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Presented by:David B. HuntJerry Benston(612) 746-1375

Diversity, Inclusion & Cultural Competence – A Leadership Imperative

• Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months.

David Hunt

Commercial Interest

Nature of Relevant Financial Relationship

What was received? For what role?Critical Measures Payment Equity Owner

• Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months.

Jerry Benston

Commercial Interest

Nature of Relevant Financial Relationship

What was received? For what role?Critical Measures Consulting fees Consultant

Disclosure Statement

• David Hunt discloses that he is the sole equity owner of the company Critical Measures and that Critical Measures is engaged in the business of diversity-related, healthcare consulting.

• Critical Measures does not offer any products or services that relate to the clinical care of patients and will not make any clinical recommendations during the course of this presentation.

• Critical Measures does, however, offer various, diversity-related organizational assessment tools and CME-accredited e-learning programs for doctors and nurses.

• Jerry Benston is an independent consultant with a long-term, consulting and training affiliation with Critical Measures.

Learning Objectives

Upon completion of this session, participants will improve their competence and performance by being able to:

1.Explain the business, medical and legal “cases” for diversity, inclusion and cultural competence.2.Recognize the workforce and patient care implications of changing demographic trends.3.Utilize new leadership skills and competencies necessary to manage a diverse workforce and treat culturally and linguistically diverse patients effectively.4.Develop an organizational action agenda to identify three top issues and three top solutions in a diversity and inclusion strategy.

Presentation Overview

• Three Demographic Megatrends• Discussion – Implications for OU Medicine• Workforce and Patient Care Implications• Attitudes Towards Differences Exercises• New Skills for the Culturally Competent Leader• Cultural Competence - National Best Practices• Creating An Action Plan

The National Context

• December 10, 2014, noon Pacific Standard Time Thousands of students from 70 medical schools throughout the United States held silent “White Coats for Black Lives” protests.

Three Key Demographic Megatrends

World’s Population: % White vs. Of Color

White

Non-White

1900 1950

2025

Racial Demographics – U.S.

• Between now and the year 2050, almost 90% of U.S. population growth will come from Asian Americans, African-Americans and Hispanic-Americans.

• Today, people of color are already a majority in 48 of the nation’s 100 largest cities, including Chicago.

• Today, four states have “minority majorities.” They include: California, Hawaii, New Mexico and Texas.

• Six other states: Maryland, Mississippi, Georgia, New York, Florida and Arizona have non-white populations around 40%.

Source: “The Emerging Minority Marketplace: Minority Population Growth 1995-2050.” U.S. Census Bureau September 21, 1999.

Workforce Workplace Marketplace Community

In the U.S., People of Color Are Becoming the “Emerging Majority”

White Of ColorSource: The Minority Business Development Agency .US Census 2000.

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2050204520402035203020252020201520102005

U.S. Population by White/People of Color: 2000- 2050

2050: White = 52.8%; Hispanic =24.5% Black =14.6%; Asian = 8.1%

Trends in U.S. Immigration

• 1 of 10 global citizens today is a migrant.• Immigration to the U.S. has tripled in the last 30 years.• During the 1990s, the U.S. received over 13 million

immigrants – the largest number in our nation’s history.• We broke even that mark during the last decade.• Significantly, most immigrants today no longer come from

Western European nations with whom we have the most in common historically….

Source: The Economics of Necessity: Economic Report of the President Underscores the Importance of Immigration. American Immigration Law Foundation

New Cultural Influences…

• Religion: Islam is now the fastest growing religion in the U.S. Source: U.S. Religion Census, May 1, 2012

• Language: 20.7 percent of Americans 5 years old and older speak a language other than English at home, with nearly half of those claiming to speak English less than "very well." Source: U.S. Census Quick Facts, Language other than English spoken at home, pct age 5+, 2009-2013

Comparisons: Oklahoma & U.S.

Population Oklahoma OK City U.S.

