From the Perspective of CEOs:What Motivates Hospitals toEmbrace Cultural Competence?Amy Wilson-Stronks, project director, Health Disparities, The Joint Commission,Oakbrook Terrace, Illinois, and Sunita Mutha, MD, professor of medicine.Department of Medicine and Center for the Health Professions, University ofCalifornia, San Francisco

E X E C U T I V E S U M M A R YThe quality domains of patient-centered and equitable care are increasingly relevantto today's healtheare leaders as hospitals care for patients with increasingly diversecultural and linguistic needs. Hospital leaders face substantial tensions in definingtheir organization's strategic priorities to improve care for diverse populations withlimited resources, increased competition, and complex regulatory and accredita-tion requirements. We sought to understand what motivates hospitals to focus onand commit resources to supporting the delivery of culturally competent care byanalyzing interviews with chief executive officers (CEOs) in 60 hospitals across theUnited States.

Hospital CEOs in our study most often embraced cultural competence effortsbecause doing so helped them achieve the organization's mission and priorities and/or meet the needs of a particular patient population. Less often, they were motivatedby perceived benefits and legal or regulatory issues. Many CEOs articulated a linkbetween quality and cultural competence, and a smaller number went on to linkcultural competence efforts to improved financial outcomes through cost savings,increased market share, and improved efficiency of care. However, the link betweenquality and cultural competence is still in the early stages. Fortunately, frameworksfor hospitals to adopt and steps that hospitals can take to improve the quality of carefor all patients have been identified. They begin with a commitment from hospitalleaders based on understanding the needs of patients and communities and are pro-pelled by data that reveal the impact of efforts to improve care. Leaders must com-municate and shepherd organizations to align the congruence between improvementefforts and business strategies.

For more information on the concepts in this article, please contact Ms. Wilson-Stronks at alwstronks@gmail.com

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BACKGROUNDPatient-centered and equitable care aretwo of the six domains of high-qualityhealthcare identified by the Instituteof Medicine in its influential reportCrossing the Quality Chasm (Instituteof Medicine 2001). These domains areof increasing importance as rapid demo-graphic changes in the United Statesresult in greater numbers of patientswith diverse cultural backgrounds andlimited English proficiency (LEP) (U.S.Census Bureau 2008). These demo-graphic changes also have implicationsfor the quality of healthcare deliveredgiven that language and cultural barriersaffect the quality of care (Baker, Hayes,and Fortier 1998; Institute of Medicine2004; Karliner et al. 2007) and increasethe likelihood of medical errors (Floreset al. 2003). One approach, then, forimproving care for diverse populationsis to provide culturally competent care,which is responsive to cultural and lin-guistic needs of patients (Betancourt etal. 2003; Brach and Fraser 2002; Lipsonand Dribble 2005).

A 2006 national survey foundthat 80 percent of hospitals fre-quently encountered patients with LEP(Hasnain-Wynia et al. 2006). For theseorganizations, the challenges of meet-ing the cultural and linguistic needs ofpatients intersect with their efforts toimprove the quality of care delivered inhospital settings. Thus, today's hospi-tal leaders face substantial tensions indefining their organization's strategicpriorities to improve care for changingpopulations with limited resources, adiverse workforce, increased compe-tition, and complex regulatory andaccreditation requirements. Little is

known about the perspectives of health-care leaders in balancing these tensions.We sought to build on the knowledgethat organizational responsiveness toexternal environments is driven by lead-ers (Dansky et al. 2003) by uncoveringwhat motivates hospital leaders to focuson and commit resources to support thedelivery of culturally competent care byanalyzing interviews with chief executiveofficers (CEOs) in 60 hospitals acrossthe United States.

M E T H O D SThe data for this analysis are derivedfrom a study conducted by The lointCommission to examine the provisionof culturally and linguistically appropri-ate care in U.S. hospitals. The Hospitals,Language, and Culture (HLC) studymethods have been previously detailed(Wilson-Stronks and Galvez 2007;available at www.jointcommission.org/patientsafety/hlc). Briefly, 59 hos-pitals were recruited using a purposiveapproach to include hospitals of varyingsize, geographic location, and teachingand ownership status (see Table 1). Thejudgment sample hospitals (n = 29)were selected because they had demon-strated efforts to provide culturally andlinguistically competent services. Thestratified sample (n = 30) hospitals com-prised a comparison group of hospitalsrandomly drawn from geographicallyand demographically diverse nationalsamples using U.S. Census Bureau andAmerican Hospital Association data(Wilson-Stronks and Calvez 2007).

