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(Editor’s note: In the second of a two-part series looking at differences in health care provided to minorities and immigrants, Healthcare Benchmarks looks at what some facilities and organizations are doing to address and prevent racial discrimination in health care. Last month, we looked at data that show such discrimination is more common than one might think.)
There are some indisputable facts about race and health care in America. First, the number of minorities is growing, and by 2030, some estimates show that 40% of the United States’ population will consist of minorities. Second, many people who are members of those minority groups believe that they receive different, apathetic, or lower quality care than their white counterparts. In fact, a study released in February by the public health department in King County, WA, found that one in five African-Americans had a serious incident of discrimination in a health care setting. (For more on the report, see Healthcare Benchmarks, April 2001.)
But along with the alarming truth that many patients perceive that they are discriminated against by health care professionals and their staffs, there is another set of facts that can’t be denied. Many organizations have taken these facts to heart and are implementing a wide variety of programs to ensure that all their patients receive the highest quality care and respect, regardless of their ethnic or racial background.
A recent report by the New York City-based New York Academy of Medicine lists more than 80 projects at dozens of institutions and organizations that are designed to tackle that very problem. Several of those projects have been undertaken by the Greater New York Hospital Association (GNYHA), also in New York City, which represents about 175 hospitals and long-term care facilities.
According to Susan Waltman, senior vice president and general counsel, it isn’t a matter of hiding their collective heads in the sand and denying a problem exists. "If there are problems with access to care and differences in how care is given, we have to address it."
After a series of articles in a local paper gave rise to research projects that showed there might be such disparities, the association took action, she says. First, Waltman and others from the association met with the Office of Civil Rights and the Office of Minority Health at the Department of Health and Human Services. They also invited local health officials to the meetings. Among the topics discussed were legal obligations, as well as what was simply the right thing to do, she explains. "We had a series of work group meetings on a variety of issues from treating patients with limited English proficiency to the cultural competence of health care workers."
Meetings also looked at how health improvement activities and outreach services differed among communities. "Memorial Sloan Kettering [in New York City] has a grant to link with community organizations to teach them to do cancer screening and education," Waltman says. But other communities don’t have that kind of program. She says she sensed a lot of members wanted to address the needs of minority communities, but they had no models to emulate. So they concentrated on finding those models and putting their work before their peers. "We could endlessly give those kinds of seminars," she says. "Our members like learning that way and gaining the understanding of how something works and how it might be done better."
Some of the programs the member hospitals are working on are unique. One major system is "mystery shopping" its emergency department by sending in people posing as patients to see how the system responds to different types of people presenting with various cases. Other programs the GNYHA has undertaken include work on a translation service that would be available 24 hours a day from a central location via advanced telecommunication services, and a cultural competence training program for medical residents, administrators, and physicians. In the first year of operation (2000), more than 45 of the member organizations expressed interest in the program.
One reason the programs the GNYHA has developed work, says Waltman, is that the association wasn’t afraid to make use of the resources at the Office of Civil Rights and Office of Minority Health. Often, she says, organizations view these groups as adversaries whose main function is to find a problem, place blame, and assess fines.
"This is a delivery system issue, and forging a partnership with the public sector is important," she notes. "Get the federal government and local public health officials involved. We weren’t afraid to work with law enforcement and public health officials. Once you realize that everyone has the same goals, it all works. Forging that partnership is the most effective way to get things done."
Many of those who haven’t progressed as far as the GNYHA and its members have had difficulty defining the problem, says Ira SenGupta, cultural competency training program manager at the Cross Cultural Health Care Program in Seattle. "It isn’t just discrimination but the perception of discrimination," she says. SenGupta spends most of her time traveling the country providing cultural competency training. She starts the sessions with the premise that everyone in the world has felt excluded at some time or another. "It happens every day; you don’t always have power, and discrimination is about feeling powerless."
