It's Time to Embrace Healthcare Diversity

Diversity Equity Inclusion

By: Shamayne Braman

Published: 11/14/2019

Share:

Diversity is not just an important moral issue - it's an existential economic one.


At the nation's third largest healthcare organization, Kaiser Permanente, nearly 60% of the 217,000 staff members are people of color. Three-quarters of all employees, nearly half of the executive team, and more than a third of the physicians are women.

At the brand-new 142-hospital CommonSpirit Health network, the result of a merger between CHI and Dignity Health, the CEO and the COO are both African American men.

At New York State's Northwell Health, following a concerted effort lasting almost a decade to promote equity, diversity and inclusion, half of the 68,000 employees are minorities and 72% are women.

For these facilities and many others, including my own, diversity and inclusion is more than just an issue of right and wrong. It's a business strategy — a way to reach out to reflect and attract the members of 140 cultures currently represented in the U.S., and to tap into the creativity afforded by different perspectives and different worldviews.

How diverse is your organization? How well do your employees understand, accept and value differences among people of different skin colors, genders, ages, religions, disabilities and sexual orientations, and involve and empower them to meaningfully participate? Increasingly, the answer may be critical to the future of your organization. Thanks to changing demographics, evolving reimbursement policy, workforce challenges and a more competitive marketplace, diversity is now not just a moral issue, but an existential economic one. Here's why.

America is changing.

Nearly 40% of all Americans now belong to a minority group, and that percentage is growing quickly. Close to 15% of the population is foreign-born; that number will grow to 19% by 2060. More than 20% of Americans speak a language other than English at home. Almost 6% of our citizens adhere to a religion other than Christianity, and 5% of our citizens identify as LGBTQ. The market is increasingly diverse for all but a few healthcare facilities.

Right now, many healthcare organizations fall woefully short in their efforts to serve patients who are diverse in their racial, religious, linguistic, and sexual and gender identities.

One reason is that even in our best medical facilities, some workers have unconscious or unintentional biases toward racially diverse individuals. Studies show that African American patients are less likely than Caucasian patients to receive needed medications or surgical procedures, even when they present with conditions identical to those of white patients. Many suffer as a result.

We know that our service to many patients of color can negatively impact patient experience, lead to poor outcomes and exacerbate health disparities. A Hospital Quality Institute study of pediatric care at several California hospitals revealed that patients who were Asian or black and patients who did not speak English at home had much worse experiences than others. In that study, 61% of English-speaking patients rated their child's experience at hospitals as excellent. Only 43% of non-English speakers did. Strikingly, 43% of black patients said nurses talked in front of their children as though they weren't there. That experience was shared by only 11% of white patients.2

REAL-LIFE ROLE MODELS A diverse team of providers is more appealing to diverse patient groups.

A 1,500-patient study by researchers at the University of Southern California found that 17% of patients feel judged or stereotyped by healthcare providers. Those same patients tended to mistrust their doctors, rate their health as poor and have a higher incidence of hypertension and depression.3

The 2015 U.S Transgender Survey revealed that a third of all transgender patients who saw a healthcare provider had at least one negative experience, including being refused treatment, verbally harassed, physically or sexually assaulted, or having to teach the provider about transgender people in order to get appropriate care. Nearly a fourth did not see a doctor when they needed to because of fear of being mistreated as a transgender person.4

The problem is not just bias from physicians. Focus groups with African American, Latino, Native American and Pacific Islander patients revealed that they felt they experienced more racial bias from medical staff than from physicians.

People of color and other underrepresented populations also experience something called "stereotype threat." These patients are aware of negative stereotypes about their cultures and they expect to be stereotyped by their healthcare providers, particularly if the provider is of a different race or cultural background. For example, black Americans may be viewed as lacking education or women may be viewed as being less talented in math or science. The awareness of these stereotypes makes them anxious, impairing cognitive performance and working memory. They may struggle to accurately share the information that providers need, or they may misrepresent information specifically to avoid conforming to the expected stereotype. Interactions between clinicians and these patients are shorter, frequently unpleasant and feature little patient involvement or shared decision-making. Patients may have trouble focusing on the information the provider gives them, which may impact their abilities to adhere to post-op instructions. As a result, these patients may struggle with compliance and experience poorer outcomes than their white counterparts who do not have such stereotypes or cultural barriers to overcome.5

Fear of being stereotyped can also cause patients to skip appointments and postpone needed care. People tend to avoid situations where they feel unwelcome or where they expect devaluation. In the past, all of this would have constituted poor patient care, but the outcomes would have been viewed as the patients' problem. Now, though, facilities share responsibility for these experiences and outcomes.

Thanks in part to the Affordable Care Act, bad outcomes impact facility revenues. Medicare's Value Based Purchasing program punishes facilities by up to 2% of reimbursement for poor scores on items like outcomes and patient experience scores, a real possibility in facilities that aren't focused on diversity. Bundled payments for procedures like total joints, hip fractures and certain heart procedures mean that hospitals must assume the costs for all related care, including complications, for 90 days. Health Maintenance Organizations and now Accountable Care Organizations (our organization is one) capitate care, making profitability dependent on keeping patients healthy.

An even more powerful influence may be shifts in market share. Especially with social media and services like Healthgrades and Yelp!, it's easier than ever for patients across all communities, including those that have been historically marginalized, to share their experiences receiving care and service from healthcare organizations. When a healthcare provider does or does not serve diverse patient populations well, word can spread within communities. Patients will choose the organizations that feel welcoming and inclusive. So facilities that embrace diversity gain market share.

Diverse providers

Facilities need to do more than just make their organizations more welcoming to racially diverse patients. They also need to make them more welcoming to diverse employees.