This study was approved byThe loint Commission's contractedinstitutional review board (IRB), Inde-pendent Review Consulting, Inc., and

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TABLE 1Select Characteristics of Hospitais in Hospitals, Language, and Culture Study

Judgment Stratified TotalN = 29* N = 30 N = 59

Region

Northeast

Midwest

South

West

LocaleRuralSemirural

Urban

Hospital size (beds)

Small (25-100)

Medium (101-299)

Large (300+ )

Teaching status of hospitalTeaching

Non-teaching

Ownership

Private

Public

Years in current position for CEO (average)

3

4

22

1

5

23

1811

21

4

4

9

13

12

513

10

11

9

4

26

23

7

5.09 years» 6.38 years''

10121621

159

35

11

16

32

22

37

44

15

5.75 years

•One judgment sample site did not complete a CEO interview.

"Twenty-four of 29 survey participants responded.

''Twenty-three of 30 survey participants responded.

IRBs at several participating hospitals.Between September 2005 and March2006, study personnel conducted sitevisits to all 60 hospitals. During thesevisits, a trained researcher audiotaped60-minute, in-depth, semistructuredinterviews with hospital CEOs. Theinterview focused on (1) changes in thepatient population and organizationalresponse to these changes; (2) chal-lenges to providing care to diverse

populations; (3) locus of organizationalresponsibility for cultural competence;(4) linkages, if any, between culturalcompetence and other organizationalinitiatives (e.g., quality improvement);(5) the governing board's interest andpriorities related to cultural compe-tence; (6) how cultural competence isaddressed in organizational strategyand financing; and (7) consequences ofproviding culturally competent care. The

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full interview protocol is available atv^^v^m^.jointcommission.org/patientsafety/hlc. Fifty-nine interviews werecompleted. Audiotapes were transcribedverbatim, resulting in 511 pages ofinterviews.

ANALYSISEach author independently reviewedten transcripts through multiple read-ings using grounded theory (Strauss andCorbin 1998) to identify themes andcategories of responses to questions. Keywords, phrases, and concepts were high-lighted to distinguish major ideas. Weused constant comparison, content, andthematic analysis to identify and codefrequently expressed ideas to supportthe systematic discovery of theory fromthe data (Miles and Huberman 1984;Patton 1990). There were no a prioricodes; all themes emerged through theprocess of transcript analysis. We thencompared the independently identi-fied themes to verify and clarify themesuntil we achieved consensus on the finalcoding scheme. Following this step,each author independently coded all59 interviews using the coding scheme.Test-retest checks were conductedthroughout to assess coding reliabil-ity. In addition, codes were comparedfor all interviews; discrepancies wereresolved by discussion. Data were man-aged using the QSR NVTVO 2.0 software(QSR International, Melbourne, Austra-lia). The final step in the analysis wasto focus on the codes that explainedCEOs' motivations to embrace culturallycompetent care. We used the methodof constant comparison to refine thesecodes and to discern subcategories anddetermine the interrelationships, if any.

among the various codes. We report theresults by describing the most frequentlyascertained themes and providing thenumber of interviews in which thethemes were identified, regardless ofhow often they were mentioned duringthe interview. Verbatim quotes are usedto illustrate the themes.

RESULTSTable 1 summarizes key characteris-tics of the 59 hospitals in this study.The sites were located throughout theUnited States, with a larger representa-tion of hospitals in western and south-ern states in urban settings. More thanhalf of the hospitals had greater than300 beds and were not teaching facili-ties. Nearly 75 percent of hospitals wereprivately owned. On average, CEOshad held their leadership position forsix years. In the following sections,we describe five common themes thatemerged from the CEO interviews asreasons for embracing cultural com-petence: alignment with mission andstrategic plans, meeting patients' needs,perceived benefits of embracing culturalcompetence, laws and regulations, andusing external funds to support culturalcompetence activities.

Alignment with Mission andStrategic PlansThe most frequent motivation citedby CEOs for embracing cultural com-petence efforts was that doing so wasaligned with realizing the organization'smission or strategic plans (49 of 59, or83 percent). CEOs from the judgmentsample were more likely to report thisalignment than were those in the strati-fied sample (28 versus 21; see Table 2).