People of Color 31% 43% 37%Foreign Born 5.5% 12% 12.9%Foreign Language 9.4% 19.2% 20.7%At Home (Age 5+)

Notes: Source: U.S. Census Quick Facts. Racial statistics from 2010. Foreign born statistics from 2009-2013. Language statistics from 2009-2013. Oklahoma has the largest Native American population in the U.S. (9%, 179,000)

Discussion:

Based on these 3 demographic megatrends,discuss:1. Implications for OU Medicine’s workforce and patients.2. Implications for You as a Leader3. Implications for You – Personally

Workforce Implications

Managing Diversity – Why It Matters

1. Recruitment, hiring and retention2. Productivity 3. Communication and teamwork.4. Respect is culturally relative.5. Role of manager and employee vary across cultures6. Reducing racial and ethnic disparities in health care.7. Bottom-line financial implications8. Legal liability

Diversity and Productivity

• Effective diversity programs are associated with higher productivity (+18%). (National Urban League, 2004)

• Gallup found that 75% of workers are not fully engaged.• “Actively disengaged" employees -- those fundamentally

disconnected from their jobs -- cost the U.S. economy between $400 billion to $550 billion a year. (Gallup)

• What causes workers to disengage at work? One notable cause is DRI’s – Diversity Related Incident’s of Disrespect.

Communication and Teamwork

• Research shows that diverse work teams outperform homogenous work-teams.

• Diverse work-teams have many advantages:• However, diverse work-teams also face several key

challenges.

Patient Care Implications

What is Cultural Competence in Healthcare?

1. Racial and Ethnic Disparities in Patient Outcomes

2. Providing Language Access to LEP Patients/Families

A. Medical - Quality/Safety Issue

B. Legal - Civil Rights Issue (Title VI, ADA)

3. Medical Disparities resulting from Globally Mobile Populations

Institute of Medicine (IOM) Finds Racial &Ethnic Disparities Are Widespread in U.S.

• People of Color receive lower-quality health care than whites do, even when insurance status, income, age and severity of conditions are comparable.

• People of Color more likely to be treated with disrespect by the health care system and more likely to believe that they would receive better care if they were of a different race.

• Major disparities found in many key diagnostic areas: cardiovascular disease, cancer, stroke, kidney dialysis, HIV/AIDS, asthma, diabetes, mental health, maternal and child health.

Source: Unequal Treatment, Institute of Medicine, 2002

Little Improvement Found In Racial Disparities Since Issuance of IOM Report

• It has now been thirteen years since the Institute of Medicine issued its clarion call for improving the quality of healthcare for the nation’s minorities.

• A recent Agency for Healthcare Research and Quality (AHRQ) report noted that disparities in quality and outcomes by income and race and ethnicity are large and persistent, and were not, through 2012, improving substantially. Source: National Disparities Report 2014, AHRQ

Racial Disparities Costs Nation $57 Billion Per Year

• Racial health disparities in infant mortality, chronic disease and many other metrics cost the U.S. health system more than $57 billion a year, according to a report authored by researchers from Johns Hopkins University and the University of Maryland.

Source: Joint Center for Political and Economic Studies (a Washington, D.C. think-tank) September, 2009

Few Hospitals Collect Race/Ethnicity Data and Tie it to Patient Outcomes.

• The National Public Health and Hospital Institute (NPHHI) asked hospitals that collect race and ethnicity data whether they used it to assess and compare quality of care, utilization of health services, health outcomes or patient satisfaction across their different patient populations.

• Sadly, less than 20 percent of surveyed hospitals collect patient race and ethnicity information and tie it to patient outcomes and quality improvement.

Medical Case for Language Access in Healthcare – Improved Quality, Safety

1. Language barriers are associated with poor quality of care in emergency departments; inadequate communication of diagnosis, treatment and prescribed medication; and higher rates of medical errors.

2. According to one study, no interpreter was used in 46% of emergency department cases involving patients with LEP.

3. Few clinicians receive training in working with interpreters; only 23 percent of U.S. teaching hospitals provide any such training and most make it optional.

