A cultural diversity assessment and the path to magnet status.

ORGANIZATIONAL INFORMATION

This urban medical center is a 758-bed, two-campus acute care facility that operates as part of an investor-owned, six-hospital system in a metropolitan region with a population of approximately one million. The campuses, six miles apart, were originally managed separately but now operate as one organization with a single executive team, medical staff, and board of directors. Named a "100 Top Hospital" in cardiovascular care for the last three years, the medical center has the largest open-heart surgery program in the region and the fourth-largest in the state.

Both campuses are designated as the only two Level-III trauma centers in the region, with a combined 100,000 emergency room visits annually. With more than 33,000 admissions, 3,500 deliveries, and more than 11,000 outpatient surgeries, the medical center has more than 23 percent of the state's market share. A major competitor serving this region is a not-for-profit system operating three hospitals, with a fourth under construction, and a tertiary academic medical center located in the heart of the downtown area and serving as the Level-I trauma center for the region.

SUMMARY OF THE PROBLEM

The communities served by the medical center's campuses, once a predominantly Caucasian and homogeneous population, have experienced an exceptional wave of diversity in the past ten years. The most significant growth has been in the Latino and Asian/Pacific Islander populations. This cultural shift in demographics introduced to the organization many opportunities and challenges to accommodate patients and employees who have limited English proficiency and whose religions and cultural customs present unusual approaches to recruitment and retention and to the delivery of patient care. As the environment became increasingly competitive, the medical center leadership had to explore ways to differentiate the medical center and to ensure that its facilities and staff could effectively manage, care for, and treat the diverse population.

DESCRIPTION OF THE PROBLEM

Healthcare is the most highly regulated industry in the United States and is in a constant state of transformation. Every day, healthcare professionals encounter a wide variety of people from a myriad of cultures, religions, and ethnicities. Hospitals cannot deny services or treatment to a patient who cannot speak English or whose cultural practices conflict with components of the patient's plan of care. Hospitals are legally required to open their doors to all who arrive and must effectively and efficiently treat these patients with compassion, caring, and respect. According to the AHA Commission on Workforce for Hospitals and Health Systems (2003), "[a]lthough 10 percent of the US civilian labor force is employed in the healthcare field, the healthcare workforce does not mirror the diversity of the general US population; ethnic and racial minorities are severely underrepresented." This fact can only exacerbate communication problems caused by misinterpretations, misunderstandings, or stereotyping.

The increase in cultural diversity across the United States, within the state in which the medical center operates, and within the communities it serves mirrors the trends in that state's population growth: Between 1990 and 2000, the population grew 14.4 percent. The Latino and Asian/Pacific Islander populations grew at 105.6 percent and 70.4 percent, respectively, while the white (non-Latino) and black (non-Latino) populations grew only by 5.6 percent and 19.4 percent, respectively, for the same time period (U.S. Census Bureau 2000). In response to this change in demographics, the chief executive officer (CEO) and principal sponsor of the medical center directed the organization to assess its readiness to meet the needs of these changing demographics and to move the organization toward cultural competency.

Having been a member of the medical center's healthcare team for more than 25 years, I knew that a move toward greater cultural competency would not be simple. This organization, with its two campuses established 25 and 30 years ago, held a monopoly in its primary service area and enjoyed a rather stable medical and professional staff. As a result of this longevity, it had deep-rooted cultures, which could hamper internal changes. Like many organizations, the medical center had to acknowledge and identify the deficiencies in the system that were a direct or indirect result of its stakeholders' collective cultural ignorance or bias. To usher in change, we first had to conduct an internal assessment of our own biases. Recognizing that this cultural diversity assessment could prove difficult, would be labor intensive, and could yield a plethora of information that could become overwhelming if not directed and applied appropriately, the medical center leadership chose to narrow its assessment focus.

At the time, the medical center was in the early stages of evaluating its readiness for applying for Magnet status for nursing. Magnet requirements emphasize a culturally sensitive environment and education in religious and cultural differences. The leadership thought that combining the Magnet status and cultural competency efforts made sense and would certainly assist in meeting both objectives.

ADMINISTRATIVE DECISIONS

The senior administrative team (including myself [the CEO at the time], chief operating officer, chief financial officer, chief nursing officer, and human resources officer) identified the challenges that, from a cultural and manpower standpoint, could possibly be barriers to both our Magnet and cultural priorities. The team agreed to combine these efforts to better enable the success of each.

As CEO and principal sponsor, I charged the administrative resident to lead the combined effort as part of her residency requirement. The chief nursing officer and associate nurse executives of each campus were given accountability for the efforts and were asked to serve with me as leadership champions. Our initial meeting resulted in the establishment of four objectives:

1. Conduct an assessment of the medical center's cultural diversity to comply with Magnet criteria.

2. Conduct an assessment of the medical center's staff, patients, and community to identify major ethnicities served in each of the three groups.