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TABLE 2Factors Motivating CEOs to Embrace Cultural

Motivating Factor

Alignment with priority and mission

Meet patient needsPerception of benefitLaw and regulation

External funding

Competence

JudgmentN = 29

28

20

21

14

5

StratifiedN = 30

21

20

15

17

13

TotalN = 59

49

40

36

31

18

In some cases, activities thatadvanced the delivery of cultural com-petence were explicitly integrated intothe hospital's strategic plan. One GEOreported: "if you look at our three-yearstrategic plan the focus is on . . . theAmish population and making surethat we understand what their desiresare, if we can help them begin to lookat us as the provider of care. . . . " Hisorganization worked to understandthis population's cultural perspectiveson health insurance and billing ser-vices and their desired access to specificservices. It responded by redesigningbilling and maternity services to increasethe likelihood that the hospital wouldbe the provider of choice for the Amishcommunity. Another GEO describedhow planning for a new hospital incor-porated an understanding of the cultureof the Native American population itwould serve: "Well, we felt the need,in designing the layout [of the newhospital] . . . to incorporate the cultureelements that are important, such asthe four directions [cardinal directionsimportant in the spiritual tradition]."

GEOs also emphasized that theyembraced cultural competence efforts

because doing so was consistent withtheir mission or, as one leader put it,"it is part of why we exist." Anothervoiced, "What really is driving us . . .is who we serve in this valley. In the8,000 square miles there are two criticalaccess hospitals that are very small, verymodest hospitals. But we are the onlyplace that provides OB [obstetrics] andsurgery, intensive care, rehab, and onand on. Eor the folks [who] live here,we are it. So we take that very seriously.That is our responsibility. And we needto serve them better, and we are outthere. It is our mission." This hospital'scultural competence efforts focused onimproving diabetes care by engagingthe community through focus groups,improving outreach by using commu-nity health workers or promotores, andeducating clinicians about communityoutcomes for diabetes.

Meeting Patients' NeedsAnother important motivation forembracing cultural competence was adesire to meet patients' needs (cited by40 of 59 respondents, or 68 percent),which did not differ in importance forGEOs in the judgment and stratified

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samples. Leaders noted that to meetpatients' needs it was essential to under-stand their perspectives of care. OneCEO said, "What drives me is the qual-ity of the patient care we provide insofaras you have to understand the patients'needs, wants, and desires and they needto understand what it is you're doingfor them or what their options are. . . .You can't do that without understand-ing their culture and communicatingwith them as effectively as possible."This hospital's efforts included recruit-ing Spanish-speaking staff expandinginterpretation services, conducting stafftraining in cultural competence, andimproving cancer screening by address-ing cultural barriers to preventive careamong Asian populations.

To meet needs, some hospitalsproactively elicited information frompatients and communities throughsurveys, focus groups, and interviewsand used this information to designservices. Other ways of identifying needsincluded reviewing community publichealth data and questioning hospitalstaff. One leader explained how staffbrought the need for increased efforts incultural competence to the attention ofhospital leadership, "I took my job in1998, and one of the things that peoplewanted to tell me right away is, 'I'm notsure we're fully honoring our diversepopulation. . . .' And these were amongstaff nurses and environmental servicefolks. You know it wasn't that they feltdeprived, it was they wanted to makesure that. . . [patients' needs were met]."

The types of patient needs that wereidentified included accommodationsfor spiritual practices, dietary require-ments, language barriers, and cultural

norms such as including multiple familymembers in the care processes. A CEOnoted that meeting needs can be costly,as in the ease of interpreter services, butdoing so is a necessity: "I know that[our hospital] has contracted with theinterpreter line, which is a fairly expen-sive thing, but again, I think those arejust the ongoing costs of trying to meetthe needs of your patients, so we don'tview it as expending additional fiscalresources, it's what's necessary to try tomeet the needs of our patients." AnotherCEO underscored the link betweenmeeting patient needs and deliveringquality care: "If you can't communicatewith the individual, then, odds are,something is going to be missed andthey are not going to get the right care orbe compliant with the regimen, whichmeans they'll end up back here at thehospital, so I think it is the right thingto do if you want to ensure the highestquality care for everyone coming intothe institution."

Perceived Benefits of EmbracingCultural CompetenceThe next most cited reason by CEOs(36 of 59, or 61 percent) for embracingcultural competence was the perceivedbenefits resulting from these efforts.CEOs from the judgment sample weremore likely to identify this motivatorthan were those in the stratified sample(21 versus 15; see Table 2). In addi-tion to improved quality of care, CEOsdescribed increased market share, costsavings, and improved work environ-ments. These benefits were not mutu-ally exclusive. Leaders gave examples ofimproved care resulting from improvedcommunication, with one CEO stating.

