring decisions.

Systems diversity relates to the differences among organizations in work structure and pursuits. This dimension includes teamwork reengineering, strategic alliances, employee empowerment, quality focus, educational devel- opment, corporate acquisitions, and innovation. Systems diversity deals with systems thinking and the ability to recognize how functions in the work envi- ronment are connected with diversity. In a multicultural, diverse, and inclu- sive workplace, organizational systems are integrated to enhance innovation, encourage teamwork, and improve productivity.

All of these dimensions are important and are present in the health- care workplace, and all leaders should recognize them. The challenge is in seeing not only our differences but also our similarities as individuals, as professionals, and as members of a group. Leaders must develop effective strategies to manage the differences (and highlight similarities), and this will lead to building effective teams and a higher-performing organization (Guillory 2003).

Managing diversity is not an easy task, as a number of barriers often get in the way of achieving a harmonious working environment. Some of these bar- riers, which revolve around the diversity dimensions mentioned earlier, can be a great source of tension and conflict. For instance, a person’s culture can be a barrier to a work team when other members of the group are not respectful of or misunderstand the person’s values, beliefs, or even clothing, which that per- son gained through his or her cultural background. Examples of a cultural dif- ference may be the person’s hairstyle or affinity to wear religious artifacts. The education, race/ethnicity, work style, empowerment, and relationship/task orientation of an individual can also become barriers if they are not properly understood and managed.

Prejudice in the Workplace

Prejudice is a set of views held by individuals about members of other groups. Prejudice is pre-judgment; hence, it is not based on facts and/or experience.

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It affects the way people react toward and think of other people, and it can be as innocent as children choosing to not play with children they deem different from themselves or as harmful as adults not associating with certain people be- cause English is not their native language.

Formally, prejudice can be defined as a set of institutionalized assump- tions, attitudes, and practices that has an invisible-hand effect in systematically advantaging members of more powerful groups over members of less domi- nant groups. This type of prejudice occurs in many healthcare institutions. Some examples include culturally biased assessment and selection criteria, cul- tural norms that condone or permit racial or sexual harassment, lower per- formance expectations for certain groups, and a collective misconception about a specific group that relegates the group’s members to unfair positions. An example of the latter is stereotyping.

Stereotypes are generalizations about individuals based on their identity, group membership, or affiliations (Dreachslin 1996). A common stereotype in the healthcare management field is the assumption that black executives are not as qualified as their white counterparts. Thus, African-American execu- tives are tested more often to prove their competence, while their white con- temporaries are assumed to be capable from the start. (This fact is substanti- ated in the race/ethnic surveys discussed later in the chapter.)

The concept of “comfort and risk” relates to a human being’s natural need to feel comfortable and to avoid risk. People tend to prefer to work with others from similar racial or ethnic backgrounds because doing so provides them with a certain amount of comfort and shields them from a certain amount of risk. Although subordinate–superior relationships that involve peo- ple from different backgrounds work sufficiently to allow people to get the job done, they often fail to lead to the close bonds that form between a men- tor and a protégé.

Given the systemic existence of prejudice and the way it influences people’s mind-set and behavior in the workplace, the fair and accurate assess- ment of minority employees (caregivers, support staff, and managers alike) remains an organizational dilemma rather than an established practice. For instance, existing literature provides evidence that managers systematically give higher performance ratings to subordinates who belong to the same racial group as they do, while high performers from minority groups remain comparatively invisible in the managerial/leadership selection process (Thomas and Gabarro 1999).

The Business Case for Diversity

In 1900, one in eight Americans was non-white; today, this ratio is one in four. By 2050, the ratio will be one in three (IOM 2004). The healthcare

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industry needs physicians, nurses, and other providers, but it also needs care- givers who reflect the diversity of the population, who, at one point or an- other, become patients. The same is true for healthcare managers and exec- utives. Therefore, healthcare organizations must ensure that their caregivers and leaders represent the backgrounds of the communities they serve. In ad- dition, healthcare executives must look for new insights, examples, and best practices to help navigate their organizations through a diversity journey. A key challenge in this journey is establishing a business case for having a di- verse workforce.

