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Cultural Competence and Proficiency Chapter Objectives After reading this chapter, you should be able to 1. Employ cultural competence in healthcare management systems. 2. Examine the effects of diversity on healthcare management. 3. Explain the role that organizational culture plays in healthcare facilities. 4. Apply diversity management and cultural competence when managing a healthcare organization. 3 © iStockphoto/Thinkstock Cultural Competence and Proficiency Chapter 3 In the 1980s, many American companies encountered competition from entirely new sources in regions they had previously dominated—primarily foreign and especially from Japan.

Firms such as Sony, Toyota, and Honda gained inroads into various consumer markets. One explanation for the successes of these and other companies was that each organization’s unique culture provided a competitive edge. For example, Japanese business practices, such as lifetime employment, combined with a more collectivist national culture, contributed to their advantage over companies in other countries.

As the role of culture in business began to receive greater attention, a great deal of confusion surfaced. The essence of the misunderstanding arose from two issues—definitional and the level of analysis. The Merriam-Webster dictionary provides several definitions of culture, including:

“the act of developing the intellectual and moral faculties especially by education;” “the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations;” and “the set of values, conventions, or social practices associated with a particular field, activity, or societal characteristic.” Like Chapter 1’s case of an elephant described by blind followers, each definition points to a different aspect of a term with numerous uses.

When considering the level of analysis, the first step is to determine whether the concept of culture is being applied to an entire nation, a region, a set of people (such as one defined by race or religion), or a specific organization. From a managerial and healthcare perspective, culture should be considered at all levels.

The United States has become increasingly diverse—a trend that can only be expected to con - tinue. National culture matters in healthcare, because increasing diversity influences patient demographics and the composition of the workforce that will be employed by various organiza - tions. Organizational culture matters because each operating unit, such as a hospital or walk-in clinic, features a unique environment, which, in turn, constrains managerial decision making and behaviors.

Chicago, Illinois, provides an example of the influence that a community’s culture can have on the cultures of healthcare organizations. Chicago has the unfortunate reputation of being a city hard-hit by gun violence. The problem has taken a toll in a variety of ways. In July 2012, 144 American soldiers were killed in Afghanistan. In the same month, 228 Chicagoans died of gun - shot wounds; many were school age or teenagers (Lee, 2012).

Then, there are financial costs. Roseanna Ander, an executive with the University of Chicago Crime Lab, commented on the high costs associated with law enforcement, court cases, and hospital stays resulting from gun violence. There are considerable indirect costs as well, a result of individuals and businesses leaving Chicago because of the crime. By Anders’s estimates, these combined costs amount to $2.5 billion per year, or $2,500 for each household (Lee, 2012). In Chicago and other major cities, gun violence may be the result of a perfect storm. The components of the storm include a lucrative marketplace for gun traffickers, reduced enforcement of current gun laws, poverty, fewer mental healthcare facilities and options, and smaller police forces.

Gunshot injuries place a great deal of stress on local healthcare systems. Emergency rooms continually treat those who have been shot, taking away time from helping others. Due to the numbers of incidents, hospitals have responded with improved methods of transporting victims (helicopters instead of ambulances), improved training programs for first responders, and more physicians on staff specializing in the care of gunshot victims. The Essence of Cultural Competence and Proficiency Chapter 3 Although much of the national debate regarding gun safety has focused on gun magazine clips that hold a high number of bullets and assault weapons, the majority of gun injuries result from handgun shootings. Police forces, local governments, and healthcare providers continue to wrestle with the situation. As it stands, gun violence in communities such as Chicago creates a difficult clash between a local culture and the culture present in various hospitals and healthcare facilities.

This chapter examines cultural competence and proficiency. The first section briefly reviews the essence of the concept of cultural competence. The next section explores the subject of diver - sity, which affects both geographic regions and individual organizations. Finally, the chapter dis - cusses diversity management programs and cultural competence with regard to patient care and the operation of a healthcare organization.

3 .1 The Essence of Cultural Competence and Proficiency The term cultural competence applies to a variety of environments, situations, and individuals.

The National Center for Cultural Competence (n.d.) defines the term at the organization level:

organizations that exhibit cultural competence (or proficiency) follow a “defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them [persons in the organization] to work effectively cross-culturally.” At the individual level, Cross et al. (1989) viewed cultural competence as a “set of congruent behaviors, attitudes, and poli - cies among professionals that allow an agency, system, or organization to work effectively in cross-cultural situations.” In healthcare, the Joint Commission on Accreditation of Healthcare Organizations described a culturally competent healthcare organization as one that is “vigi- lant for ethnic disparities in screening, prescriptions, procedures, and health outcomes and has policies and procedures in place to address any disparities found” (quoted in McDaniel, 2000).