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CEOs' PERSPECTIVE: WHAT MOTIVATES HOSPITALS TO EMBRACE CULTURAL COMPETENCE?

"We in this community compare mor-tality stats, and it turns out you cankeep people alive better if you can talkto them!" Another echoed this senti-ment: "When you can communicatewith someone, really communicate withsomeone, and they understand whattheir role and our role is in their care, Ithink it improves their outcomes. All thesafety literature proves that as well."

Discussions of improved quality ofcare frequently touched on cost sav-ings. For example, a CEO describedhow the hospital discovered that Latinomothers were making frequent emer-gency department (ED) visits for theirchildren's earaches because they did notunderstand how to take the children'stemperature. The hospital's responsewas to develop kits that included athermometer and easy-to-foUow instruc-tions. He noted, "Instead of spending$400 an hour [in the ED] we give thema $3 kit."

Another CEO detailed how her orga-nization's effort to create services forlargely homeless and minority popula-tions of intravenous drug users with softtissue infections led to improved careand increased market share. Before theorganization undertook changes, thesepatients would wait in the ED until anoperating room was available for themto undergo drainage and then be admit-ted for a "two-week hospital stay forantibiotics, which was very expensive."To improve this situation, the organiza-tion "got our substance abuse, surgeons,and ED folks together to find out howwe can provide care better to this group[because] we're missing this culturalclimate. . . . We created wraparoundservice for [the patients]—we have

counseling and can get them hookedin with social workers, counselors,methadone slots; we a have clinic forwound care and abscess draining andantibiotic therapy daily. You talk aboutmarket share—all we did was open theclinic—didn't send flyers or do postingsat shelters—we were never at a loss forpeople coming in." This CEO noted thatthe hospital's efforts also resulted in costsavings and improved patient satisfac-tion. She summarized, "When you docultural competency right, you can savemoney. You need to know how to doit right."

In most cases the benefits ofembracing cultural competence werenot quantified or perhaps even quan-tifiable. One CEO remarked, "The way[that cultural competence] shouldhelp us—though I don't have the evi-dence—is length of stay. Our length ofstay is going down, but is our abilityto communicate with patients helpingthis? I don't know. I don't have a wayto measure. I can say that we have spent[lots of money on this] and we are notworse off for having spent this money."Another noted, "I can't tell [what thefiscal impact of cultural competence]has been . . . other than we're very busyand our performance is going up as weput more effort into this. Our finan-cial performance is getting better. I'mnot telling you whether it's becauseofthat, but it certainly hasn't gonedown as we expend more effort intothis area." Another CEO echoed, "It ishard to quantify everything. There arethe direct costs . . . but also, the coststhat are hard to measure . . . [such asthe] cost of delays in care because of alanguage barrier."

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Laws and RegulationsDespite a common perception that regu-lation is the only way to engage leaders,CEOs were infrequently motivated toembrace cultural competence for regula-tory or legal reasons. Approximatelyone-half of CEOs (31 of 59) indicatedthat their cultural competence effortswere motivated by law and regulation.Judgment sample CEOs were less likelyto report this motivator than were thosein the stratified sample (14 versus 17).Only a few could cite a specific exampleor indicate detailed knowledge of suchregulations. In fact, most CEOs wereunaware of existing regulatory require-ments for the provision of languageaccess services. A typical response was,"I know that we have to provide amechanism for communication. Maybeit is not legal or regulatory; it might beaccreditation."

CEOs acknowledged that law andregulation helped focus priorities, butthey often found other factors morecompelling, as noted by a CEO whosaid, "We have gone beyond what thelaws [are] to embrace it [cultural com-petence] as a business strategy. " Hewent on to explain that the decisionwas driven by the organization's desireto "be attractive to patients and try toincrease market share and make this aninstitution that they look to, to providecare." To accomplish this, the organi-zation invested substantial effort andresources into workforce recruitmentand training as well as interpreter anddietary services for local communitiesthat included Chinese, Orthodox Jewish,Latino, and Arabic populations. Inter-estingly, only three CEOs reported thatlawsuits motivated their organization'scultural competence efforts. Each went

on to state that the legal action ulti-mately improved their language services.

Using External Funds to SupportCultural Competence ActivitiesLess than one-third of CEOs (18 of 59)reported that external funds played akey role in their organization's deci-sion to embrace cultural competence.Interestingly, only five of these respon-dents were in the judgment sample. Thefunds, often in the form of grants, wereused to improve chronic disease care,provide clinical services and patienteducation, improve access to care, trainstaff, and offset infrastructure costsfor improving interpreter services. ACEO remarked, "The way we are ableto do a lot of our [cultural competenceactivities] is through the funds of privatephilanthropists."