The business case for diversity is unique for each organization. The cir- cumstances, environment, and community demographics of one organization cannot be generalized to another institution. However, some elements are common in all organizations, which can be the basis of a diversity program: the healthcare marketplace, employee skills and talent, and organizational ef- fectiveness. These elements will drive the institution’s investment in and com- mitment to diversity. An organization can achieve and sustain growth and profitability by doing the following:

• Expand market share by adding or enhancing services that target diverse populations.

• Link the marketplace with the workplace through recruiting, developing, and retaining employees with diverse racial/ethnic backgrounds.

• Create and implement workplace policies and management practices that maximize the talent and productivity of employees with diverse backgrounds.

The facts are that all minority groups buy and consume healthcare serv- ices, many of them are educated and trained to either provide healthcare serv- ices or manage operations, and many of them currently work within the field and understand its complexities. Hospitals and other healthcare organizations cannot afford to miss such opportunities. They can seek, cultivate, and retain minority talent to help them compete in today’s diverse healthcare environ- ment. Failure to take advantage of these opportunities will mean the differ- ence between being a provider and employer of choice and losing ground to competitors.

Governance Impact

The organization’s board of governance can help in this regard. Members of the board or trustees are the ultimate links to the communities served by a healthcare organization. They know the makeup of the population the organ- ization serves and seeks to target, and they have insights into their communi- ties’ healthcare needs. Because board members are part of the community, they have an interest in making sure that the organization that they represent is not only providing inclusive services but is also being a fair and equitable

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employer and neighbor. With this perspective in mind, governance should support a business strategy that promotes community goodwill, encourages growth, considers present social and demographic transformations and hence future needs, and emphasizes culturally competent and sensitive healthcare. Most importantly, members of the board should also reflect the multicultural mix of the surrounding communities.

Considering all of the challenges faced by any healthcare board, why should it be concerned with diversity? One of the many reasons is to protect the organization’s bottom line. The financial impact of problems stemming from racial discrimination and discriminatory practices can be substantial. Well-publicized cases of large organizations committing or turning their backs on such practices provide evidence of the extent of cost consequences. For ex- ample, in 2007, two Equal Employment Opportunity Commission lawsuits were filed alleging racial and sexual discrimination. The first was filed in South Florida claiming that a manager at two Nordstrom stores in Palm Beach County harassed a Hispanic woman and other “similarly situated individuals” based on these individuals’ national origin and race and that the company failed to take prompt action (Puget Sound Business Journal 2007). The second was a lawsuit against United HealthCare of Florida that accused a male execu- tive of subjecting another male executive to repeated verbal sexual harassment (EEOC. 2007). This latter case resulted in a $1.8 million settlement and an order for United HealthCare to distribute a new antiharassment policy to all of its employees (EEOC 2007). Another reason that the board should sup- port diversity initiatives is to encourage and strengthen employee commit- ment to the organization. Simply, a diverse workforce is an asset. It differen- tiates an organization in the marketplace, giving it an edge against its competitors in terms of inclusiveness, cultural sensitivity and competency, and even progressive practice.

Board commitment to the principles of diversity may lead to shifts in the corporate culture as well, allowing all stakeholders to contribute to the overall success of the organization and its mission. Trustees should hold orga- nizational leaders and managers accountable for setting and following high di- versity standards. This practice will lead to an improved organization and to healthy communities.

Legal Issues

The debate continues over whether having a diversity program is the right thing to do or whether it enhances shareholder/stakeholder value. The answer is both—not only is it the right thing to do, but it also adds value to the organiza- tion. Educated, skilled, and experienced professionals and workers who are con- sidered in the minority (including but are not limited to women, racial and eth- nic minorities, and people with physical challenges) bring strategic and unique perspectives into their roles, generate productive dialogue, and challenge the

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status quo. All of these are essential to the practices, products and services, and operations of a healthcare organization. If these are not reasons enough to main- tain a diverse workforce, various laws also prohibit employment discrimination.