These definitions outline the nature of cultural competence at all levels. The perspectives identify cultural competence in terms of the following:

• Awareness of diversity • Identification of cultural disparities in healthcare • Creation of programs designed to address disparities • Individual behaviors associated with cultural sensitivity and proficiency The nature of cultural competence begins with awareness of the various forms of diversity within an organization’s boundaries, as well as the effects of local demographics and national and inter - national trends. Medical care transcends borders of all kinds. Thus, culturally competent indi - viduals, managers, and organizations can note the impact of culture on their operations.

In medical care, substantial attention must be paid to cultural disparities with regard to treat - ment and care. The National Institutes of Health (2013) defined health disparity as a circum- stance in which a distinct populous encounters a significant or great difference in the overall rates of disease incidence, morbidity, or mortality when compared with the health status of the general population. Health disparity reflects significant differences in access to healthcare, the quality of that care, the overall environment, and health outcomes for specific groups. Culturally compe - tent individuals and organizations are acutely aware of health disparities such as the following:

• Infant mortality • Diabetes The Essence of Cultural Competence and Proficiency Chapter 3 • Heart disease and stroke • Cancer • Mental health • Eye disease • HIV and AIDS Beyond recognizing diversity and disparity, culturally competent physicians, collectives of doc - tors, and managers in the healthcare system seek to create programs designed to address dispar - ity issues. Some of these programs are described later in this chapter.

Finally, in many ways, cultural competence comes down to individual actions. Each person can improve cultural sensitivity processes by realizing that culture evolves over time. This means cultural competence requires continual updating. A culturally proficient individual contributes to the well-being of the healthcare community by influencing those in a specific organization, members of the community, and the larger healthcare system.

With regard to the practice of management, culture affects managerial behaviors and decision-making processes at every rank. A manager in any organization adapts to the culture of the nation in which he or she is employed, to the culture of a region within that country, to various cultural character- istics displayed by members of the organiza - tion, and to the culture of the organization itself. Culture dictates what a social group values and what members of that group believe are the proper methods to achieve individual and organizational goals. In essence, managers require cultural compe - tence to succeed.

Culture competence, or the lack thereof, has both legal and moral implications. Legal issues include potential claims of discrimination in treatment of patients or in employment practices.

A healthcare organization that systematically excludes or discriminates against members of pro - tected categories may be in legal jeopardy for such practices. Furthermore, healthcare, at its core, has a basis in fair and equitable treatment of all. As a matter of moral and ethical standing, cul - tural competence, reductions in healthcare disparity, and equal opportunity represent important issues for healthcare managers to consider and address.

Philosophically, a case can be made that cultural competence represents the best in a society.

From this perspective, a collective of people that understands how culture shapes the words and deeds of others and that respects those differences creates a more civil environment. Cultural understanding reduces unnecessary conflicts. It also has the potential to create harmony among those with different characteristics.

Thus, cultural competence is of unique importance in healthcare. The coming sections explore how increased cultural competence identifies healthcare disparity and seeks to reduce it for dis - advantaged groups. Cultural competence can also result in better care for all citizens and foster an improved work environment for those who serve in the healthcare industry. © Fancy Collection/SuperStock ▲ ▲ Cultural competence arguably should be one of society's highest aims. Diversity Demographics and Healthcare Disparity Chapter 3 3.2 Diversity Demographics and Healthcare Disparity Over time, the culture of a nation, region, identifiable or distinct group, or organization can be affected or reshaped by increasing diversity. Managers in all types of organizations, including healthcare operations, are expected to understand and adapt to the effects of diversity, in terms of the changes it presents to everyday procedures and the effects it has on the agency’s culture.

The term diversit y describes a spectrum of differences between people. At the individual level, the categories used to describe diversity include race, ethnic background, nationality, age, reli - gion, gender, sexual orientation, disability, socioeconomic status, and occupational role, along with combinations of those and other factors. Diversity concepts apply to individuals, groups, and organizations. For example, a woman veteran (an individual) might feel uncomfortable seeking care at a veteran’s hospital (an organization) that is staffed predominantly by men. Similarly, from a manager’s perspective, diversity is important to consider when soliciting feedback or forming committees, as doing so ensures a desirable range of opinions.