D I S C U S S I O NHospital CEOs in our study most oftenembraced cultural competence effortsbecause doing so helped them achievethe organization's mission and prioritiesand/or meet the needs of a particularpatient population. Less often, theywere motivated by perceived benefitsand legal or regulatory issues. The last isnot surprising given the limited num-ber of national or state regulations inthis arena beyond those focusing onaccess to medical interpreters. WhileThe Joint Commission has some stan-dards that support the provision ofculturally competent care (The JointCommission 2009), they tend not tobe prescriptive, which may help explainwhy they are not an important motiva-tor for hospital leaders. With the excep-tion of interpreter services, the range ofapproaches and activities reported by

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CEOs' PERSPECTIVE: WHAT MOTIVATES HOSPITALS TO EMBRACE CULTURAL COMPETENCE?

CEOs underscores that when it comesto delivering care responsive to culturaland linguistic needs of patients, "onesize may not fit all" (Wilson-Stronks etal. 2008).

We expected to see more differencesin the factors that motivate the twosamples of hospital leaders, reflectinga greater awareness of and interest incultural competence among judgment-sample respondents. The largest dif-ference was the role external fundingplayed for stratified-sample CEOs,which suggests that external motiva-tors can stimulate cultural competenceinitiatives for organizations at an earlierstage of commitment to culturally com-petent care. One explanation for the lackof difference between the two samplesmay reflect the fact that CEOs in thestratified sample were running hospitalsin racially, ethnically, and linguisticallydiverse areas. In this respect, it could bestated that cultural competence is a nec-essary consideration for serving a diversepopulation.

A national survey of hospital CEOsfound that their first two concerns areclinical and financial outcomes; diver-sity issues ranked as number twelve offifteen critical focus areas for organiza-tion success (Cejka Search and SolucientLLC 2005). However, the inextricablelink between quality of care and racial,ethnic, and linguistic diversity is welldocumented (Karliner et al. 2007;Newman Ciger and Davidhizar 2007;Smedley, Stith, and Nelson 2003), mak-ing diversity and cultural competenceefforts highly relevant for all leadersinterested in improving clinical out-comes and patient safety. Some CEOs inour study articulated this understanding,and a smaller number went on to link

cultural competence efforts to improvedfinancial outcomes through cost savings,increased market share, and improvedefficiency of care. Overall, the under-standing of the linkage between qualitycare and cultural competence remains inan early stage for several reasons. First,awareness is limited of the intersec-tion between quality of care, healthcaredisparities, and cultural competence.And many leaders believe that theyalready provide high-quality health-care to all their patients regardless ofrace, ethnicity, or language (Siegel et al.2007). Next, most organizations do notstratify quality outcomes by sociodemo-graphic characteristics (e.g., race, eth-nicity, preferred language, educationlevel), which could help uncover localhealth disparities. In addition, a lack ofrecognition of existing laws and regu-lations for language services may alsocontribute to inequity in care throughlimited access or underutilization oflanguage services (Hasnain-Wynia etal. 2006). Finally, knowledge is lim-ited about effective interventions andstrategies for tailoring care to improveequitable health outcomes. Fortunately,frameworks for hospitals to adopt andsteps that hospitals can take have beenidentified to begin to improve thequality of care for all patients, includ-ing those most vulnerable to disparities(American Medical Association 2006;Karliner and Mutha 2010; Martinez etal. 2003; Smedley et al. 2003; UnitedStates Department of Health andHuman Services Office for Civil Rights2003; Wilson-Stronks and Calvez 2007;Wilson-Stronks et al. 2008). While"no checklist of concrete behaviorallybased performance indicators can everfully capture the essence of diversity

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leadership" (Dreachslin 1999), a fewguiding principles, detailed in the fol-lowing sections, can be used by leadersto focus cultural competence efforts in ameaningful manner.

Know Your CustomerTo provide high-quality and equitablecare, hospitals need to know whomthey serve and tailor their clinical andadministrative services to meet theneeds of patients and communities.We echo the recommendations of theInstitute of Medicine, National QualityEorum, National Gommittee for Qual-ity Assurance, and The Joint Gommis-sion that organizations systematicallycollect uniform data on patients' race,ethnicity, and language needs (Instituteof Medicine 2009; National QualityForum 2009; The Joint Gommission2009, 2010; Wilson-Stronks and Galvez2007; Wilson-Stronks et al. 2008). Thesedata are essential to effectively plan for,provide, and monitor services. Otherwell-established methods for identifyingcommunity needs include using publichealth data and engaging patients, com-munity leaders, lay health workers, andkey social institutions (e.g., churches,ethnic media) in ongoing dialogs toidentify health needs as well as provideinsight in planning, delivering, andevaluating health services (Tripp-Reimeret al. 2001).