The Civil Rights Act of 1964 was signed into law on July 2, 1964. This legislation was intended to ensure that the financial resources of the federal government would no longer subsidize racial discrimination (Smith 1999). This law bans discrimination in any activities, such as training, employment, or construction, that are funded by federal monies. Discrimination is also pro- hibited in entities that contract with organizations that receive federal funds. Every recipient of federal funds is required to provide written assurances that nondiscrimination is practiced throughout the institution. Among the first major tests of the Civil Rights Act was the decision of the U.S. Court of Ap- peals for the Fourth Circuit on the case of Simkins v. Moses Cone Memorial Hospital. The decision struck down the separate-but-equal provisions of the Hill-Burton Act and gave the federal government the necessary power to en- force the Civil Rights Act (Smith 1999).

The Civil Rights Act also protects individuals whose native language is not English. The U.S. Department of Justice has issued the “National Origin Discrimination Against Persons with Limited English Proficiency (LEP) Guidance.” This guidance, intended for recipients of federal funds, prohibits discrimination of people who have limited English-language proficiency. It re- quires federally funded entities to ensure that people whose primary language is not English can access and understand services, programs, and activities pro- vided by these organizations. This mandate has made a serious impact in the way healthcare organizations, especially those in areas with large numbers of individuals who speak English as a second language (ESL), frame their serv- ice offerings. The National Council on Interpreting in Health Care has put together “The Terminology of Health Care Interpreting,” a glossary of terms intended to help healthcare leaders in developing programs for ESL patients; visit www.ncihc.org for more information on this glossary.

See Chapter 5 for a comprehensive discussion of the Civil Rights Act and other laws that protect groups who are considered in the minority.

Diversity in Healthcare Leadership: Two Major Studies

Despite the demographic changes in the U.S. population, and hence in the healthcare field, few minorities are present in the executive suite. Within the last decades, two major studies were undertaken to understand the factors be- hind minorities’ difficult climb on the healthcare management ladder. As the findings of these studies indicate, although improvements are continually be- ing made in terms of how workforce and leadership diversity is viewed and val- ued in healthcare organizations, a lot of work is left to be done.

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Study 1: A Race/Ethnic Comparison of Career Attainments

in Healthcare Management

In 1992, the American College of Healthcare Executives (ACHE) and the National Association of Health Services Executives (NAHSE) conducted a study that compared the career attainment of Caucasian and African-American healthcare executives. The study found that among executives with similar training and experience, African Americans were in lower-level positions, made less money, and had lower levels of job satisfaction (ACHE 2002). The results of this study made way for the creation of the Institute for Diversity in Health Management (IFD), the only organization committed exclusively to promoting managerial diversity within the healthcare field.

In 1996, ACHE, with assistance and support from NAHSE, IFD, the Association of Hispanic Healthcare Executives (AHHE), and the Executive Leadership Development Program of the Indian Health Services (IHS), con- ducted a follow-up survey using many of the items included in the first sur- vey. This second survey, completed and published in 1997, revealed that 23 percent of the U.S. hospital workforce was made up of African Americans and Hispanics. Unfortunately, less than 2 percent of these minority groups held the positions of president, chief executive officer, and chief operating officer.

The third cross-sectional study, released in 2002, was conducted to de- termine if the race/ethnic disparities in healthcare management careers had narrowed since the 1997 release of the second survey and was based on the observations and experiences of a similar pool of respondents. In planning this study, leaders of ACHE, AHHE, IFD, and NAHSE invited the collaboration of the Executive Leadership Development Program of the IHS so that the ca- reer attainments of Native-American executives could also be assessed.

Following is a summary of the most important findings of the third study (ACHE 2003):

• More white administrators than minority administrators worked in hospital settings.

• White female administrators earned more than female minority administrators. When controlling for education and experience, compensation earned by white women remained higher than the compensation for male and female members of minority groups.

• White male administrators earned more than male minority administrators. When controlling for experience and education, the total compensation of male African-American and Hispanic administrators was approximately equal to that of their white counterparts.

• Minority administrators expressed lower levels of job satisfaction than did white administrators. The items with which low satisfaction was reported included the following: 1. Pay and fringe benefits were not proportionate to the minority

administrators’ contribution to their organization.