One of the more common problems associated with diversity is stereotyping, which occurs when someone applies assumed (and often inaccurate) averages or characteristics to every indi - vidual in a group. For example, among the more negative stereotypes targeted at Hispanics are a lack of punctuality, higher levels of absenteeism, and the inability to plan and schedule work (Banach, 1990). When physicians, healthcare managers, or coworkers make these false assump - tions, the workplace becomes divisive and unpleasant.

An example of a stereotype that affects patients occurs when employees of a healthcare facility assume minorities do not have health insurance; as a result, the quality of care that is provided suffers. Culturally competent healthcare providers work diligently to combat such problems and perceptions. The following sections consider diversity factors, health disparities, and ways in which healthcare staff can address disparities and prevent stereotyping.

Race, Ethnicity, and Nationality Diversity issues associated with race, ethnicity, and nationality have long existed. Each generation of Americans has experienced an influx of groups of individuals from other countries. One issue that poses a major challenge is language. When employees in a healthcare organization encoun - ter patients from other cultures, there may be issues with communication of proper care. For example, individuals whose primary language is Spanish may struggle with misunderstandings and other problems associated with English.

Healthcare supervisors who do not speak Spanish may encounter a similar difficulty, in terms of both assisting patients and managing Hispanic employees. Thus, bilingual managers and staff offer a valued resource to companies in regions that have more diverse populations. In addition to seeking multilingual staff, managers in healthcare organizations must ensure that non-English- speaking patients are provided with an interpreter who can explain procedures at an eighth- grade level of understanding in order to avoid legal and ethical repercussions. These services are provided at the expense of the organization, which does not receive reimbursement.

According to the U.S. Census Bureau (2013), three of the largest minority groups in the United States are Hispanics, African Americans, and Asian Americans. Statistical racial composition profiles are somewhat skewed, however, because experts do not consider “Hispanic” to be a race.

With that caveat in mind, Figure 3.1 identifies the composition of minorities and the majority in the United States. Diversity Demographics and Healthcare Disparity Chapter 3 Figure 3.1 Ethnic composition of the United States, 2011 statistics f03.01_HCA340 Caucasian/Anglo(not Hispanic) 64% Hispanic 16%African American 13% Asian American 4% Other 3% Source: U.S. Census Bureau, 2013.

Hispanics The term Hispanic is often applied to a set of individuals with common characteristics, including Spanish as a primary language, the Catholic religion, and ancestry in former colonies of Spain.

In the United States, about 60% of Hispanics are of Mexican heritage, 12% are from Puerto Rico, and 5% are from Cuba. Spanish surnames and customs are found in Spain, Mexico, Cuba, Central America, South America, and Guatemala.

A variety of health disparity issues affect the overall Hispanic population. In 2010, the per - centage of Hispanics lacking health insurance was 30.7% (Centers for Disease Control and Prevention, 2012a). Historically, Hispanic individuals in the United States were prone to higher rates of various forms of cancer when compared with U.S. Caucasians. Smoking rates, strokes, liver disease, obesity, and mortality rates were also all higher than the same comparison group.

In addition, Hispanic women were less likely to receive prenatal care (Office of Minority Health, 2004).

African Americans Approximately 11% of the U.S. workforce is African American. The 2008–2009 recession dra - matically affected employment statistics of African Americans, who suffered disproportionate job losses relative to the larger population. Some people view this as evidence that discrimination and an unfair playing field continue to occur.

Healthcare disparities are starkly evident in statistics related to HIV. In 2002, African Americans who died from HIV lost, per 100,000 persons, about 11 times as many years of potential life before age 75 as did Caucasians. African Americans also lost considerably more years of potential Diversity Demographics and Healthcare Disparity Chapter 3 life than did Caucasians as a result of homicide, stroke, perinatal diseases, and diabetes. (Office of Minority Health, 2005).

Asian Americans Asian Americans also originate from a variety of countries representing a multitude of diversity factors, including culture, language, and socioeconomic levels. As a group, Asian Americans con- stitute about 4% of the U.S. population.

Native Americans As of the 2010 Census, the nation’s population of American Indians and Alaska Natives, includ - ing those of more than one race, made up 1.7% of the total population (U.S. Census Bureau, 2011a). Of this total, 2.9 million were American Indian and Alaska Native only, and 2.3 million were American Indian and Alaska Native in combination with one or more other races. Health disparity issues continue for Native Americans at alarming rates (Roubideaux, 2004). WEB FIELD TRIP For a more in-depth look at specific health issues facing different racial and ethnic groups, visit the Minority Health website at ht tp: //

Under the “Data/Statistics” tab, select “Data by Health Topics.” • Which groups are most susceptible to childhood asthma?