3. Develop an educational plan for hospital staff that promotes cultural competency when caring for a diverse population.

4. Seek endorsement from the governing board for the pursuit of both Magnet status and cultural competency.

Objective 1: Assess Cultural Diversity to Comply with Magnet Criteria

The associate nurse executives had initiated the process to review the medical center's readiness to apply for Magnet status. Because the Magnet requirements or core criteria for hospitals are separated into individual chapters, we decided to carve out the two chapters that dealt specifically with diversity:

1. Measurement criterion 5.1 speaks to the implementation and improvement of systems that ensure "safe, effective, efficient, and culturally sensitive" patient interventions (ANCC 2003).

2. Measurement criterion 11.4 mandates a facility to "foster a non-discriminatory climate in which care is delivered in a manner that is culturally sensitive and that is reflective to the cultural diversity that exists within the organization" (ANCC 2003) and deals with diversity within the overall facility. This criterion thereby encompasses both patients and staff and requires educational programs, assessment of patient population and employee population for ethnic diversity, and specific procedures for language interpretation services for patients. (This chapter was used to establish the framework on which we would build goals and objectives.)

Objective 2: Assess Staff, Patients, and Community to Identify Ethnicities Served

Data on staff, indicating the total number of employees, by ethnicity, in predefined clinical and nonclinical job categories, were taken from reports submitted to the Equal Employment Opportunity Commission. This data set included 3,199 employees of the medical center as of December 2003.

Patient information, for approximately 334,000 registered inpatients and outpatients as of 2002, was extracted from the medical center's registration software modules. The ethnic categories of patients were "White," "Black," "Asian," "Hispanic/Latino," "American/Indian," and "Other/Unknown." Although this information was required at the time of entrance into the system, it had never been used for tracking or trending purposes. To establish the percentage increase in this patient population, the same data were collected for the years 1998 through 2002. In addition, usage data from the "language line," a phone-based interpreter service that provides interpretation of 150 languages, provided insight into the languages being requested by callers as well as anecdotal accounts from employees of their day-to-day experiences.

Several resources were used for the community assessment. The 2000 U.S. Census report proved to be integral and accounted for approximately 600,000 residents in the medical center's primary service area. The Immigrant Health Needs Assessment for the Greater Metropolitan Area, which outlined statistical census data and interview findings with recent Hispanic and Asian immigrants within the same community, was also helpful.

Objective 3: Develop a Cultural Competency Education Plan

Completion of Objective 2 analysis served to assist the leadership in understanding the ethnic composition of the medical center's patients, employees, and communities served. With this understanding, the organization could begin to identify the gaps in current knowledge, practices, and cultures. This knowledge would also serve to shape the development of a structured education plan, with comprehensive materials that require staff to demonstrate an understanding of key cultural issues pertaining to the healthcare setting. We believed that on the path to cultural competence, "education is an essential component for organizational transformation" (American College of Healthcare Executives 2004). Research from The Advisory Board's "Fact Brief of Diversity Programs" was used by the administrative resident to assist and guide the plan of action for the education programs. In addition, site visits to the medical center's sister facilities in culturally diverse states, such as Florida and Texas, were also used in development. Lessons and best demonstrated practices learned from these organizations served to shape the final education product.

Objective 4: Seek Endorsement from the Governing Board

Senior leadership and front-line management were not expected to create barriers, but the possibility that the governing board and medical staff might pose roadblocks to success was anticipated; therefore, careful consideration was put into shaping the message to the board about the combined efforts.

RESULTS

Patient, Employee, and Community Assessment

As mentioned, the organization did not collect and extrapolate data on patients' ethnicities for the purposes of tracking and trending, nor were formal training programs on cultural diversity in place. Although policies and procedures existed to address Title III of the Americans with Disabilities Act and Title VI of the Civil Rights Act of 1964, the policies were not widely understood, accessible, or regularly used. This lack of education across the board represented the largest gap in achieving the Magnet requirements.

Employee demographic findings revealed that the organization's base was less diverse overall than its patient and community populations. The team deduced that diversity was increasing from year to year while the employee base remained constant. The patient and community diversity growth was further validated by the usage rates of the language line. This growth was consistent with the Immigrant Health Needs Assessment results referenced earlier.

Clearly, there were limitations to the assessments conducted (i.e., accuracy of data, projecting trends based on historical data, changing samples, and different or conflicting staff perceptions that presented challenges for the timely and precise analysis of the information), but the data were inclusive enough for the team to formalize the following recommendations to the senior administrative team and the governing board:

1. Formalize specific demographic information to be collected at the point of registration regarding ethnicity, primary language, and any condition that might affect patients' communication with their clinicians.