Plan for and Study ImprovementAwareness and knowledge of thepopulations served can inform strategiesfor improving the quality of care. Eorexample, knowledge of a communitycan inform the location of services andhours of operation to improve access.

efficiency, and continuity. This infor-mation can also guide staff hiring (e.g.,bilingual, bicultural staff), the use oflay health workers to improve chronicdisease care education and training forstaff and patients (Tripp-Reimer et al.2001), and the use of language servicesto improve communication. Once suchchanges are in place, ongoing monitor-ing and evaluation is required to assesstheir impact on the quality of care. Hos-pital GEOs can ensure that the journeybegins and stays on course by buildingcommitment and accountability (Jayneand Dipboye 2004) by working withclinicians and communities to establishmetrics for successful outcomes andputting in place quality improvementmonitoring systems. The effort mustinclude a commitment to monitoringthe effect of improvements on health-care disparities. This crucial step isfacilitated by recent advances in healthinformation technology and effectivemethods for stratifying, analyzing, andusing performance data (Gummings etal. 2008; Weinick, Elaherty, and Bristol2008). They allow organizations to usedata, not intuition, to assess what worksand what does not and to contribute toimproving care by sharing their learn-ing with others. Such efforts will bringhealthcare closer to achieving nationalgoals for reducing healthcare dispari-ties (Healthy People 2010). Additionalresearch is needed to demonstrate theeffect of quality improvement efforts onhealthcare disparities.

iVlai(e It a Business PriorityGultural competence efforts can rein-force hospitals' mission, facilitateachieving strategic priorities such as

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CEOs' PERSPECTIVE: WHAT MOTIVATES HOSPITALS TO EMBRACE CULTURAL COMPETENCE?

expanding market reach, help institu-tions improve patient and employee sat-isfaction, and, most important, improvethe quality of eare. Integrating culturalcompetence into organizational priori-ties and processes requires commitment,determination, and resources. Leadersplay an important role in transformingorganizations through specific actions(Dansky et al. 2003; Kochan et al. 2003;Kotter 1995; Reeleder et al. 2006). First,leaders need to communicate the orga-nization's vision and priorities regardingculturally competent care within andoutside the organization. This com-munication helps to set priorities basedon knowledge of communities servedand local health disparities data, and itenables alignment with strategic goals.Next, leaders can assemble a high-levelgroup to lead and take responsibilityfor the hospital's cultural competenceefforts. This group can oversee thecreation of effective systems, policies,and interventions to support ongoingeffort to ensure that care and servicesare tailored to meet the needs of diversepopulations. Finally, leaders must allo-cate resources—people and money—asboth are required to establish an infra-structure to support the delivery of cul-turally competent services. An importantarea of future research is to more clearlydefine and quantify, where possible, thebenefits of culturally competent eare, asthis will help address the business easefor eultural competence.

C O N C L U S I O NGultural competence is a "journey, not adesrination" (Martinez et al., 2003). Thejourney begins with commitment fromhospital leaders that is based on an

understanding of the needs of patientsand communities and is propelled bydata that reveal the impact of effortsto improve care. The entire initiativerequires that leaders communicate andshepherd the organization to alignimprovement efforts and business strat-egies. Future research is needed to moreclearly define metrics and quantify thebenefits of cultural competence so thatit may be effectively integrated into hos-pital quality improvement processes.

ACKNOWLEDGMENTSWe would like to thank the followingindividuals for their helpful reviewsof earlier versions of this manuscript:Romana Hasnain-Wynia, PhD; LeahKarliner, MD; Ed Martinez; and KarenLee. We would also like to thank KarenLee for assistance with data manage-ment and Isa Rodriguez for administra-tive support. This work was supportedwith funding from The GaliforniaEndowment. Special thanks to IgnatiusBau, JD, for his guidance and leadershipin envisioning the HLG study.

R E F E R E N C E SAmerican Medical Association (AMA). 2006.

"Improving Communication—Improv-ing Care: How Health Care OrganizationsCan Ensure Effective, Patient-CenteredCommunication with People from DiversePopulations." Chicago: AMA Ethical ForceProgram.