• What are some of the potential causes of chronic liver disease? Which groups are most affected by chronic liver disease?

• What are some of the reasons that minorities make up 56% of the organ donation lists, and yet are the recipients of only 34% of actual donations?

• Clicking through some of the other health issues, what other trends do you see? How do you think these disparities can be addressed? Gender Women make up more than half the workforce in the United States. About 45% of the U.S.

workforce consists of two-income families in which both spouses work (U.S. Department of Labor, 2013b). Female physicians constituted about 34% of all doctors in 2011 (Bureau of Labor Statistics, 2012a). Issues of marriage, child raising, career development, and work–life balance persist for both men and women, and these issues carry over into the healthcare system.

In the United States, many women postpone marriage in order to begin careers. Numerous careers are then interrupted by either having children or deferring to a spouse’s career path.

Women seeking to become physicians often encounter this issue, though by 2011, nearly 48% of first-year medical students were female (Knowledge Center, 2012). Only a few hospital and major healthcare facilities have responded to these challenges by offering on-site day care, job sharing, and other programs.

Many sources that examine the concept of diversity only consider women as the unique part of the workforce. A more expansive view seeks to understand how gender roles and interrelation - ships between men and women can either cause problems and complicate organizational life or serve as an advantage for the company. For example, family-friendly hospitals find it easier to Diversity Demographics and Healthcare Disparity Chapter 3 recruit and retain quality employees. Numerous studies regarding patient care have compared satisfaction levels with female versus male physicians (Chen, 2010), with mixed results.

Age By 2006, the average age of the U.S. workforce had reached 40 (Gomez-Mejia, Balkin, & Cardy, 2005, p. 475). The trend toward an increasingly older work population began to decline in this century, as some members of the Baby Boomer generation entered retirement. The 2008 eco- nomic downturn slowed the number of individuals who could afford to retire, however, further complicating the workplace environment.

Age differences can complicate not only the healthcare manager’s role but also a practitioner’s standing in a healthcare organization. Senior workers often hold the greatest level of experience and can teach and mentor younger employees. Although physical strength and endurance are not required in most of the services sector in the United States, the situation may be different in the healthcare industry. Many physicians, surgeons, nurses, and other healthcare employees work long shifts and long hours each week, which some older workers may find challenging.

Unfortunately, age may not be respected in many organizations, including those providing health - care. Companies employing large numbers of senior workers experience rising health insurance costs. Most of those same workers have also accumulated longer vacation packages and sick leave days. Longer vacations and days set aside for a lengthy recovery from a medical issue remove the employee from the workplace, and others will be required to pick up the slack. Some managers might notice resentment directed at those who are away for longer periods of time.

Age diversity also affects younger workers. Some may become frustrated by the inability to move up the career ladder because senior managers stay on the job past the traditional retirement age.

Younger employees might express frustration that their newer, more cutting-edge skills are not fully utilized. Healthcare managers should monitor and respond to these potential rivalries. For example, progressive companies include senior employees in formal mentoring programs and strategy sessions (Cadrain, 2008).

Religion Matters of religion have affected interactions among citizens for centuries. In the 1960s, concerns were expressed that President John F. Kennedy was Roman Catholic. The events of September 11, 2001, caused members of the Islamic faith to become targets of hostility in some parts of the media, in local communities, and in the workplace. As time passes, however, the hope is that greater cultural integration will include a reduction in such religious divisions.

As a matter of law, employment discrimination based on a person’s religion is prohibited. In practical terms, religious intolerance creates a hostile workplace, making it difficult to work effec - tively. Ethical managers seek to reduce these tensions and create understanding among employ - ees with diverse religious beliefs. Table 3.1 presents the 10 largest denominations in the United States and the largest general affiliation categories. Note that Islam represents less than 1% of the U.S. population.

In healthcare organizations, the role of religion leads to additional complications. Many hospi - tals have roots or continuing ties with religious denominations—most notably, but not limited to, Catholicism. Opposition to various birth control methods and abortion services has led to conflicts among the hospitals, insurance companies, and the federal government. Likewise, Diversity Demographics and Healthcare Disparity Chapter 3 many nursing homes are affiliated with religious organizations. End-of-life decisions are of particular concern to managers in these circumstances, where various directives must be completed by patients and residents. Healthcare managers are expected to cope with these controversies.