Obviously one reason is the law. For more than 50 years, organizations with 15 employees or more have been prohibited from discriminating against people because of skin color, religion, national origin, disability, gender, age or veteran status.

Organizations with federal contracts must comply with stiffer affirmative action policies, including establishing and complying with quotas for hiring women, ethnic minorities, individuals with disabilities and veterans. For decades the government did not consider hospitals to be subject to these policies, but as of 2010, that attitude has changed. The government now considers hospitals that participate in HMOs where federal civilian employees are beneficiaries and those that provide services to the Department of Veterans' Affairs, Federal Bureau of Prisons or Department of Defense to fall under these rules.

Another reason is that patients who are racially diverse may feel more comfortable interacting with staff who share their racial identity. Studies show that when patients see role models from their own groups in positions of power it can reduce the effect of stereotype threat on performance. In the words of former Hewlett Packard CEO Lew Platt, we "need to be like our customers, including the need to understand and communicate with them in terms that reflects their concerns."6

Unfortunately, it's typically not possible to match patients with physicians who are members of their own groups. For example, just 6% of physicians are African American, Hispanic or Native American, whereas 31.5% of the population is. The American Hospital Association's Institute for Diversity observes that Hispanics and blacks represent 31% of patients nationally, but hold a mere 14% of hospital board positions, 12% of executive leadership positions and 17% of first- and mid-level management positions. Even when it isn't possible or appropriate to select a provider that reflects the patient's racial identity, fostering an inclusive environment staffed with culturally responsive providers ensures that racially discordant patient-provider interactions can also be healthy and valuable.

A third reason is that accepting and embracing people who are different expands the talent pool from which you draw, an important consideration in a "full employment" economy. If you are not hiring from minority populations, you're paring your potential pool by two-fifths. Many people of color are under-recruited and represent gold mines of talent.

A fourth reason is that diversity allows for innovative solutions that help to narrow our communities' most pressing health disparities. Diverse groups can frequently come up with more successful solutions to the problems facilities are facing.

STAYING CONNECTED Minority patients can easily share their surgical care experiences on social media platforms or rating websites.

At HealthPartners, our commitment to ensuring that all patients, regardless of identity, have access to quality health and experience led us to find innovative solutions for narrowing the colorectal cancer screening gap between white patients and people of color. In 2009, only 43% of patients of color were screened for colon cancer compared to 69% of white patients. By changing our approach to screenings and offering fecal immunochemical tests (FIT), patients were offered a more convenient option for completing the screening. By expanding our communication to include a variety of languages, we successfully increased the screening rates for patients of color by 67%.

It was this same commitment that helped us to improve our care and service to LGBTQ patients. We set a goal to ensure that LGBTQ patients received care that was clinically sound and culturally appropriate. This meant modifying patient intake forms to include gender identity, preferred name and pronoun designations, and also building colleagues' awareness of these concepts so that they interacted appropriately with patients and their family members. Finally, although managing a diverse workforce and the interpersonal challenges that frequently accompanies it can be challenging, study after study shows that diversity and inclusion is a key driver of ?internal innovation ?and ?business growth. Diverse groups do better at new product and new market development. They perform better at problem solving and, according to a McKinsey analysis, organizations that include women and ethnic minorities at the top levels of leadership are much more likely to achieve high profitability and excellent long-term value creation as opposed to companies that are not diverse in race and gender.

How to increase diversity

HealthPartners, like many other organizations, has a team that helps to drive the organization's diversity and inclusion priorities. What makes the organization unique in its diversity efforts is that it has a highly engaged and committed leadership team that integrates health equity into the operational practices of the system as well as diversity and inclusion into culture and people practices. So what can organizations that want to make progress in their diversity efforts do? Here are a few ideas to help drive and sustain change in this area.

  • Commit. Leaders must understand the power of diversity and have a vision for how to implement it. Make your commitment to diversity known. Post mission statements and solicit patient feedback about your goal to provide high-quality care to patients from all backgrounds, and then really listen and incorporate the feedback that patients share. Integrate the feedback into your values and practices and then seek feedback again.
  • Practice humility. Cultural humility is the acknowledgement that it is impossible to know everything there is to know about another culture, and even if we do gain a level of knowledge, we may not know that person's orientation to their culture. Our colleagues recognize this fact, and embrace a mindset of curiosity and a desire to engage patients as partners in their own care by asking, "What should I know about you in order to best serve you?"
  • Evaluate practices. Our teams also work hard to understand and be sensitive to the changing realities of our patients' experiences. For instance, well-intentioned questions like, "Have you been out of the country recently?" could be huge triggers for populations that may be concerned about their identity as immigrants. Taking the time to explain the reason for seeking this information and continually re-evaluating the necessity of collecting such data is one way to provide an inclusive environment that takes into account the experiences of all patients.
  • Embrace assets-orientation. Frame advice to minority patients positively. Avoid any hint of criticism, as it may be seen as stereotyping. Evaluate communication and ensure understanding. Many cultures are oral and so while providing written communication can be beneficial, it does not always solve communication gaps that may exist between providers and patients. If resources allow, these gaps can be filled by designating staff to review after-visit summaries and follow-up information with patients, providing interpreters when language barriers are a challenge, and identifying any non-clinical barriers that may prevent adherence, such as financial constraints, transportation, or religious/cultural views about medicine.

Surveys show Americans favor diverse workplaces, but the majority favor a "go-slow" approach. With the market rapidly changing, inaction may no longer be a viable option. Organizations that embrace diversity and work to change to better meet the needs of patients will be rewarded with increased market share, better patient experience scores, more profits, a competent, loyal workforce and a dynamic, creative workplace. OSM

Footnotes to this article can be found here.

Related Articles