Baker, D. W., R. Hayes, and 1. P. Fortier. 1998."Interpreter Use and Satisfaction withInterpersonal Aspects of Care for Spanish-Speaking Patients." Medical Care 36 (10):1461-70.

Betancourt, |. R., A. R. Creen, J. E. Carrillo, andO. Ananeh-Firempong. 2003. "DefiningCultural Competence: A Practical Frame-work for addressing Racial/Ethnic Dispari-ties in Health and Health Care." PublicHealth Report 118 (4): 293-302.

349

JOURNAL OF HEALTHCARE MANAGEMENT 55:5 SEPTEMBER/OGTOBER 2010

Brach, C, and 1. Fraser. 2002. "ReducingDisparities Through Culturally CompetentHealth Care: An Analysis of the BusinessCase." Quality Management in Healthcare10 (4): 15-28.

Cejka Search and Solucient LLC. 2005. HospitalCEO Leadership Survey. St. Louis, MO:Cejka Search and Solucient LLC.

Cummings, L., B. Bennett, A. Boutwell, andE. Martinez. 2008. "Assuring HealthcareEquity: A Healthcare Equity Blueprint."Washington, DC: National Public Healthand Hospital Institute.

Dansky, K. H., R. Weech-Maldonado, C. DeSouza, and J. L. Dreachslin. 2003. "Orga-nizational Strategy and Diversity Man-agement: Diversity-Sensitive Orientationas a Moderating Influence." Health CareManagement Review 28 (3): 243-53.

Dreachslin, J. L. 1999. "Diversity Leadershipand Organizational Transformation:Performance Indicators for Health ServicesOrganizations." Journal of Healthcare Man-agement 44 (6): 427-39.

Flores, C , M. B. Laws, S. J. Mayo, B. Zucker-man, M. Abreu, L. Medina, and E. J. Hardt.2003. "Errors in Medical Interpretationand Their Potential Clinical Consequencesin Pédiatrie Encounters." Pediatrics 111{1):6-14.

Hasnain-Wynia, R., J. Yonek, D. Pierce,R. Kang, and C. H. Creising. 2006. HospitalLanguage Services for Patients with LimitedEnglish Proficiency: Results from a NationalSurvey. Chicago: Health Research andEducational Trust.

Healthy People. 2010. Healthy People 2010.[Online information; retrieved 1/26/10.]www.healthypeople.gov/About/goals.htm.

Institute of Medicine. 2009. Race, Ethnicity, andLanguage Data: Standardization for HealthCare Quality Improvement. Washington,DC: National Academies Press.

Institute of Medicine. 2004. Health Literacy: APrescription to End Confusion. Washington,DC: National Academies Press.

Institute of Medicine. 2001. Crossing the QualityChasm: A New Health System for the 21stCentury. Washington, DC: National Acad-emies Press.

Jayne, M., and R. Dipboye. 2004. "LeveragingDiversity to Improve Business Perfor-mance: Research Findings and Recom-mendations for Organizations." HumanResource Management 43 (4): 409-24.

Joint Commission, The. 2010. 2010 HospitalAccreditation Standards. Oakbrook Terrace,IL: The Joint Commission.

Joint Commission, The. 2009. 2009 HospitalAccreditation Standards. Oakbrook Terrace,IL: The Joint Commission.

Karliner, L. S., E. A. Jacobs, A. H. Chen, andS. Mutha. 2007. "Do Professional Inter-preters Improve Clinical Care for Patientswith Limited English Proficiency? A Sys-tematic Review of the Literature." HealthServices Research 42(2): 727-54.

Karliner L. S., and M. S. Mutha. 2010. "Achiev-ing Quality in Health Care ThroughLanguage Access Services: Lessons froma California Public Hospital." AmericanJournal of Medical Quality 25 (1).

Kochan, T., K. Bezrukova, R. Ely, S. Jackson,A. Joshi, and K. Jehn. 2003. "The Effectsof Diversity on Business Performance:Report of the Diversity Research Network."Human Resource Management 42(1): 3-21.

Kotter, J. 1995. Leading Change: Why Trans-formation Efforts Fail. Cambridge, MA:Harvard Business Review.

Lipson, J., and S. Dribble. 2005. Culture andClinical Care. San Francisco: University ofCalifornia San Francisco Nursing Press.

Martinez, E. L., L. Cummings, L. A. Davison,I.A. Singer, D. Sickler, and A. DeCuz-man. 2003. Serving Diverse Communities inHospitals and Health Systems. Washington,DC: National Public Health and HospitalInstitute.