Table 3.1 Religious denominations Top 10 denominations 1. Roman Catholic Church 2. Southern Baptist Convention 3. United Methodist Church 4. Church of Jesus Christ of Latter Day Saints 5. Church of God in Christ 6. N ational Baptist Convention 7. E vangelical Lutheran Church in America 8. N ational Baptist Convention of America 9. P resbyterian Church 10. A ssemblies of God Top affiliations 1. Christianity 2. Jewish 3. Agnostic or atheist 4. Other Source: w w , retrieved June 16, 2011. Copyright © Sexual Orientation In 2010, repeal of the “don’t ask, don’t tell” policy regarding members of the military took place in the context of a continuing national debate regarding the rights of the lesbian, gay, bisex - ual, and transgender community. Issues surrounding this issue include the ability to marry and live together with the same rights as heterosexual couples, including hospital visitation, access to health insurance coverage, and inheritance rights. These issues may not be resolved in the near future.

In the workplace, intolerance of persons with differ - ing sexual orientations persists. Gay slurs continue to make headlines in the worlds of entertainment and sports. Debates then move to other places, including the office. Managers are expected to cope with defam - atory statements and try to instill a basic measure of respect toward others, regardless of these differences.

The same holds true in the treatment of nonheterosex - ual patients in hospitals and other healthcare facilities.

Persons with Disabilities A disability represents diversity in the sense that it is a distinguishing characteristic. The Americans with Disabilities Act of 1990 covers the basic rights of individuals with disabilities. The Equal Employment Opportunity Commission takes further steps to help those with special needs in the workplace. Many busi - ness organizations have taken dramatic steps to help accommodate those with disabilities who wish to work. © George Doyle/Stockbyte/Thinkstock ▲ ▲ Statistics indicate that disabled workers are less prone to absenteeism and turnover than other employees. Culture and the Healthcare System Chapter 3 By 2012, approximately 17 million disabled U.S. citizens were employed (U.S. Department of Labor, 2013a).

Statistics indicate that disabled workers are less prone to absenteeism and turnover than other employees (Hasse, 2010). Managers must remain aware that disabled workers can make others feel uncomfortable or may feel isolated or patronized in many working situations. Therefore, increas- ing sensitivity toward disabled workers remains an important goal in many companies.

One response to assisting disabled workers has been the imple - mentation of telecommuting positions for those less able to travel, especially in the areas of patient diagnostics and the preparation of health insurance claims. These and other inno - vative approaches can become part of an overall diversity man - agement strategy in a healthcare setting. Managerial Employment Opportunities In terms of employment opportunities, one of the more com - monly noted problems—the glass ceiling —occurs when women find it difficult to advance into management positions.

Unfortunately, the pattern persists in many healthcare organi - zations. Historically, women and members of minority groups have been vastly underrepresented in management positions.

Managers who fail to address this issue miss the opportunity to enrich the pool of potential physicians, medical profession - als, and managers, as well as the potential to build better rela - tionships with local communities (Weil, 2009). For example, in some places, mentoring programs and other systems have been designed to reduce the problem.

Medical care professionals and managers are expected to respond to these and all other diversity challenges in proactive, positive ways in order to satisfy legal, ethical, and social demands presented by the community, government, and other organizations. Culturally competent healthcare organizations develop programs to recruit, train, and promote minority members. They also work to provide care for as many minority members as possible. The next section addresses issues of culture and cultural differences as they apply to the healthcare system. 3.3 Culture and the Healthcare System As noted at the outset of this chapter, conceptualizations of cultural can create confusion. Unless the level of analysis has been clearly outlined, observers may or may not be describing and dis - cussing the same issues when they talk about culture. In addition to organizational culture, dis - cussed in detail in the following section, three levels of cultural analysis are:

1. Culture of an identifiable group (diversity) Section 3.2 analyzed the impact of diver - sity on healthcare disparity problems and on employment. Race and nationality, gender, age, sexual orientation, and physical disabilities may be used to define diversity categories. © Jupiterimages/Creatas/Thinkstock ▲ ▲ Minority members and females are often underrepresented at managerial levels in healthcare organizations. Culture and the Healthcare System Chapter 3 Organizational responses to these groups should be adapted to the specific needs and issues of each group and individuals within the group, depending on the situation. 2. National culture The culture of a country influences individual organizations and indi- viduals within that nation’s boundaries. As described in Chapter 1, political, social, eco - nomic, technological, and competitive environments all shape organizational activities and responses to new trends. The social trends currently affecting a national culture include an increasing population, increasing life expectancies and the aging of the population, and population shifts to urban areas and specific geographic regions. Cultural and subcultural trends also include an increased emphasis on prevention and treatment of sexually transmit - ted diseases, persons reaching puberty at an earlier age, an ever-changing popular cul - ture, and various lifestyle choices made by large segments of the community. These trends continue to challenge the healthcare system in as many ways as political shifts and other forces do. 3. International cultural concerns Cultural competence and proficiency apply equally well to diversity issues within a nation’s boundaries and to organizations conducting opera - tions internationally. In medical care, boundaries often limit a physician’s ability to provide care in other countries, except for instances in which the physician volunteers his or her time, such as the Doctors without Borders program. At the same time, some patients travel across national boundaries to gain access to care they cannot receive in a home country. For example, many U.S. citizens living near Canada or Mexico traverse national boundaries to purchase prescription drugs at lower costs. Similarly, some Canadian citizens travel to the United States or other nations to receive medical care in various forms. In addition, some medical procedures are essentially “outsourced” to other countries. In the future, it would not be surprising to encounter an increasingly multinational approach to healthcare. Organizational Culture The healthcare system may experience many profound cultural effects at the organizational level.