2. Create a new field in the information system used by both registrar and clinicians and accessed by the patient care provider that can roll over into any system facility within the region and serve as a trigger for case management intervention.

3. Track patient, employee, and community demographics semiannually and integrate this information into the organization's strategic planning process.

These recommendations were adopted and successfully implemented, and they remained in place one year after their adoption, for use in patient care planning and for tracking and trending. These changes have also been enacted across the organization's sister facilities. In addition, the information from the analysis was used in the medical center's diversity plans, which became part of the strategic plan.

Education Programs

A formal education plan and competency requirements were recommended to be introduced or rolled out to all existing and new employees. This rollout was designed to expose employees to different cultures, religions, and ethnicities and to stimulate discussion. This formal education was in addition to existing education on policies and procedures regarding LEP and deaf patients, which is required by regulatory bodies. An annual customer service class was required for all employees, encompassing a training on how other cultures affect the healthcare working environment and how staff must communicate with patients and families of other cultures or ethnicities. Employees were not the only target audience; diversity education also was aimed at the governing board, medical staff, volunteers, and chaplains.

The following were other accomplishments in this area:

1. A diversity leader from the organizational development department was appointed to ensure the development and integration of education throughout the medical center.

2. One hundred percent of the staff attended customer service trainings, encouraging the medical center to continue to offer classes throughout the year for new employees.

3. Diversity training was offered at clinical-staff orientation and was added to the new-manager orientation.

4. Leadership staff attended (and continue to attend) an annual diversity in-service day.

5. Brief articles on cultural diversity were published (and continue to appear) in each issue of the organization's employee/medical staff newsletter.

6. A cultural diversity resource manual has been placed in each patient care area, and the Journal of Cultural Diversity would be added to the medical library.

Diversity education at the medical center has evolved from merely looking at cultural differences among patients to understanding the organization's own biases and assumptions. The education has been well received and well attended by employees, volunteers, and medical personnel.

Centralization of Sign-Language Interpreter Service

Centralization of interpreter service was recommended to simplify the process of requesting and coordinating the service. This change was intended to increase usage as appropriate and knowledge of the service's benefits. The patient liaison office was assigned to be the central point of contact, and an after-hours call line was established. This recommendation was the first to be implemented as it required the least amount of change. Management tools, developed to meet regulatory and risk compliance; documentation standards; and education regarding acquiring an interpreter were added to the employee orientation manual under the patient rights section. The medical staff executive committee and the governing board were given formal education regarding their responsibilities and risks.

Leadership and Governing Board Endorsement of Pursuing Magnet Status for Nursing

The plan was that once a structured education plan was in place and implemented and the patient/employee assessment and tracking were solidly in place, development of the Magnet diversity chapters would begin. The leadership team and frontline management endorsed the plan but, unfortunately, the governing board felt that the pursuit of Magnet status would divert nursing resources away from core services at a critical time for the organization. Although this was a disappointment to leadership, the pursuit of Magnet status at the time would not have had the leadership necessary for successful execution because of changes in senior management that occurred shortly thereafter.

SUMMARY

Magnet hospitals understand that healthcare providers no longer work with a homogeneous stakeholder population (including healthcare professionals, employees, and patients); thus, organizations must ensure that their practices accommodate the patients and employees of today and tomorrow. Although the medical center did not pursue its Magnet status goal, it is on the path to transforming its culture into a culturally competent environment. Such an environment allows the organization to be better poised for success when the time is right to, once again, pursue Magnet designation.

RESOURCES

(1.) AHA Commission on Workforce for Hospitals and Health Systems, 2003

(2.) American College of Healthcare Executives, 2004

(3.) Financial, Strategic Planning, and Dashboard Documents of the medical center

(4.) Administrative Resident's Management Project

(5.) U.S. Census Bureau, 2000

(6.) American Nurses Credentialing Center, 2003

Margaret G. Lewis, FACHE, president, Capital Division HCA, Reston, Virginia 

Margaret G. Lewis, FACHE, is president of HCNs Capital Division. She is a member of the State Council of Higher Education for Virginia and the Healthcare Workforce Taskforce, a founding board member of LEAD Virginia, a board member of the Medical Society of Virginia Foundation and the Virginia Hospital and Healthcare Association, and a board chair of the John Tyler Community College Foundation. In 2005, Ms. Lewis received the Alumni Star Award for Nursing from the Virginia Commonwealth University (VCU) and was appointed as assistant professor in the School of Allied Health Professions at VCU. She earned an associate's degree from John Tyler Community College, a bachelor's degree in nursing from the Medical College of Virginia, and a master's degree in business administration from Averett College. This Fellow Project was chosen as one of the best in 2005.