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2. The degree of respect and fair treatment that minority administrators received from their leaders was inadequate.

3. The sanctions and treatment that minority administrators faced when they made a mistake were more severe than their action called for.

• Fewer minority administrators than white administrators expressed that their organizations had great personal meaning to them.

• More minority administrators than white administrators stated that they experienced racial/ethnic discriminatory acts in the past five years, such as not being hired or being evaluated with inappropriate standards.

• Only about 15 percent of female minority administrators aspired to be chief executive officers. More white male administrators had such aspirations than male minority administrators.

• The majority of minority administrators endorsed efforts to increase the percentage of racial/ethnic minorities in senior healthcare management positions. Nearly half of their white counterparts were neutral or opposed to such efforts.

Recommendations to address the disparities found between the white and mi- nority groups are being developed. A fourth race/ethnic survey is expected to be conducted in 2008.

Study 2: Advancing Diversity Leadership in Healthcare

In 1998, Witt/Kieffer, an executive search firm, conducted a national survey of healthcare leaders (e.g., chief executive officers, presidents, human re- sources executives) to determine the advances in and barriers to recruiting and retaining women and minority leaders in the industry. The survey revealed di- vergences in opinions between nonminority and minority respondents. Non- minority respondents reported that minority leaders were hard to find, while minority respondents claimed that these leaders were not looking either hard enough or in the right places. Another significant difference in perspective was on the issue of whether organizational or even individual resistance to minor- ity leadership was part of the problem (Witt/Kieffer 2006).

In 2006, Witt/Kieffer conducted a follow-up survey that involved hu- man resources executives and minority leaders in hospitals and health systems nationwide. Seventy-one percent of respondents were nonminorities, and 29 percent were from minority groups. The project also included phone inter- views with respondents who were willing to share additional thoughts regard- ing diversity leadership (Witt/Kieffer 2006).

The following are the main findings of the 2006 study:

• Eighty-two percent of the nonminority respondents and 81 percent of the minority group agreed or strongly agreed with the statement, “Internal diversity programs support the organization’s overall mission/vision.”

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• Seventy-nine percent of minority and 68 percent of nonminority respondents agreed that “Internal diversity programs are strategic to organizational success.”

• Virtually all respondents agreed that “Internal diversity programs demonstrate the value of cultural differences in an organization.” By and large, both groups also shared the belief that organizations commit to diversity recruiting because they want to achieve “cultural competence” organization-wide.

• Seventy-two percent of minority and 63 percent of nonminority respondents agreed that “Internal diversity programs provide diversity staffing that mirrors the diversity of the patient population.”

• Only 28 percent of nonminority respondents and 12 percent of the minority group agreed that “Healthcare organizations have been effective in closing the diversity leadership gap over the past five years.”

• Nearly 73 percent of nonminority respondents personally believed that opportunities for diversity in leadership have improved over the past five years. Only 34 percent of minorities shared that personal belief. Also, 67 percent of nonminorities agreed that “The availability of diversity leadership positions in healthcare organizations has improved over the past five years,” but only 30 percent of minority respondents agreed.

• Minority respondents remained unconvinced that they are “well represented today in healthcare organization management teams.”

• Both respondent groups agreed that internal diversity programs drive organizational success and cultural competence. However, respondents, particularly minorities, expressed skepticism about whether hospitals and healthcare systems commit to diversity recruiting because those organizations believe diversity is good for business.

• Seventy-two percent of nonminorities and 53 percent of minorities agreed that healthcare organizations are effective in diversity recruiting because they have a genuine interest in it. Seventy-three percent of nonminorities and about 50 percent of minorities believed healthcare organizations are effective at diversity recruiting because they take their responsibility to do so seriously.

• Respondents held widely divergent views on the most important barriers to diversity recruitment, retention, and leadership development. The only barrier for which general agreement was reached was the “lack of commitment by top management.”