Organizational culture consists of a set of shared meaning and values held by a set of members in an organization that distinguish that organization from others and that determine how that organization perceives and reacts to the larger environment (Schein, 1996; Becker, 1982). Culture also determines the nature of an individual’s experience in an organization in both profit-seeking companies and nonprofit enterprises. Some common cultural characteristics of an organization include:

• Degree of encouragement of innovation and risk taking • Attention to detail and precision • Outcome orientation (rather than processes or techniques orientation) • People orientation • Team orientation • Level of aggressiveness and competitiveness • Emphasis on stability and the status quo Culture represents a relatively fixed element of daily life in an organization. Culture reflects the organization’s history and may be summarized as symbols, rituals, language, and social dramas— including myths, stories, and jargon—that highlight organizational life (Smircich, 1984). Symbols include the Golden Arches at McDonalds, a Star of David in a hospital with Jewish support, or a Culture and the Healthcare System Chapter 3 cross reflecting an affiliation with the Catholic Church. Culture also consists of shared meanings associated with those symbols, rituals, and language; it combines the philosophy of the firm with beliefs, expectations, and values shared by members. Culture often begins with and relies on sto- ries and myths about the company’s founder and its current leading figures—in other words, the firm’s heroes and heroines (Gordon, 1993; Schein, 1985).

At the same time, organizational culture should not be considered as having only one dimen - sion. Instead, culture can divide into additional viewpoints, actions, and activities. The dominant culture articulates the core values shared by a majority of an organization’s members. A subcul- ture , in an organizational context, refers to the common values, problems, situations, and experi - ences that a set of members faces. An organization with a strong culture employs members who intensely hold and readily share the organization’s core values. Strong cultures are readily evident in military, religious, and healthcare organizations with rich histories and traditions.

Functions of Culture An organization’s culture provides many important functions that can improve not only the organization’s efficiency but also the employment experiences of individual workers. In any medi - cal facility, the organization’s culture shapes both internal and external perceptions of its opera - tions. Culture makes an organization distinct, creates a sense of identity, builds a strong social system, and helps employees “fit in.” Each of these functions applies to healthcare (Baack, 2012).

Culture Makes the Organization Distinct Culture creates identifiable differences among organizations. These distinctions attract some people to join an organization and encourage others to go elsewhere. This idea also extends to patients, other organizations, and even the government. Possibly one of the most notable examples of a distinct healthcare facil - ity would be the Mayo Clinic, which enjoys widespread acclaim across the United States. The Mayo Clinic assigns teams of pro - fessionals to each patient. The teams work collaboratively to provide a holistic assessment of the individual’s health status, along with all forms of recommended care. This approach sets the clinic apart from many other hospitals and healthcare oper - ations, in which individual physicians and medical personnel sequentially tend to a patient’s care (in individual silos of care), rather than working as a collective group.

Thus, in any local community, a progressive hospital that is family-friendly and welcoming to members of minority groups would create organizational distinctiveness, and its culture would distinguish it from other organizations.

Culture Creates a Sense of Identity Hospitals and other healthcare organizations with strong cul - tures are most inclined to engender a sense of identity in organi - zational members. Many physicians contract to practice in more than one hospital, which often limits any sense of identity in that group. Instead, the sense of identity primarily rests with nurses and other workers serving under only one employer. © Alvis Upitis/Purestock/SuperStock ▲ ▲ A unique culture makes the Mayo Clinic distinct from other healthcare facilities. Culture and the Healthcare System Chapter 3 Culture Builds a Strong Social System Culture has been compared to social glue that helps hold an organization together. As people join various organizations, they learn how to promote themselves and become more fully aware of how each organization operates. The social system explains the “rules of the game,” including what are acceptable and unacceptable behaviors in terms of patient care, relationships among employees and physicians, and other internal activities. Social dramas occur when norms and rules are violated, such as when others discover that a physician has prescribed unnecessary pain medications. Rewards and promotions accumulate to those who follow the rules and play the game as expected (O’Reilly & Chatman, 1996).