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Medical Case for Language Access in Healthcare – Improved Quality, Safety

4. Glenn Flores conducted research on mistakes by inadequately trained interpreters. His results showed:

• An average of 31 mistakes per doctor-patient visit• Two-thirds could have negative consequences for patients

5. According to the Joint Commission, fully half of LEP patients who reported adverse events experienced some degree of physical harm – compared to less than a third of English speaking patients.

6. The same report found that the rate at which LEP patients suffered permanent or severe harm or death was more than twice that of English-speaking patients.

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Patient Satisfaction Data – Language

1. Research has highlighted that patients with limited English proficiency (LEP) have more difficulty communicating with health care providers and are less satisfied with the care they receive than those who are proficient in English.

2. Studies show that the perceived quality of the interpreter is strongly associated with patients' assessments of quality of care overall.

3. Patients who needed and got an interpreter rated their hospital experience and the care they received more positively than those patients who needed an interpreter but did not get one. Other studies have found that linguistic minorities of any race reported worse care than did English-speaking racial and ethnic minorities.

More Hospitals Seeing LEP Patients

1. More hospitals are seeing LEP patients.

A. 80% of American hospitals encounter LEP frequently.B. 43% of hospitals encounter LEP patients daily, 20% of hospitals encounter LEP patients weekly,17% of hospitals encounter LEP patients monthly.

2. Yet less than 30 percent of U.S. hospitals have quality improvement efforts underway to improve the quality of their language access programs.

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More Physicians Seeing Non-English Speaking Patients

1. While nearly 97 percent of physicians have at least some non-English speaking patients, only slightly more than half of physicians (56%) were in practices that provided interpreter services in 2008.

2. Nearly half (48.6%) of all U.S. physicians in 2008 reported that difficulty communicating with patients because of language or cultural barriers was at least a minor problem affecting their ability to provide high quality care. Modest and Uneven, Feb. 10, 2010.

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Legal Case for Language Access

1. Federal Law - Language Access for LEP & the Disableda. Title VI of the Civil Rights Act of 1964 b. ADA, Sect. 503 Rehabilitation Act of 1973

2. State Law – All 50 states now have language access laws.3. Other: National Cultural and Linguistically Appropriate Service

(CLAS) Standards, Joint Commission, National Committee on Quality Assurance (NCQA), Magnet Status for Nurses

4. Issues: medical malpractice, informed consent, breach of duty to warn, breach of patient’s privacy rights.

5. Most medical malpractice insurance policies do not cover language access/civil rights claims.

With 1 billion people crossing international borders each year, there is no where in the world from which we are

remote and no one from whom we are disconnected.

Sometimes It Looks Like A….

• Horse …

• And gallops like a horse …

• But it’s a …..

Moral: In A Globally Mobile World, Today’s Doctors Are Seeing More…

Attitudes Towards DifferencesExercises

The Layers of Diversity Model

Copyright: Critical Measures, 2015

The 6 “C” Model

1. Courage2. Conditions3. Connections4. Communication5. Commitment6. Continuation

Copyright: Critical Measures, 2015

“The Danger of a Single Story”

“The Danger of a Single Story”

1. What ‘single stories’ might you have about others?

2. What might be others ‘single story’ about you?

3. What single stories might OU Medicine have about its

patients?

4. What single stories might OU Medicine patients have

about OU Medicine?

Cultural Competence – New Skills For Leaders and Providers

Cultural Competence

Culturally Competent Leaders

Cultural Awareness

Cultural Sensitivity, Cultural Biases

Cultural Knowledge

Cultural World Views, Theoretical & Conceptual Frameworks

Cultural SkillsCultural Assessment

Tools

Cultural Encounter

Cultural Exposure, Cultural Practice

Awareness: New Research re: Bias

1. In the past, bias was regarded as aberrant, conscious and intentional.

2. Today, we understand that bias is normative, unconscious and largely unintentional.

3. Social Cognition Theory establishes that mental categories and personal experiences become “hard-wired” into cognitive functioning.

4. As a result, human biases can be seen as evolutionarily adaptive behaviors.

What Activates Our Biases?

