Minorities have become the majority in nearly half of America’s largest cities. In an intimately personal business like health care, this demographic shift is significant. Are healthcare organizations doing enough to make certain that patients from all walks of life feel comfortable and cared for? Are current organizational efforts to close diversity and inclusion gaps in healthcare enough? Each organization needs to answer these questions for itself, but the first step is to identify where changes need to be made, and then to make diversity and inclusion an ongoing mission.
Adewalé Soluade, MBA, CDP, assistant vice president of corporate inclusion and diversity manager at Commerce Bank, discussed the concept of unconscious bias at HFMA’s 2017 ANI in June and how it affects an organization from both employee engagement and patient care perspectives.
Unconscious bias is difficult to address because, by nature, it’s under the surface. Tools like implicit association tests reveal areas to increase awareness.
“We get socialized about expectations when it comes to age, gender, you name it, that we develop from childhood through adulthood,” Soluade says. “These tests use our response times to the questions asked to identify where some of these unstated biases are. As individuals, we have something to gain to know where we have some sort of bias that can impact our overall leadership focus and skill set.”
Soluade revealed that 76 percent of those who take the test more readily associate men with careers and women with family. The effect of these biases is clear in the workplace, he says, with typically “white-sounding names” receiving 50 percent more calls back based on resumes alone than typically “black-sounding names.”
There have even been connections made to unconscious bias and treatment practices—physicians are more likely to prescribe pain medications to whites over blacks, and pro-white bias was associated with poorer ratings of interpersonal care among black patients, Soluade adds. There has also been evidence that minority patients report lower quality in overall interaction with physicians, less time spent with physicians, poorer communication, and lower levels of trust and respect.
These biases are costly, too, not just to the health and wellness of the patient, but financially as well. Soluade says employee lawsuits related to bias have increased 400 percent during the last 20 years to the current 6.5 claims per 1,000 employees each year, with the average cost to settle a suit at $300,000.
Forty-eight of the 100 largest cities in the United States now have minorities as the majority population, and almost 90 percent of all population growth in the country by 2050 will come from people of color, Soluade notes.
“When we start diving into that population growth, there is a very large portion of that that will be driven by immigration. They will all come with perceptions on what health care should look like,” Soluade says. “We will see more foreign and diverse doctors. What organizations are doing today is important to make sure they have the cultural competency in place in their workplace to make sure patient care doesn’t suffer.”
Diana Gueits, director of diversity and inclusion at the Cleveland Clinic, agrees that unconscious bias can be a real problem. She adds that the Cleveland Clinic is now
working through a program to address unconscious bias at every level of the organization. Anyone can take an implicit association test, a free tool developed at Harvard University, she says. People—including herself—are often surprised at their results, and she reveals that she found out she had a preference for men in professional roles. She had always considered herself to be a feminist, so this revelation was a shock, but one Gueits says she was able to learn from.
“When you get the response from the tool, what does that say to you? Did that really resonate with you in terms of what you thought your preferences were?” Gueits says. “We all have bias. We know that bias lives in the genesis of everyone’s thoughts and certainly impacts how we perceive and behave in the world. It really permeates every facet of life, and you don’t even have to be in a professional capacity to have bias.”
Individuals must be aware of their biases, she adds, and be willing to expose those biases and some aspects of vulnerability to have cultural humility. “There are things we don’t know about other groups, and we have to be curious and learn from others,” she says.
Soluade says it also comes down to making the basic connections that are so important to healthcare. Without those connections, healthcare fails to provide the necessary level of service it requires. “Healthcare being a space that is what you would consider customer-facing, you are dealing with people every single day. And what those people look like and what they bring to the table is shifting at a much quicker pace than in other industries,” Soluade says. “At its very core, you want to get to the ability to connect with a person as an individual. So, if you’re holding on to some sort of bias, you automatically have a barrier in place that prevents that connection from being able to fully happen. It’s something you can’t see because you choose not to or never pay attention to it, and you may wonder why you don’t connect. It’s like this wall in front of us that we don’t want to examine too closely.”
, senior partner for education and healthcare practices at Witt/Kieffer, says demographics across the country are changing so rapidly that organizations have no choice but to embrace diversity and inclusion to stay competitive in the marketplace. “You’re going to have to be able to connect with your customer or patient base,” Tomlin says. “The best way to do that is to have your workforce also reflect the demographics that you’re serving.”
Institutions need to know about the populations they are serving and develop strategies that best serve them. “Your demographics see that you’re reflecting their values and community, and they have a comfort level of trust,” Tomlin says. “Internally, your competitive knowledge and understanding helps you in appealing to the population base you’re trying to attract.” Part of this is making sure you have a diverse workforce that reflects your patient demographics, and that the organization is set up to help patients in the ways they need to be helped.