With that definition, it becomes easier for an organization to admit that it probably has a problem and that the situation can be improved. "It isn’t enough to say you are doing your best to be inclusive," says SenGupta. "No one has a policy saying you will discriminate. Policies don’t provide disparate care. People do."
Another element of taking control involves keeping track of who lives in your service area, she says. "Who is moving in? What are the issues that affect the populations who are moving in? Are there language differences or historical elements of the community you should know about?" For instance, a refugee who escaped the Rwandan massacres of the 1990s may be very afraid of people in positions of power, SenGupta explains.
Knowing a particular community’s perception of terminal disease, its traditional family involvement in medical decision making, or how it prefers diagnoses to be given to the patient are all important. But if you don’t know what groups you serve, SenGupta asks, "how can you know how to treat them respectfully?"
And if an organization as a whole hasn’t done the work, then providers can and should take the time to find out for themselves, she says. "All they have to do is ask the questions. Ask how the patients feel about giving and receiving diagnoses. They’ll tell you. And it doesn’t take too much time. If you do this from the start, you’re going to make allies of your patients and increase their compliance."
One of the hospitals in the Seattle area that has taken the issue of cultural competence to heart is Children’s Hospital and Regional Medical Center. For at least seven years, there has been some sort of cultural competence program at the hospital, says Kathy Salmonson, RN, a nurse consultant at the facility’s Center for Children with Special Health Care Needs. "Various groups would wax and wane. People would have momentum, sometimes for a couple years, and each time the momentum was greater and more people involved," Salmonson says. Finally, a new CEO put the issue of cultural competency on the hospital’s list of "Legacy Goals."
That set the ball rolling, she says, and a cultural competency and diversity committee was formed. "Initially, the discussions were how to meet the needs of minorities, whether we had interpreters, whether our signage was universal," she says. "But we ran into problems in figuring out how to measure this and figure out how it adds value to the organization when it was just the right thing to do."
To a degree, says Salmonson, there was a feeling that the committee — which included the nursing executive, the COO, the heads of social work and human relations, physicians, staff from communications, and community and government affairs — had to use "infiltration" to spread its message throughout the hospital.
Finding ways to justify the programs became a way to do that. In working with SenGupta and her organization, Salmonson says they were able to put the program in terms that everyone would agree were vital to the success of Children’s in the future.
"First and foremost, you talk about regulations, and you talk about negative incentives like not wanting a lawsuit. And then you move to the discussion of how minorities are becoming the majority, so if you don’t provide appropriate care, then you lose your market share." Suddenly, people who pooh-poohed the idea of cultural competency are ready to listen, says Salmonson.
But there are many places where the committee could focus its attention. "We figured the first thing to do was train supervisors and managers," she recalls. "That was a flop. What we found after doing an assessment of that program was that people were interested in doing specific projects and training sessions only if necessary."
At the same time that the cultural competency and diversity committee was struggling with direction, the hospital started using a facilitywide patient satisfaction survey. "It used to be department-specific," Salmonson explains. What that showed was that to improve patient satisfaction, Children’s had to support staff and improve their morale. "If staff aren’t the happiest, then patients and families aren’t doing the best. We had to find a way for us to leverage that into focus on the program."
The way, says Salmonson, is to help staff be culturally competent with each other. "Teamwork will help us partner better with each other and with patients." So the committee focused on increasing staff awareness of diversity, different cultures, and how those issues relate back to patients and their families. A series of brown-bag seminars was held, in which people from the University of Washington, the Cross Cultural Health Care Program, and Harborview Medical Center came to talk to staff. Among the topics covered in the last year:
A display case has a rotating array of artwork by patients. Currently, it has masks made by psychiatric inpatients. "That increases knowledge of mental health patients," Salmonson explains. There have been displays about staff who came from other countries, contributions from schools, and a display for Black History Month. "The more ways we communicate and increase awareness, the better."
The hospital also started trying to assess staff in a positive way on cultural competency. "We try to show strengths, not weaknesses, through asset mapping," Salmonson explains. "We don’t look at needs, and that’s great for staff to talk about the things they do well."