Our biases are most likely to be activated by fourkey conditions. They are:

stress time constraints multi-tasking need for closure

Implicit Association Test (IAT) Findings

1. Age

2. Gender

3. Race

4. Other IAT Results

Workforce Implications

Unconscious biases can infect management decisions throughout

the employment life cycle:

1.Interviewing, recruitment, hiring and retention.

2.Expectations of and interactions with employees (“Micro-inequities”).

3.Employee evaluations (“Set Up to Fail Syndrome” – Harvard Business

Review).

4.Decisions about promotions, training and other job benefits.

5.Termination and discharge decisions.

Patient Care Implications

Unconscious biases can affect:

1.Clinical objectivity

2.Patient care, treatment decisions, outcomes

3.Patient provider trust, communication and relationship

4.Patient compliance

5.Patient satisfaction

Ten Core Cross-Cultural Issues (Trompenaars/Hampden-Turner)

1. Orientation: Individualistic vs. Collectivistic2. Status: Achieved vs. Ascribed3. Focus: Task vs. Relationship (Univ. Rules vs. Partic.)4. Communication: High Context vs. Low Context 5. Time: Clock Time vs. Cyclical Time6. Mental Processes: Linear vs. Lateral7. Affect: Neutral vs. Emotional8. Conflict Style: Harmony vs. Confrontation9. Locus of Control: Internal vs. External (Fate)10. Power: Egalitarian vs. Hierarchical .

.

The Culturally Competent Leader: Skills

• Culturally inquisitive, manages own biases• Capable of perspective shifting• Hires, retains, manages and mentors diverse workforce• Trust building with diverse employees• Cross-cultural communication• Teambuilding• Cross-cultural conflict resolution• Issue-spots diversity-related employment matters that

could create liability• Masters the art of complaint handling

New Skills for the Clinically Competent Global Physician

1. How to conduct a culturally competent patient examination/history using the LEARN Model (Listen, Explain, Acknowledge, Recommend, Negotiate)

2. How lack of knowledge of epidemiological and pathophysiological differences may lead to unintended iatrogenic consequences.

3. How to work with patients using qualified medical interpreters & ASL4. Understanding the Law of Language Access (implications for informed

consent, medical malpractice and other legal issues)5. Given the increase in globally mobile populations, physicians should know

their patients national origin and travel history and be mindful of diseases endemic to other parts of the world that might share symptoms with diseases commonly seen in the U.S.

6. Health care providers should be aware of at least the five most common infectious diseases most commonly encountered in refugee populations.

New Skills for the Clinically Competent Global Physician

7. Cross-Cultural Medical Ethics (examples: cultural differences around death and dying, blood beliefs, surgery, organ transplants, mental health etc.)

8. Ethnopharmacology and its implications for current clinical practice 9. Understand the New Science of Unconscious Bias and its implications for

clinical decision-making.10. Be able to take a competent sexual history.11. Be able to take a competent patient history from immigrant and/or refugee

patients.

Source: Critical Measures, 2015.

Cultural Competence – National Best Practices

Best Practices – Hospitals

1. Collect patient race, ethnicity and language (REL) data.2. Tie patient REL data to patient outcomes. (<20% currently do…)3. Stratify patient complaints by patient demographics.4. Stratify patient satisfaction data by patient demographic data.5. Create patient satisfaction report cards for providers based on different

patient demographics. (Kaiser Permanente)6. Conduct Diversity Workforce Assessments or Climate Audits to assess

employee satisfaction/engagement by diverse groups.7. Conduct Provider Cultural and Linguistic Competence Assessments to

examine self-assessed preparedness and clinical practice behaviors with regard to diverse groups of patients.

8. Create “disparities” dashboards for key metrics on both sides of the healthcare “house” (workforce and patient experience).