“It really is a complex and dynamic set of issues we have to deal with today in health care that makes this imperative,” Tomlin says. “If you’re not growing and you don’t understand diversity and inclusion and the global nature of health care, you can cease to be relevant pretty quickly,” Gueits says. “It is the nature of the world that we’re living in. More organizations are under constraints to do more with less. You have to be strategic and identify thought leaders in your organizations who can really integrate the work of diversity and inclusion.”
For those that don’t have it already, Tomlin says one of the best things organizations can do is to create an office of diversity and hire a chief diversity officer who serves as the point person and strategist for the organization.
“There should be a chief diversity officer who people turn to and say, ‘If we do this, what are the implications to our diversity and equity?’” Tomlin says, adding that he or she should have a seat at the table with other top-level executives. “You need somebody with that same level of involvement that you would provide to the chief financial officer or chief nursing officer.”
Organizations can have a wide range of programs within a diversity and inclusion initiative—there is no singular solution.
“At one extreme, it could be as simple as developing diversity supplier initiatives to engage the community—minority vendors, for example—in purchasing products and supplies for the institution,” Tomlin says. “At the other extreme, it could be as complex and esoteric as developing programs that specifically address healthcare disparities on an interdisciplinary level, meaning not simply develop a diabetes program but programs for large groups of people using a team approach.”
To offer more developed programs, however, Tomlin says the organization must understand the community it is serving. “One size does not fit all anymore; we know that,” Tomlin adds.
Gueits says it’s important in her role to act as a compass for the organization, working to reach what the institution as a whole has identified as its North Star. She works with other leaders at the Cleveland Clinic to identify goals, then incorporates messages of diversity and inclusion into the fabric of the entire organization, not just in programs specific to diversity and inclusion.
These include patient access, supplier diversity, marketing, community outreach, talent acquisition programs, education and training for caregivers, language-enrichment programs, and resources that include a calendar of events that addresses culturally diverse events and observations across the enterprise.
Gueits says the organization places a lot of focus on determining what is best for patients and making sure the “patients first” mantra drives every decision. To support this, they have created staff-development and education programs to share the vision across the enterprise. Many times, language to support diversity and inclusion is embedded into other programs to ensure continuity and share the message that diversity and inclusion belong in every aspect of health care. “Sometimes because people don’t see the term ‘diversity and inclusion’ in a program, they might not automatically recognize that as such,” Gueits says.
The Timing of Change
It’s an important time to address these concerns, Tomlin says. Not only are demographics rapidly changing, but cultural and political trends have increased tension.
“What’s going on right now politically has raised anxiety levels across the country,” Tomlin says. “That creates an even stronger argument for this position of a chief diversity officer in all organizations at the senior level that can really have an impact. We need to be more proactive than reactive.”
Gueits agrees but says there are always challenges to diversity and inclusion that organizations must face; the key is to keep moving forward. “We’re learning as we go,” she says. “I think we’ve made tremendous progress. There are things that happen in society that slow us down for a little bit, but we have to define strategies that help address that so at the end of it, we all come out better than where we started from,” she adds.
But diversity and inclusion also aren’t issues that can be solved in pockets of the population or by one-time initiatives—especially not in the healthcare industry. They are evergreen, evolving, and universal concerns that have far-reaching effects.
“Health care affects everyone; it’s not like you’re making widgets,” Tomlin says. “If people are not getting adequate health care, they are not being included in population health management, and it’s going to affect all of us.” Proactive programs help to prevent disease, save healthcare dollars, improve outcomes, and help patients feel more welcome to receive the care that is available to them, he says.
“It’s got to evolve beyond the training that we’re requiring you to do, and that’s where the conversation ends,” Soluade adds. “It’s now getting into this space where there were things we didn’t talk about in the workplace and now we need to.”
The problem of disparity in health care is not new, but it also hasn’t been adequately solved. It wasn’t until 2002 that the federal government began to research health disparities across different ethnic, racial, and social groups. When outcomes showed the level of disparity, the work started—but there is still much to be done.
“It’s sobering that we’re in 2017 and we’re still dealing with disparities and gaps in health care. These things still exist and are pretty insidious,” Gueits says. “You have to invest in the education, and you have to have a sense of humility about the work and where you want to be, but also prepare yourself to have a long road ahead of you because this work is never complete. It’s a moving target. You have to have a pulse of what’s going on and some sort of strategy to mitigate those biases as much as you can.”
Rachael Zimlich, RN, is a healthcare writer from Cleveland.