Debra Gumbardo, MS, RN, the hospital’s director of inpatient psychiatry and partial hospitalization programs, says she gained a real understanding through the process of what her staff need to be successful. "One question was about how they learned the mission of our unit," Gumbardo says. "Some people identified particular staff and mechanisms that were helpful, while others said they needed something more structured. I ended up revising my orientation."
And even though the focus was on strengths, areas of weakness showed up anyway, says Salmonson. "We did hear those things, but what was different was, it wasn’t a gripe session."
In the future, issues about how responsive staff are to other people’s cultures will be an element of performance appraisals for managers and supervisors. "People will be asked, What are you doing to enhance cultural competency in your department?’" says Gumbardo. All those efforts have been going on for just under a year, and Gumbardo says she’d like to see it affect patient satisfaction. "We did this without baseline data, but we hope to see positive changes over time."
In the future, Children’s will look at staff turnover, recruitment, and retention, Gumbardo adds. If those numbers are good, she can assume the program is having a positive impact. "I do think my staff feel more empowered and are more satisfied than they used to be," she says.
The hospital also is starting to track complaints centrally, Gumbardo adds. Those will be collated and looked at to see if there are any patterns or changes.
Training still occurs, but not in the way it was tried in the past. "We offer ourselves as consultants and give overviews at various group and department meetings," says Salmonson. "It helps us to gauge how well we have infiltrated." The training sessions include exercises that get participants to challenge how they see other people, Salmonson explains. "One group of nurses was just starting, and I talked about if the earth is 100 people, who are those people? What do they look like? How many are educated? Who has the wealth?"
There also are stereotype exercises in which adjectives are applied to certain people. "How people respond to that is amazing," Salmonson says. "If you say, African-American woman, single mother, wealthy, physician,’ the picture changes. Another one is Japanese man, father, farmer, gay.’"
Although the whole hospital has made cultural competency an overall goal, individual departments and units still have the ability to enact positive change on their own. For instance, nurses on the medical unit were having trouble finding interpreters in a timely manner, says Salmonson. "So they developed this communication tool made of pictures as a way to communicate when there are no interpreters readily available," she explains.
Gumbardo says looking back at past agendas for the cultural competence committee doesn’t show a lot of change in what is on them. More than two years ago, the agenda for a meeting might include recruiting diverse staff, providing a welcoming environment, integrating with diverse communities, and assessing the need for broad-based training and competencies. In the last two years, the agendas include training frontline staff in "hospitality Spanish," facilitating provider interactions with specific patients and their families, dealing with patient and family complaints, and diversity representation in all key hospital initiatives and goals.
"What has changed is our approach. The focus is on being culturally competent with our staff, our most valuable asset, and our broadening the definition of cultural competence," Gumbardo says.
The broader definition, she says, is based on a statement by Okokon O. Udo, the executive director at the Center for Cross-Cultural Health in Minneapolis. "To be culturally competent doesn’t mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and willing to accept, that there are many ways of viewing the world."
[To obtain a copy of the New York Academy of Medicine report Addressing Racial Disparities in Health Care Delivery: A Regional Response to the Problem, contact Emily Wood at email@example.com. Telephone: (212) 822-7222.
For more information, contact:
• Debra Gumbardo, MS, RN, Director of Inpatient Psychiatry and Partial Hospitalization Programs, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way, Seattle, WA 98105. Telephone: (206) 526-2000.
• Kathy Salmonson, RN, Nurse Consultant, Center for Children with Special Health Care Needs, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way, Seattle, WA 98105. Telephone: (206) 526-2000.
• Susan Waltman, Senior Vice President and General Counsel, Greater New York Hospital Association, 555 W. 57th St., New York, NY 10019. Telephone: (212) 506-5405.
• Ira SenGupta, Cultural Competency Training Program Manager, The Cross Cultural Health Care Program, 1200 12th Ave S., Quarters 8/9, Seattle, WA 98144. Telephone: (206) 621-4478.]