Cultural Integration and Workforce Diversity

ALL OF US Embracing Diversity in Healthcare By Susan Birk

I n approaching the complex, sometimes contro-

versial and profoundly important subject of

diversity, ACHE Chairman Gayle L. Capozzalo,

FACHE, believes it comes down to respect.

"I believe that the bedrock principle upon which our

endeavors to provide compassionate and culturally

competent care is based is respect," Capozzalo, execu-

tive vice president. Strategy and System Development,

Yale New Haven (Conn.) Health System, said during

the 2012 American Hospital Association Annual

Meeting May 6—9. "We embrace diversity because it is

fundamentally about respect, and we believe it is both

an ethical and business imperative that can improve

our organization's quality, safety and services."

Implicit in her words is what some leaders might call les-

son No. 1 about this issue: Diversity is not merely a jaded

nod in the direction of affirmative action (although

affirmative action is an important element of diversity

programs). Nor is it a "social program" to be delegated to

Human Resources. Rather, it requires a desire by senior

leadership to welcome many perspectives and differences

and to inculcate respect and appreciation for those per-

spectives as a basic organizational value.

More Than Policies Patricia Harris, global chief diversity officer of

McDonald's Corp., sums it up in the title of her

book: None of Us Is as Good as All of Us: How

McDonald's Prospers by Embracing Inclusion and

Diversity (Wiley, 2009).

"You need to embed in your organization's culture

the recognition that diversity and equal treatment

are not simply policies to be policed," says Susan M.

Nordstrom Lopez, FACHE, president of Advocate

Illinois Masonic Medical Center, Chicago.

"It has to come from inside," she says. "And like all organizational values, it has to come from the top, and it has to be observed consistently throughout the organization." That inclusivity applies to race, generation, gender, ethnicity, reli- gious affiliation, culture and sexual orientation. And it holds true whether attending to the cultural needs of patients, building a workforce or develop- ing a leadership team that mirrors the community it serves.

Signs of Progress The healthcare sector's progress in this regard has been "somewhere between fair and significant," says Frederick D. Hobby, president and CEO of the Institute for Diversity in Health Management, Chicago. According to Hobby, evidence of prog- ress can be seen in the national call to action to eliminate healthcare disparities launched last year

by the American Association of Medical Colleges, ACHE, American Hospital Association, Catholic Health Association of the United States and National Association of Public Hospitals and Health Systems.

The Equity of Care initiative aims to: (1) increase the collection and use of race, ethnicity and lan- guage (REAL) preference data by hospitals and health systems, (2) increase cultural competency training for clinicians and support staff, and (3) increase diversity in governance and management.

But the Institute for Diversity in Health Management's latest "Diversity and Disparities: A Benchmarking Study of U.S. Hospitals," released in June, found that only 15 percent of hospital board positions, 14 percent of executive leadership positions and 9 percent of CEO positions are held by people of

ALL OF US Embracing Diversity in Healthcare color despite the fact that these

minorities represent an average of 29

percent of the patient population. In

some metropolitan areas, that per-

centage is much higher.

"Obviously, there's a lot of room for

improvement," Hobby says. Still, he

adds, "we're excited to see some of

the largest healthcare associations

Another sign of progress is the

Healthcare Equality Index (HEI) of

the H u m a n Rights Campaign

(HRC) Eoundation, Washington,

D.C., a nonprofit organization

working to achieve equality and fair-

ness for lesbian, gay, bisexual and

transgender (LGBT) Americans.

HEI surveys hospitals and health

facilities annually regarding their

I "When we promote diversity, we're not promoting it for I the sake of some numerical goal; we're promoting it |

because individuals from diverse communities are going to have more insight into the beliefs and preferences of

those communities. It results in better care."

—Frederick D. Hobby Institute for Diversity in Health Management I

in the country join hands around

this issue."

"There has been more of a focus on

inclusion within the cultural space,

which I think is a great advance-

ment," says Stephanie Drake, execu-

tive director of the American Society

for Healthcare Human Resources

Administration (ASHHRA),

Chicago. ASHHRA's annual mem-

bership surveys reveal growing inter-

est in the recruitment and retention

of diverse employees and in cross-

generational workforce issues, she

reports (see sidebar page 36). "Still,

we need to do a lot of work to ensure

that our employee population is con-

sistent with our patient population."

policies and practices and recognizes

top-performing providers. The sur-

vey has drawn increased national

attention to the rights of LGBT

patients and their families.

"While considerable work remains to be

done, it is clear that a sea change in the

healthcare landscape [for LGBT

Americans] is now under way," states Joe

Solmonese, HRC president, in the HEI

2010 report.

As key developments, Solmonese cites

the new Joint Commission standards

prohibiting discrimination and

President Barack Obama's directive giv-

ing patients the right to designate their

visitors and have their choices respected

about who will make healthcare deci-

sions for them.

Good for People, Good for Business Diversity initiatives are gaining

momentum in part because healthcare

executives are beginning to understand

that diversity is a business issue as well

as a human one, says Hobby. "When

we promote diversity, we're not promot-

ing it for the sake of some numerical

goal; we're promoting it because indi-

viduals from diverse communities are

going to have more insight into the

beliefs and preferences of those com-

munities. It results in better care."

Hospitals and health systems with

effective diversity programs and inclu-

sive hiring and promoting practices

that have taken bold steps to eliminate

disparities will find themselves more

favorably positioned in the market-

place. Hobby says.

"We're encouraging hospitals to

address these challenges now and to

start to build loyalty with minority

patients and communities before they

reach majority status," he says.

"Potentially, 30 million more citizens

will have health insurance after 2014.

A disproportionate number of them

will be minorities. We have not always

done a great job of creating a welcom-

ing environment for the uninsured.

Hospitals need to be able to manage

the diversity of this increasing insured

population and be prepared to com-

pete for their business."

3 2 Healthcare Executive JULY/AUG 2012

ALL OF US ''''''^'*"'™*'™'°'™'*^'"

North Shore-Long Island Jewish Health Center North Shore-Long Island Jewish

Health Center (NSLIJ), New Hyde

Park, N.Y., has long known that build-

ing loyalty with minority patients and

creating a culturally competent work-

force are "the right things to do and

the right business things to do," says

Joseph Cabrai, senior vice president

and chief human resources officer.

The 15-hospital system employs a staff

of 43,000 and serves a population that

speaks 135 languages.

"When you are as large and diverse as

we are, having a workforce that repre-

sents your patients becomes a business

imperative," Cabrai says. "We can

build a hospital, but if we don't get the

community to embrace it, they're not

necessarily going to come to us."

Despite impressive accomplish-

ments—a 51 percent minority work-

force, a team of hospital CEOs that is

75 percent female, and a cardiologist

serving as chief diversity and Wellness

officer—the system deals with some

hefty challenges.

Chief among these is finding caregivers

who are fluent in the languages spoken.

For example, though NSLIJ treats a

large Latino population, it doesn't have

enough nurses who speak Spanish,

Cabrai says.

To tackle the shortage, the system has

developed workforce readiness programs

in high schools, colleges and even some

junior high schools in underserved areas

to encourage students to enter health-

care. These programs yield dual benefits

of creating job opportunities and build-

ing a culturally astute workforce. "If we

don't take care of the pipeline issue we

won't be able to provide effective health-

care," he says.

The system has also created a "high

potential" program to groom future

senior leaders from minority groups.

Cabrai says. And at Hofstra North

Shore-LIJ Medical School at Hofstra

University, Hempstead, N.Y, the

organization's new teaching institu-

tion, cultural competency training

was integrated into the curriculum

from the start.

Minority representation on the sys-

tem's hospital boards needs

improvement. Cabrai acknowl-

edges. "But we're not afraid to have

healthy conversations about it, and

we have a recruitment plan," partic-

ularly in the Asian and Latino com-

munities, he says.

"Diversity is not about quotas; it's

about how we can serve our patients

with a workforce that feels engaged,

respected and valued," says Cabrai.

"It's not an isolated area; it's woven

through everything we do."

Georgia Center for Oncology Research and Education Diversity is also threaded through the

organizational fabric of the Georgia

Center for Oncology Research and

Education (Ceorgia CORE), Atlanta,

a nonprofit organization that joins

specialists in designing and conduct-

ing clinical trials statewide. Founded

in 2003, the organization counts

increasing access to leading-edge

clinical trials among minority and

rural populations as one of its chief

accomplishments.

That accomplishment grew naturally

from Ceorgia CORE's mission,

which includes reducing disparities

in cancer treatment, notes Nancy M.

Paris, FACHE, president. "We have

"We have doctors and nurses from many types of institutions and specialties who want to serve a

hroad spectrum of the community. Diversity is part and parcel of the way that they work, and

consequently, it's the way our network functions. That's what you get when you have strategic

alignment from the top."

—Nancy M. Paris, FACHE Georgia Center for Oncology Research and Education

I

I 3 4 Healthcare Executive

JULY/AUG 2012

Embracing Diversity in Healthcare

doctors and nurses from many types of institutions and specialties who want to serve a broad spectrum of the community," she says. "Diversity is part and parcel of the way that they work, and consequently, it's the way our network functions. That's what you get when you have strate- gic alignment from the top. We're not deliberately trying to develop tactics at the point of care or hiring to fulfill a quota. Diversity flows from our commitment to improving cancer care for everyone."

Georgia CORE's creation of an eth- nically and racially diverse board of trustees, however, was intentional, Paris says; so was the inclusion of many different types of specialists on the board. "The perspectives of many are critically important in cancer treatment."

"We model that multiplicity of per- spectives in the way we run our orga- nization," Paris says. That involves reaching out to patients in a diverse geographic range of cultural and socioeconomic pockets in both rural and urban areas. Paris believes healthcare has a way to go, particu- larly with the inclusion of women at senior levels. The low numbet of women leaders "is alarming when you consider the importance of reflecting healthcare consumers within leadership," she says.

The common but misguided ten- dency for people to want to connect

primarily with others like themselves does not translate into effective orga- nizational management, Paris con- tends. That tunnel vision doesn't generate the diversity of perspectives that enables an organization to respond to its workforce and patients, she says. "It's hard for me to see that an organization can look only one way [with regard to its executive ranks] and say with complete honesty that patients who are different are receiving equal care."

Advocate Illinois Masonic Medical Center At Advocate Illinois Masonic Medical

Center, Chicago, where equality is a key

organizational value, "diversity is a natu-

ral for us," says Susan M. Nordstrom

Lopez, FACHE, president. The commu-

nity speaks 40 languages and has one of

the richest mixes of residents in the coun-

try in terms of race, ethnicity, age, income

and sexual orientation. According to the

Healthcate Equality Index 2010, Illinois

Masonic is one of the eight top-perform-

ing hospitals in the United States.

"In a sense, all we've done is open our

doors so that what's inside the hospital

reflects what's outside," Lopez says.

"Discrimination of any kind can be an

impediment to productivity, job satisfac-

tion and excellence. A culture that

embraces diversity benefits your com-

munity and your institution. It's good

business. It opens up new markets."

According to Lopez, developing and

sustaining that inclusivity requires

some formal structures. "You have to

have systems in place, articulate your

commitment strongly and hold peo-

ple accountable, and you can never

declare victory," she says.

At Advocate Illinois Masonic, those

structures include annual system goals

regarding the hiring and promotion of

diverse candidates; a targeted tectuit-

ment strategy to ensure a diverse mix

of candidates for executive and mana-

gerial positions; intetnships and fel-

lowships for diverse new professionals

through the University of Illinois at

Chicago's health administration pro-

gram; cultural training for all new

associates; clinical training on special

topics, such as HIV and the aging of

and caring for LGBT elders; and initia-

tives to reach special populations,

including Latinos, Polish-speaking resi-

dents, and the deaf and hard of hearing.

Lopez believes it is her job to lead by

example. She regularly rounds with

other members of the senior leadership

team and encourages employees to con-

tact her directly with diversity-related

concerns via a "Dear Susan" internal

email address. "If someone is ever wor-

ried that we're not being inclusive, I

hope that they would bring that for-

ward," she says. "I don't think anything

is more effective than modeling the

behavior that you want to encourage."

Cardon Children's Medical Center At Cardon Children's Medical Center, Mesa, Ariz., cultural

Healthcare Executive 3 5 JULY/AUG 2012

ALL OF US Embracing Diversity in Healthcare competency and respect for

diversity are natural outgrowths of

the organization's focus on family-

centered, person-centered care, says

CEO Rhonda M. Anderson, RN,

DNSc, FACHE. Cultural

sensitivity is inherent in the

collaborative approach to care

planning that is a part ofthe

organization's mission to "make a

difference in people's lives through

excellent patient care," she says.

The medical center is part ofthe 583-

bed Banner Desert Medical Center,

also in Mesa, and one of the 23 hospi-

tals and health facilities in seven states

that make up Banner Health,

Phoenix, one ofthe largest nonprofit

health systems in the country.

"What worries me when we talk spe-

cifically about diversity is that we

begin to stereotype, and then we have

as much of a problem or more when

we try to individualize care,"

Anderson says. "You can't make

Closing the Generational Gap In terms of diversity, perhaps no other issue cuts as broad a

swath across the work of a healthcare organization as gen-

eration. The "natural disconnect" between healthcare

workers and patients of widely disparate ages presents spe-

cial challenges for providers that will become increasingly

evident as the baby boomer generation ages, says Robert

W. Wendover, CSP, director of The Center for

Generational Studies, Litdeton, Colo.

The recession also kept more older workers in the industry

out of financial necessity, producing workforces that can

span many generations, each with its own set of motiva-

tors and career outlooks, notes Stephanie Drake, executive

director ofthe American Society for Healthcare Human

Resource Administration, Chicago.

Adding to the challenge is the reality that "there are just

not a lot of opportunities to sit people down and talk

about this issue," Wendover says. "The attitude is 'let's do

it but let's do it in 15 minutes because we all have to get

back to work."'

To deal with these time constraints, Wendover recom-

mends educating staff in short snippets using video clips

and Twitter. "One ofthe stories I hear regularly is ofthe

22-year-old with no life experience and no way to connect

in a hospital full of 60-, 70- and 80-somethings," he says.

A smartphone video offering five or six conversation start-

ers with older patients can be uploaded to YouTube or the

hospital's intranet, with a tweet reminding staff to watch

it. "It has to be accessible," Wendover notes. "If it takes less

than two minutes and they get used to it, that's a better

way to program the process. Otherwise people just don't

get around to it."

Wendover advocates informal mentoring opportunities as

well. "One ofthe downsides of a formal mentoring pro-

gram is that there are a lot of mismatches, and then people

abandon the process. It's not something that can be

assigned. It takes trust and exposure," he says.

"Younger people in the workplace are dependent on older

people to learn a lot of what they do, so you've got to foster

that cross-generational relationship because otherwise

you'll end up with two camps, " Wendover says. And it's

up to leadership to make generational issues part ofthe

conversation. If an older and a younger worker have

formed a partnership, publicize it, he recommends. "This

invites others to do the same thing."

ALL OF US Embracing Diversity in Healthcare assumptions. Every patient and fam- ily member is diverse. It doesn't mat- ter what color they are or what culture they are from. The real core is individualizing care for every person who comes into our facility."

At Cardon, that focus manifests most clearly in the hospital's cove- nant for all staff to view care "through the eyes of a child." "It's about understanding what that child is thinking and bringing to their hospital experience," Anderson says. "Their culture is a part ofthat. We have a lot of Asian, black and Latino patients. Our goal is to understand their perspective. Before we say 'this will happen,' we want to know what they want to have happen."

According to Anderson, that cove- nant dovetails with the essence of the clinical measures that are at the heart of healthcare reform. Those clinical measures include the development of a care plan that actively involves the person using the services in their own care. "That's the switch we're all try- ing to make in healthcare," she says. "Does the care plan have the person using your services at the center? Is it merely your plan for them, or do they help create it and endorse it?"

At Cardon, those care plans are created in multidisciplinary care conferences also involving physicians, nurses, family members, translators, spiritual care associates and social workers. These conferences infuse awareness

of and sensitivity to cultural and social needs into clinicians' daily work because they're "not just about science, and they're not about making associates do something; they're about what they do in their jobs every day."

Anderson sees her role as "ensuring that our associates understand that we need to meet our patients and their families where they are in their understanding, acceptance and cul- tural beliefs about their illness, and then help them based on what they want. That has to be a core, heartfelt center of what the organization means to the community."

Susan Birk is a freelance writer based in Wheaton, III.

\

Related Resources

American College of Healthcare Executives

A C H E ' S "Statement on Diversity." Visit the Diversity section of ache.org and see pages 98—99 in this issue.

ACHE Policy Statements "Increasing and Sustaining Racial/Ethnic Diversity in Healthcare Management," "Considering the Value of Older, Experienced Healthcare Executives" and "Strengthening Healthcare Employment Opportunities for Persons With Disabilities." Visit the Policy Statements section of ache.org.

"Fueling the Pipeline: Diversity in Health Professions as a Key Strategy." Webinar/Audio CD. Visit ache.org/Education.

"Diversity in Healthcare—Leading Toward Culturally Competent Care." Frontiers of Health Services Management, spring 2010. Visit ache.org/HAP.

American Society for Healthcare Human Resources Administration Visit ashhra.org.

Equity of Care Eliminating Health Care Disparities: Implementing the National Call to Action Using Lessons Learned, February 2012. Visit equityofcare.org.

Institute for Diversity in Health Management Visit diversityconnection.org.

The Center for Generational Studies Visit generationaldiversity.com.

3 8 Healthcare Executive JULY/AUG 2012

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