Race, Ethnicity and Perceptions of Workplace Relationships in Healthcare Management

White Asian Black Hispanic

Race relations within my company Women 79% 60% 41% 55%are good. Men 90% 70% 53% 73%Managers of Color usually have to Women 6% 29% 75% 47%be more qualified to get ahead here. Men 3% 33% 66% 35%White managers share vital growth Women 57% 29% 10% 18%and career-related information with Men 55% 37% 12% 30%managers of color.The evaluation of both whites and Women 69% 51% 18% 33%employees of color are equally Men 75% 50% 22% 43%thorough and carefully evaluated .Has a strong feeling of belonging Women 82% 70% 58% 71%to the organization. Men 85% 72% 72% 79%

Source: A Race/Ethnic Comparison of Career Attainment in Healthcare Management: American College of Healthcare Executives; Institute for Diversity in Healthcare Management, 2012

M.D. Cultural Competence Results

1. 97% of MD’s had LEP patients. (Exactly on par with U.S. avg.)2. Nearly half felt “less than well prepared” to care for these patients.3. Primary care MDs often felt least prepared to provide care to LEP

patients.4. 30% did not use qualified interpreters to obtain informed consent.

50% did not record use of interpreter in pt’s medical record.5. 92% treat immigrants and refugees.+60% = less than well prepared

6. 56% to 70% of MDs did not routinely ask about country of origin or

recent travel history . 7. 52% of MDs unfamiliar with Schistosomaisis; 65% unfamiliar with

Strongyloides – two of the five most common diseases found in immigrants and refugees to the United States;

Picker – Inpatient Satisfaction with Doctors By Race, CLIENT

Question/Statement White Of Color Signif?

Didn’t always have confidence/trust 14.5% 26.1% Yesin my doctors.Doctors talked as if I wasn’t there. 6.3% 23.2% YesCourtesy of doctors “fair” or “poor” 2.5% 5.5% YesDoctors/nurses gave conflicting info. 21.5% 26.5% Yes

* Scores over 20% are considered “problems” by Picker.

Picker – Inpatient Satisfaction with Nurses By Race, CLIENT

Question/Statement White Of Color Signif?

Didn’t always have confidence/trust 24.8% 34.7% Yesin my nurses.Nurses talked as if I wasn’t there. 6.5% 22.9% YesCourtesy of nurses “fair” or “poor” 3.5% 5.6% YesNurses answers to questions . 25.8% 29.6% Yesweren’t always understood.

* Scores over 20% are considered “problems” by Picker.

Picker – Treated with Courtesy, By Race, CLIENT

Question/Statement White Of Color Signif?Courtesy of admissions staff rated 2.0% 5.9% Yesfair or poor.Courtesy of people who took blood 2.8% 8.8% Yessamples rated fair or poorCourtesy of people who brought food 5.0% 8.8% Yesrated fair or poor.Courtesy of people bringing to and from 1.2% 6.2% Yesroom rated fair or poor.Courtesy of people taking x-rays rated 1.4% 7.6% Yesfair or poor.Courtesy of people who cleaned room 3.3% 8.6% Yesrated fair or poor

Picker – Other Key Indicators of Care By Race, CLIENT Question/Statement White Of Color Signif?Not always treated with respect and 13.1% 21.6% Yesdignity.Didn’t always get help in time going 20.4% 30.8% Yesto the bathroom.After using call button, had to wait > 15 2.1% 4.3% Yesminutes for help.Staff definitely did not do everything 19.7% 26.3% Yesthey could to control pain.Didn’t have enough say about pain 26.1% 38.4% Yescontrol during delivery.Probably would or would not 23.9% 28.8% Yesrecommend to family/friends.

Building an Action PlanAt OU Medicine

OU Medicine Diversity Initiatives

1. Lunch and Language Program2. Diversity & Cultural Competence Training3. Spanish E-Learning4. Rosetta Stone Spanish Program5. Interpreting/Translation Services6. Diversity Health Screenings7. Certified Spanish Medical Interpreter Program8. Other initiatives – Multicultural Committee

Discussion:

In small groups, discuss possible next stepsfor OU Medicine in the following areas:1. Workforce Diversity2. Racial and Ethnic Disparities3. Language Access4. Global Medicine

Questions? Contact Information

For Further Information:David B. Hunt

President and CEOCritical Measures, LLC.

(612) 746-1375dbhunt@criticalmeasures.net

Website: www.cmelearning.com