Diversity Management

According to the Institute for Diversity in Health Management (2007), man- aging a diverse workforce involves the following elements:

• Employee perspective. Diversity management creates an environment where every hospital or health system employee feels valued, appreciated

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and respected and who, in turn, talks about the organization within the community with pride. Diversity management allows 100 percent of employees, whatever their capabilities, to achieve 100 percent of their potential 100 percent of the time.

• Patient focus. Diversity management creates an environment where because all patients feel valued, they are highly satisfied and loyal. Diversity management means understanding the cultural and ethnic values within a community. As a result, community members choose the organization, which increases market share.

• Inclusion. Diversity management means sending a message to minorities that there are leaders within the organization to champion their medical needs. If a minority patient knows the COO [chief operating officer] shares his or her ethnicity, for example, then that patient likely assumes his or her best interests will be served.

• Community perspective. Diversity management means bringing the community into the organization, specifically at the governance level. Putting prominent minority leaders on the hospital or health system board forges a bond with the community, which in turn creates patient comfort with and loyalty to the organization.

The Impact of Diversity on Care Delivery

According to the National Institutes of Health, “the diversity of the Ameri- can population is one of the nation’s greatest assets; one of its greatest chal- lenges is reducing the profound disparity in health status of America’s racial and ethnic minorities” (Smedley and Stith 2002). The Institute of Medicine’s landmark report in 2002, entitled Unequal Treatment, reveals the presence of significant disparities in the way white and minority patients receive healthcare services, especially in treatment for heart disease, cancer, and HIV (Smedley and Stith 2002). Addressing such disparities in care, including the dispropor- tionate recruitment and selection of a minority workforce, and ensuring cul- tural competence of caregivers are interconnected. To minimize care dispari- ties, institutions and providers have to develop cultural competence. To develop cultural competence, a diverse group of providers, support staff, and managers needs to be in place and diversity training and policies for all employ- ees and caregivers have to be established. Simply, the lack of a culturally com- petent healthcare workforce is a possible contributor to the disparities in care.

Having examined how a diverse physician community also benefits healthcare, researchers Cohen, Gabriel, and Terrell (2002) posited at least four practical reasons for attaining greater diversity: (1) it advances cultural competency, (2) it increases access to high-quality care, (3) it strengthens the medical research agenda, and (4) it ensures optimal management. These find- ings are relevant and applicable to healthcare management and leadership as

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well. As stated by Cohen, Gabriel, and Terrell, “the first and perhaps most compelling reason for increasing the proportion of medical students and other prospective health care professionals who are drawn from underrepresented minority groups: preparing a culturally competent health care workforce.”

Cultural competence may be defined as a set of complementary behav- iors, practices, attitudes, and policies that enables a system, an agency, or in- dividuals to effectively work and serve pluralistic, multiethnic, and linguisti- cally diverse communities. The demographic makeup of this country will continue to change in the years ahead, and culturally competent and sensi- tive care is and will be expected from current and future healthcare profes- sionals. To effectively provide such care, leaders, clinical staff, and all the em- ployees in between must have a firm understanding of how and why belief systems, personal biases, ethnic origins, family structures, and other cultur- ally determined factors influence the manner in which patients experience ill- ness, adhere to medical advice, and respond to treatment. Such factors ulti- mately affect the outcomes of care. Physicians and other healthcare professionals who are not mindful of the potential impact of language barri- ers, religious taboos, unconventional views of illness and disease, or alterna- tive remedies are not only unlikely to satisfy their patients but, more impor- tant, are also unlikely to provide their patients with optimally effective care (Cohen, Gabriel, and Terrell 2002).

A study finds that although African-American physicians make up only 4 percent of the total physician workforce in the United States, they care for more than 20 percent of African-American patients in the United States (Saha et al. 2000). The study suggests that African Americans prefer to get care from black physicians, and a contributing factor to this may be that many African-American physicians locate their practices in predominantly black communities and are, therefore, more geographically accessible to African- American healthcare consumers. If the hypothesis is true that minority con- sumers prefer care from physicians of their own race simply because of geo- graphic accessibility, then organizational policies aimed at better serving the needs of minority communities need not consider physician race and ethnic- ity in the equation. If, however, minority patients have this preference be- cause of a shared language or culture, for example, then increasing the sup- ply of underrepresented minority physicians is justifiable and necessary.

An understanding of the factors that influence the disparities in health- care is essential in developing effective strategies to minimize the problem. Figure 6.1 presents two sets of factors: patient-related factors and health-system- related factors. Patient-related factors are cultural characteristics of patients that prevent them from getting fair and adequate treatment in an organiza- tion that is not culturally competent or sensitive. Health-system-related fac- tors are organizational dynamics (e.g., employee attributes and biases) that in- fluence the methods used to treat patients.

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Components of an Effective Diversity Program

Healthcare leaders can establish a diversity program that will lead to a more diverse and inclusive organization (see Figure 6.2). Some actions that leaders can take toward this goal include, but are not limited to, the following:

• Ensure that senior management and the governing board are committed to the development and implementation of a diversity program.

• Broaden the definition of diversity to include factors beyond race and ethnicity.

• Recognize the business case for bringing in diversity at the leadership level. • Tie diversity goals to business objectives. • Hold recruiting events that target racial and ethnic groups, women,

people with disabilities, older but capable workers, and others who are considered minorities.

• Encourage senior executives to mentor minorities. • Develop employee programs that emphasize and celebrate diversity and

inclusivity.

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FIGURE 6.1 Factors that Influence Disparities in Healthcare

Patient-Related Factors Health-System-Related Factors

Socioeconomic Cultural competence Low income and education Insufficient knowledge of and sensitivity

to cultural differences

Health education Language Lack of knowledge of health Inability to communicate sufficiently symptoms, conditions, and with patients and families whose native possible treatments language is not English

Health behavior Discrimination Patient willingness and ability to Healthcare system and provider seek care, adhere to treatment bias and stereotyping protocols, and trust and work with healthcare providers Workforce diversity

Poor racial and ethnic match between healthcare professionals and the patients they serve

Payment Insufficient reimbursement for treating Medicare, Medicaid, and uninsured patients

SOURCE: Smedley and Stith (2002)

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The business imperatives and organizational necessities for aggressively creating a diversity program include, but are not limited to, the following:

1. Reflection of the service population. The healthcare organization’s caregivers and support staff should mirror the diversity of the population that the institution serves. Toward this end, the organization should attract and take advantage of the talents, skills, and growth potential of minority professionals within the community.

2. Workforce utilization. Minority employees have a lot to contribute to the organization. Leaders should recognize this fact and should be open to, sensitive to, knowledgeable about, and understanding of the cultures, mind-set, and practices of the organization’s diverse workforce. Doing so will not only enhance staff productivity and overall performance but will also boost staff morale.

3. Work–life quality and balance. Leaders should recognize that work and personal activities are interrelated, not separate preoccupations. Both are performed on the basis of necessity, practicality, efficiency, and spontaneity.

4. Recruitment and retention. Attracting and retaining a diverse workforce have a lot to do with the state of the workplace. Leaders should create an environment in which minorities feel included, professionally developed, and safe.

5. Bridging generations. Generational differences in expectations, education, and values exist between younger and older staff. Such gaps should be acknowledged, and attention should be paid to the physical, mental, and emotional well-being of all caregivers and staff at all ages regardless of backgrounds.

6. Cultural competence. This competence is an in-depth understanding of and sensitivity to the values and viewpoints of minority staff, patients,

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FIGURE 6.2 How to

Create an Inclusive Culture

1. Study the culture, climate (i.e., what employees are thinking, feeling, or hearing about diversity issues), and demographics of the organization.

2. Select the diversity issues that allow the greatest breakthrough.

3. Create a diversity strategic plan.

4. Secure leadership’s financial support for the plan.

5. Establish leadership and management accountabilities for the plan.

6. Implement the plan.

7. Provide continual training related to the new skills and competencies necessary to successfully achieve the plan goals.

8. Conduct a follow-up survey one or one-and-one-half years after implementing the plan.

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and other customers. Leaders should master the skills necessary to work with and serve these groups and should provide training in this matter to all employees to ensure provision of culturally competent care.

7. Organization-wide respect. Leaders should create an environment in which the differences in title, role, position, and department are valued and respected but not held too lofty above everything else. Each employee, regardless of his or her level within the organization, should be viewed as integral to the overall success of the team.

Summary

Healthcare organizations in the United States are beginning to make a com- mitment to embracing and fostering workforce diversity. This cultural change means adopting new values in terms of being inclusive and attracting a diverse workforce. The business case for diversity is unique for each organization, as circumstances, the environment, and community demographics of one organ- ization vary from those of another. However, elements (such as the market- place and organizational effectiveness) that are common in all organizations can be the basis of a diversity program.

One of the many reasons that senior management and the governing board should pay attention to diversity issues is to protect the organization’s bottom line. The financial costs of problems that stem from racial discrimina- tion and discriminatory practices can be substantial. Studies have found dis- parities in two areas: (1) minority healthcare administrators ascend in rank more slowly within their organizations than do their white counterparts, and (2) patients who belong to minority groups receive different medical treat- ments than patients who are white. Such disparities may be bridged with the development of a diversity program.

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Discussion Questions

1. While this chapter discussed the many benefits of diversity, an alternative view suggests that no empirical evidence exists that a diverse workforce has a positive effect on organizational performance, employee commitment, and employee satisfaction. In fact, anecdotal evidence indicates that diversity can negatively affect business

performance because of the possibility for internal conflict, dissension, and turnover. What is your reaction to this perspective in light of the content of this chapter? Do these arguments have merit? Why or why not?

2. Respond to this statement: Diverse leadership is a competitive advantage. What is the most compelling business

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argument for or against diverse leadership teams?

3. What are the legal, moral, and ethical consequences that prohibit hospitals from turning away patients based on race?

4. Why are there are no such consequences to patients who demand doctors, nurses, or workers of a specific race to administer their healthcare?

5. Can hospitals that adhere to gender- or race-based patient demands face discrimination lawsuits from their employees?

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6. When an employer denies an employee (or a group of employees) his or her full employment opportunity based on the racial bias of customers, is the employer violating the employee’s civil rights?

7. Does workforce diversity enhance organizational performance? Explain your answer.

8. Can an internal diversity program support an organization’s overall mission and vision? How?

Experiential Exercise

Note: This case was adapted from Davis, R. A. 2003. “No African Americans Allowed:

White Patient’s Racism Rules at Pennsylvania Hospital.” DiversityInc.com, October 9.

Abington Memorial Hos- pital is a 508-bed hospital

located in Abington, Pennsylvania. It serv- ices patients from Philadelphia and the sur- rounding suburbs of Bucks and Mont- gomery counties. The hospital’s mission “is to provide patients with the highest quality care possible, regardless of the health-care professionals’ race. . . .”

Supervisors at the hospital told African-American healthcare professionals, as well as food-service and housekeeping staff, not to enter a certain white patient’s room or interact with the family. This caused an out- rage among the African-American staff. Abington administrators said they broke hos- pital policy to avoid a potentially “volatile sit- uation” by adhering to the request of the pa-

tient’s husband: Only white employees could enter his wife’s room on the maternity ward. “We were wrong,” said Meg McGoldrick, a vice president at Abington Memorial Hospi- tal. “We should have followed our policy. The whole incident has greatly upset many of our employees who perceived that we were acquiescing to the family’s wishes.’’ Despite the hospital’s policy that states, “care will be provided on a nondiscriminatory basis,” the administrators’ actions seemed as though pa- tients were allowed to discriminate. Catholic Health Care West’s medical ethicist, Carol Bayley, said that Abington failed in its respon- sibility to its employees and the community to accommodate a patient’s racial preference: “This was a fundamental disrespect of these professionals’ skills and their fundamental

Case

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References

American College of Healthcare Executives (ACHE). 2002. A Race/Ethnic Comparison of Career Attainments in Healthcare Management. Chicago: ACHE.

———. 2003. “Increasing and Sustaining Racial/Ethnic Diversity in Healthcare Manage- ment.” Healthcare Executive 18 (6): 60–61.

Cohen, J., B. Gabriel, and C. Terrell. 2002. “The Case for Diversity in the Healthcare Workforce.” Health Affairs 21 (5): 90–102.

Dreachslin, J. L. 1996. Diversity Leadership. Chicago: Health Administration Press. Equal Employment Opportunity Commission (EEOC). 2007. “United Healthcare of

Florida to Pay $1.8 Million for Same-Sex Harassment and Retaliation.” [Online in- formation; retrieved 2/4/08.] www.eeoc.gov/press/10-1-07.html.

Guillory, W. 2003. “The Business of Diversity: The Case for Action.” Health & Social Work 28 (1): 3–7.

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dignities . . . a hospital needs to stand against this undercurrent of racism in our society.”

The Philadelphia office of the Anti- Defamation League (ADL) said that pro- hibiting African-American employees from carrying out the full scope of their duties is reprehensible. “I don’t see why and how a hospital could justify accommodating a re- quest that the professionals attending to a patient be of a particular background,” said Barry Morrison, director of the Philadelphia chapter of the ADL; he added, “Certainly, it’s demoralizing for the people who work there.” The American Hospital Association (AHA), the largest hospital association in the United States, acknowledged that no hard- and-fast industry guidelines exist for hospi- tals to follow when a patient or a family member makes a racially biased request. AHA does not offer hospitals a suggestion on how to address this situation. “It’s subjec- tive,” said Rick Wade, senior vice president at the AHA. “I’m sure the person who made the decision at Abington thought they were doing the right thing.” McGoldrick said su- pervisors at Abington were acting with good

intentions and sought to deflect any con- frontation between its African-American staff and the Caucasian family. No incident was reported during the patient’s stay.

Since then, Abington’s president, Richard L. Jones, sent a letter to all its employ- ees and volunteers apologizing for the situa- tion, which he termed “morally reprehensi- ble.” In addition to creating a diversity task force at the 508-bed hospital, Abington has hired consultants and revised its antidiscrimina- tion policy. The AHA bestowed on Abington the Quest for Quality Award for raising aware- ness of the need for an organizational commit- ment to patient safety and quality. Wade said hospitals are constantly evaluating how to pro- vide the best treatment for their patients, while protecting and maintaining the dignity of their employees. He said that a hospital’s constant patient turnover sometimes subjected workers to society’s underbelly. “Perhaps Abington could have been more protective of their em- ployees,” Wade said. “Patients come and go, [but] the most important thing at a hospital is the work-force,” he said.

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Institute for Diversity in Health Management (IFD). 2007. [Online information; re- trieved 11/12/07.] http://www.diversityconnection.org/diversityconnection_ app/homepage/index.jsp?SSO_COOKIE_ID=0a2f011430daf6dc821f57c54388 ae60bb29ec14700b.

Institute of Medicine (IOM). 2004. In the Nation’s Compelling Interest: Ensuring Diver- sity in the Health Care Workforce. Washington, DC: National Academies Press.

Puget Sound Business Journal. 2007. “EEOC Sues Nordstrom in South Florida Over Ha- rassment.” [Online information; retrieved 6/1/07.] http://seattle.bizjournals.com/ seattle/stories/2007/10/01/daily6.html.

Saha, S., S. Taggart, M. Komaromy, and A. Bindman. 2000. “Do Patients Choose Their Own Race?” Health Affairs 19: 76–83.

Smedley, B. D., and A. Y. Stith. 2002. Unequal Treatment, Confronting Racial and Eth- nic Disparities in Health Care. Washington, DC: Institute of Medicine, National Academies Press.

Smith, D. B. 1999. Health Care Divided: Race and Healing a Nation. Ann Arbor, MI: University of Michigan Press.

Thomas, D., and J. J. Gabarro. 1999. Breaking Through: The Making of Minority Execu- tives in Corporate America. Boston: Harvard Business School Press.

Williams, M. 2001. The 10 Lenses: Your Guide to Living and Working in a Multicultural World. Sterling, VA: Capital Books.

Witt/Kieffer. 2006. Advancing Diversity Leadership in Health Care: A National Survey of Healthcare Executives. Oak Brook, IL: Witt/Kieffer.

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