Culture Helps Employees “Fit In” When an individual joins an organization, he or she learns its lingo and may, over time, more strongly accept the institution’s core values. Understanding and adapting to a culture can assist in building a successful career. For example, the practice of defensive medicine, in which physicians employ diagnostic or therapeutic measures not necessarily to ensure the health of the patient but as a safeguard against possible malpractice liability , may be commonplace in one hospital but not in others (Panting, 2005). Nonphysician employees will most likely quickly understand whether this practice exists in a medical facility.

The medical profession has many strong mores and dictates, beginning with the Hippocratic oath, which contains provisions regarding relationships with patients, administration of medi - cine and surgery, and issues regarding patient privacy. In nursing homes, issues regarding end- of-life decisions often become a major component of each organization’s culture. Methods and decision-making procedures are quickly transmitted to new employees and to loved ones of patients, thereby assisting all in fitting in to the organization’s constraints.

Layers of Culture Just as people have layers to their personalities, layers may be found in the personality of an organization. Some characteristics of an organization’s culture can be readily observed, whereas others remain more subtle and hidden. Three levels of culture interact with one another and influence behaviors in organizations: observ - able artifacts, espoused values, and enacted values.

Observable Artifacts Artifacts include the physical signs of an organization’s dominant culture. In healthcare, numerous artifacts appear, beginning with white coats, hospital gowns, stethoscopes, and other readily observ - able indicators of the nature of the organization. Physician offices and other medical practices share many similar characteristics, including waiting rooms and walled-off space designed to ensure patient privacy during examinations and consultations. Hospitals with religious affiliations, whether current or historical, often dis - play symbols in the building’s entry area. In essence, a person often quickly understands when he or she enters a religiously affiliated healthcare facility because of the presence of observable artifacts.

These, in turn, influence employee behaviors and attitudes. © DreamPictures/SuperStock ▲ ▲ Observable artifacts indicate the nature of an organization’s culture. Culture and the Healthcare System Chapter 3 Espoused Values Espoused values are the explicitly stated values and norms found in organizations. Healthcare organizations routinely provide such statements in a variety of forms, including public state- ments of mission; in advertisements; and in speeches made by organizational leaders. These same values are normally strongly reinforced in internal meetings, especially since such organizations are often characterized as having strong cultures.

Enacted Values The values and norms exhibited as employee and managerial behaviors, such as a physician care - fully documenting every medical procedure or a nurse recording patient statistics, are enacted values. Enacted values also include statements of loyalty (e.g., “this is a great place to work”) made to insiders and outsiders that reflect the person’s commitment to an organization The combination of observable artifacts, espoused values, and enacted values can create role clarity for an employee. Role clarity exists when a person has a clear understanding of his or her function in the organization and how to complete all assigned tasks. In essence, role clarity means, “I know what I’m supposed to be doing.” The reminders that come from seeing observ - able artifacts, hearing espoused values, and carrying out enacted values generates a greater sense of clarity.

Forms of Culture Culture can take several different forms within an organization. Employees in a clan culture enjoy positive relationships with peers. In healthcare, a highly collaborative organization, such as the Mayo Clinic, would attract physicians with an interest in this form of medical practice. The culture would then extend to other members of the organization.

Employees in a hierarchy culture quickly learn that rules and procedures are important.

Healthcare organizations with assertive management teams, as well as organizations in which physicians dictate the degree to which protocols are enforced, are examples of a hierarchy cul - ture. Nonmedical employees in such organizations must quickly follow suit.

In an adhocracy culture , trying something that does not work out will have different conse - quences than it would in other organizations. Hospitals that seek to provide the most cutting- edge forms of medical care, including experimental procedures, tend to reward persons who identify and carry out innovative approaches.

In a market culture , pay raises, promotions, and rewards are likely to be based on visible perfor - mance measures related to service quality. Patient care and other operations within the organiza - tion are clearly influenced by such an emphasis.

Table 3.2 displays the various forms of culture. Logically, healthcare facilities tend to adopt just one of these forms, and the impact of this adoption on staff should be readily apparent.

Over time, employees find out how the healthcare organization works, what is acceptable, what is rewarded, and what is punished. Questions, answers, myths, stories, and jargon all become part of the organizational experience. When the person’s own personality matches the organizational type, the fit produces the best chances for individual success. Culture and the Healthcare System Chapter 3 Table 3.2 Forms of culture Culture typeCharacteristics Clan • Internally focused • Family-type • High levels of collaboration • Emphasis on involvement, commitment, consensus • Decentralized management Hierarchy • Internally focused • Driven by strong control mechanisms • Standardized rules • Formal procedures • Centralized management • Stable • Inflexible Adhocracy • Externally focused • Values flexibility • Emphasis on innovation • Encourages risk taking • Decentralized management Market • Strong external focus • Driven by competition • Values stability and control • Customer centered • Centralized management Source: Adapted from K.S. Cameron, R.E. Quinn, J. Degraff, and V. Thakor (2006). Competing values leadership. Northampton, MA: Edward Elgar Publishing. CASE The Reunion Joan Lawson, Mark Ramirez, Albert Renfro, and Chien-Hui Shieh became board-certified physicians in 2009. They were part of a cohort group that graduated from the University of Eastern Missouri's medical school. At the most recent class reunion, they reminisced about the nature of their training while there. They recalled extremely long hours (such as 24-hour shifts), “scut” (menial) work, com - petitive rankings against peers, and basic fears of attending physicians. All four confessed to having had major worries about “killing” a patient with a wrong diagnosis or treatment program. (continued) Diversity Management and Cultural Competence Chapter 3 3.4 Diversity Management and Cultural Competence Cultural competence and proficiency should be viewed as an ongoing process, rather than as a static, one-time activity. As the composition of the population changes nationally, regionally, and locally, healthcare managers should expect to adapt over time. Although many of the elements of a culture remain highly fixed (white lab coats, the Hippocratic oath, an emphasis on patient privacy), the impact of diversity and gradual cultural shifts over time will continue to affect the delivery and management of healthcare. After graduation, Joan moved to an acute care hospital, which provides patients with hospital care after surgery or treatment of severe illness or injury. Such a hospital requires highly specialized per- sonnel and frequently involves the use of sophisticated and multifaceted technical equipment. One continuing goal of Joan’s organization involves helping patients become able to care for themselves so they can be discharged. Acute care is nearly opposite from chronic care, or longer term care.

Joan works with teams of physicians and technicians who assist in managing each case.

Mark, who has Mexican ancestry, began service in a public health agency. He views public health as an exciting and growing field that challenges its professionals to confront complex health issues, such as improving access to healthcare; controlling infectious disease; and reducing environmental hazards, violence, substance abuse, and injury. Mark believes that the public health field seeks to serve others. Public health professionals come from varying educational backgrounds and can spe - cialize in an array of fields and serve local, national, or international communities. A host of special - ists, including teachers, journalists, researchers, administrators, environmentalists, demographers, social workers, laboratory scientists, and attorneys, work together to protect the health of the public. The field offers great personal fulfillment for Mark as he works toward improving people’s health and well-being on a daily basis.

Albert developed his own private practice as a family practitioner in a small town in Georgia. He sees patients with a variety of infirmities and provides wide-ranging care. His challenges include hiring and maintaining an effective support staff, which consists of one nurse, one laboratory spe - cialist, a receptionist, and an insurance professional. His work includes managerial and supervisory duties, in addition to providing medical care. He has visiting privileges at the local hospital and makes a point of seeing patients who stay more than one day in the facility.

Chien-Hui provides physician care in a relatively large nursing home. The organization has nearly 100 beds and operates at full capacity. His practice involves a Monday– Friday schedule, though he occasionally visits on the weekend. He cares for patients with small ailments and acute problems and is assisted by a nursing staff consisting of three individuals who cover night and weekend shifts.

The nursing staff are instructed to call 911 when an individual requires emergency care and Chien- Hui is not on duty. He consults with families regarding circumstances such as Alzheimer’s disease, dementia, congestive heart failure, and other conditions in which the patient deteriorates over time.

He also helps families design end-of-life and extraordinary-measures provisos.

1. Describe the culture of medical training the four likely received as students. 2. Explain how the culture each physician encounters has changed, with regard to his or her time in medical school. 3. How would the culture of each person’s organization differ from the others, especially with regard to managing each unit? 4. Explain how diversity issues might affect the career of each physician. 5. How would diversity issues affect the patients and employees in each physician’s organization? Diversity Management and Cultural Competence Chapter 3 Cultural Competence and Proficiency Goals and Objectives Bearing in mind cultural shifts and physicians building relationships with more than one institu- tion, it is still possible to identify goals reflecting the overall values of diversity management and culture competence. