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

Weech-Maldonado, Robert; Dreachslin, Janice L.; Epané, Josué Patien; Gail, Judith; Gupta, Shivani; Wainio, Joyce Anne

doi: 10.1097/HMR.0000000000000128
Features

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 pre–post control group design. 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 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.

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: rweech@uab.edu.

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.

The need for health care organizations to implement cultural competency practices is supported by demographic 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 Healthcare Research and Quality, 2014). Similarly, the American College of Healthcare Executives (2008, 2012) has found that, despite some improvements, disparities in career accomplishment persist even after controlling for human capital variables, such as education and experience. Furthermore, racial/ethnic gaps in perceptions of workplace equity and opportunity remain, with non-Hispanic White men expressing 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 competency has been defined as the “ongoing capacity of health care systems” to provide for high-quality care to diverse patient populations (National Quality Forum, 2009). Cultural competency is achieved through policies, learning processes, and structures by which organizations and individuals 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 organizational commitment toward a systems approach so that the health care organization’s complex structure of interconnected people, policies, and practices can work in concert to achieve the common goal of a culturally competent organization.

However, very few studies have examined the impact of systematic, organizational level cultural competency interventions 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 services (CLAS) standards and inpatient experiences with care in California hospitals. This study makes a contribution to the literature by using a pre–post intervention assessment 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.

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Conceptual Framework

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 organizations 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 identity) as determinants of diversity climate, whereas diversity climate ultimately affects individual career outcomes and organizational outcomes. Using tenets from both models, we hypothesize that a systematic, multifaceted, and organizational level cultural competency/diversity intervention aimed at improving organizational and individual level competencies of diversity can positively affect diversity climate and workforce diversity (Figure 1).

Figure 1

Figure 1

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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 competencies 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 conducted interviews, focus groups, and a website analysis of the intervention hospitals at baseline. A feedback report was developed for each intervention hospital documenting the results of the quantitative and qualitative data analysis. Then, a diversity coach discussed the preassessment 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 organizational 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 pre–post intervention change.

Figure 2

Figure 2

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Organizational Level Competencies

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

Diversity leadership is described as top management commitment toward cultural competency and includes (a) integrating cultural competency into strategic planning 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 diverse workforce, (d) diversity training, and (e) community engagement in decision-making (Weech-Maldonado, Dreachslin, et al., 2012).

Strategic human resource management represents a “strategic deployment of a highly committed and capable workforce” using an array of personnel practices (Storey, 2001, p. 6). Strategic human resource management practices include (a) recruitment and selection (process of attracting and choosing candidates for employment), (b) job design/work systems (specification and allocation of tasks and responsibilities), (c) learning and development (educational activities or learning experiences to enhance employee performance), (d) performance management (process used to define, measure, and provide feedback on strategic goals), (e) reward and recognition (formal or informal programs to acknowledge good performance or goal attainment), and (f) succession planning (formal process 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) patient–provider communication (provision of interpreter 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).

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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 intervention 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 identity 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 training and related strategic diversity management initiatives is to move leadership, staff, and the organization to increasingly more evolved or sophisticated ways of experiencing 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 “favorable 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, flexibility, 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 development consists of a series of statuses, each of which is more emotionally, cognitively, and behaviorally sophisticated than the previous status. The maturation or development 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.

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Organizational Outcomes

In this article, we focus on two organizational level outcomes 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 context in which diverse groups can realize their full potential.

Hospital staff and leadership at all levels of the organization 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 organizational and individual competencies will result in greater improvement in organizational outcomes, such as diversity climate and workforce diversity for the intervention hospitals as compared to their respective control hospital.

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Methods

Sample and Design

This study design consisted of pretest–posttest control group design, which allows for within-group pretest–posttest comparisons. A purposeful national sample of 25 hospital systems was invited by mail to participate in the National Center for Healthcare Leadership (NCHL) Diversity Demonstration Project. An overview of the project was included with the invitation, and follow-up calls were made to encourage 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 systems 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 diversity interventions and the control not. In addition, a vertical 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 pre–post assessments but did not experience the diversity interventions. See Table 1 for participant characteristics.

Table 1

Table 1

Preassessment interviews revealed that both intervention 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 intervention phase, and 6 months for postassessments with completion in December 2013. The study was approved by the Pennsylvania State University Institutional Review Board.

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Measures

Preassessments and postassessments were completed by participants 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.

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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 Competency 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 competence and diversity management in determining the organization’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 intervention 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 Management Systems and Quality Improvement (3 items), Human Resources Practices (8 items), Diversity Training (3 items), and Community Representation (2 items). Each item assesses the presence or absence of cultural competency practices. CCATH composite mean scores were obtained by (a) linear transformation of each item to 0–100 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 submitted via e-mail. The survey questionnaire was developed based on empirical evidence and a review of current literature. 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 survey 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) competencies. Each item has a 7-point response scale (1 = not at all to 7 = a great deal). Composite scores are obtained by averaging 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: patient–provider 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).

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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 (awareness, 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, 10–40) for each 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 respondents 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, respectively (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.

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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 dimensions) and has been found to have appropriate construct validity and adequate internal consistency (Barak, Cherin, & Berkman, 1998). We focus on the organizational dimension, which refers to perceptions of management’s policies, procedures, and practices affecting diversity. This dimension has two subscales: organizational fairness (Items 1–6) and organizational inclusion (Items 7–10). An average score was obtained for each subscale.

2. Workforce Diversity. Using data from the Equal Employment Opportunity’s Employer Information Report (EEO-1), we compare workforce diversity for each intervention and control hospital pre- and postintervention. Diversity is assessed in terms of percentage of women and percentage of non-White minorities and is reported for the following occupational categories: Executive/Senior Management, First/Mid Managers, Professionals, Technicians, Administrative Support, and Service Workers.

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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 pre–post score differences and to test whether the pre–post change score was significantly different when comparing the intervention to the control hospital within each system. Hypotheses involving single observations at the hospital level were evaluated descriptively by comparing the change scores (before and after the intervention) for intervention and control hospitals.

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Findings

All eight hypotheses were supported or partially supported for Intervention Hospital X, but only six of eight were supported 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 competencies: diversity attitudes, implicit bias, racial/ethnic identity. Results were mixed for patient cultural competency and workforce diversity. Results by competency and organizational outcomes are presented in Table 2 and discussed below.

Table 2

Table 2

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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 dimensions compared to the control hospitals. However, intervention hospitals at both systems experienced higher change scores in most CCATH diversity leadership dimensions, compared to their respective control hospitals.

Strategic Human Resource Management (Hypothesis 1b). Intervention hospitals at both systems experienced greater positive change scores across the dimensions of the National 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.

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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 preference for women with careers. On the other hand, Intervention 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.

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 experienced improvements in their racial/ethnic identity profile postintervention, compared to their respective control hospitals.

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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 experienced more positive change for both Organizational Inclusion 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 management level, although Intervention Hospital X had a greater improvement (16.7%) compared to its control. Both control and intervention hospitals in Health System Y experienced 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 intervention hospitals at both systems, particularly at the management level, compared to their respective control hospitals.

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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 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. 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 hospitals 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 backlash 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 leadership 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 improvement than Intervention Hospital Y across most metrics of the study. Although both hospitals experienced 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 implementation of their organizational action plan as part of the intervention. Postassessment interviews suggest that health system factors, such as Hospital X having more direct control 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 intervention 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 pre–post 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 pre–post improvement in diversity attitudes and pre–post reduction in implicit bias at both intervention hospitals, relative to their control hospital, may be indicative of a more culturally competent workforce postintervention.

Another study limitation is that the original demonstration project design called for pre–post 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 management 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 participated in the project, and this small sample limits the generalizability of the findings. Future research that also employs a pre–post 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. Systematic, multifaceted, and organizational level cultural competency initiatives show promise in improving diversity performance metrics and in aligning health care organizations with the opportunities and challenges of an increasingly diverse population. However, these initiatives should be aligned with other health system strategic priorities for them to be effective.

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    Keywords:

    cultural competency; diversity climate; diversity management

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