Miles, M., and A. Huberman. 1984. QualitativeData Analysis: A Sourcebook of New Meth-ods. Newbury Park, CA: Sage Publications.

National Quality Forum. 2009. A Comprehen-sive Framework and Preferred Practices forMeasuring and Reporting Cultural Compe-tency: A Consensus Report. Washington, DC:National Quality Forum.

Newman Ciger, J., and R. Davidhizar. 2007."Eliminating Health Disparities: Under-standing This Important Phenomenon."Health Care Manager 26 (3): 221-33.

Patton, M. 1990. Qualitative Evaluation andResearch Methods. Newbury Park: SagePublications.

Reeleder, D., V. Coel, P.A. Singer, and D. K.Martin. 2006. "Leadership and Prior-ity Setting: The Perspective of HospitalCEOs." Health Policy 79 (1): 24-34.

Siegel, B., J. Bretsch, V. Sears, M. Regenstein,and M. Wilson. 2007. "Assumed Equity:

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CEOs' PERSPECTIVE: WHAT MOTIVATES HOSPITALS TO EMBRACE CULTURAL COMPETENCE?

Early Observations from the First Hospi-tal Disparities Collaborative."/oumai/orHealthcare Quality 29 (5): 11-15.

Smedley, B. C, A. Y. Stith, and A. R. Nelson.2003. Unequal Treatment: Confronting Racialand Ethnic Disparities in Health Care. Wash-ington, DC: National Academies Press.

Strauss, A., and J. Corbin. 1998. Basics of Quali-tative Research. Thousand Oaks, CA: SagePublications.

Tripp-Reimer, T., E. Choi, L. Skemp Kelley, andJ. Enslein. 2001. "Cultural Barriers to Care:Inverting the Problem." Diabetes Spectrum14(1): 13-22.

United States Census Bureau. 2008. An Qlderand More Diverse Nation by Midcentury.[Online information; retrieved 1/26/10.]www.census.gov/Press-Release/www/releases/archives/population/012496.html.

United States Department of Health andHuman Services Office for Civil Rights.

2003. Cuidance to Federal Financial Assis-tance Recipients Regarding Title VI Prohibi-tion Against National Origin DiscriminationAffecting Limited English Proficient Persons.Washington, DC: United States Depart-ment of Health and Human ServicesOffice for Civil Rights.

Weinick, R. M., K. Flaherty, and J. Bristol.2008. Creating Equity Reports: A Guide forHospitals. Boston: Disparities SolutionsCenter, Massachusetts Ceneral Hospital.

Wilson-Stronks, A., and E. Calvez. 2007. Hos-pitals, Language, and Culture: A Snapshot ofthe Nation Exploring Cultural and LinguisticServices in the Nation's Hospitals A Report ofFindings. Oakbrook Terrace, IL: The JointCommission.

Wilson-Stronks, A., K. L. Lee, C. L. Cordero,A. L. Kopp, and E. Calvez. 2008. One SizeDoes Not Fit All: Meeting the Health CareNeeds of Diverse Populations. Oakbrook Ter-race, IL: The Joint Commission.

P R A C T I T I 0 A P P L I C A T I 0

Joseph R. Stuedish, FACHE, president and CEO, Trinity Health, Novi, Michigan

I n my experience as a healthcare executive, I have found that the vast majority ofhealth professionals are passionately committed to improving the health of all peo-

ple. In today's increasingly diverse society, however, the actualization of our commit-ment to serve all is becoming more difficult to achieve. Gaps exist in the way peopleare treated, and these disparities parallel racial and ethnic backgrounds regardless ofincome.

This study, examining the motivations of GEOs who embrace cultural com-petence as a strategic priority, comes at an especially opportune time. Patients ofminority populations undoubtedly perceive the U.S. healthcare system as servingsome members of society extremely well—and serving others without respect for orsensitivity to their needs. Such unintentional intolerance is difficult for health profes-sionals to acknowledge because of their lack of eultural eompetenee, yet it can nolonger be ignored or accepted.

More than one-third of the U.S. population belongs to a minority group,according to the U.S. Gensus Bureau. Even more telling for the future: 47 percentof children under five are from minority families. Likewise, the nation's workforceis becoming more diverse, from 18 percent minority representation in 1980 to anestimated 41 percent by 2030. The most dramatic workforce transformation of thelast half century is the progress of women, from 30 percent representation in 1950 to

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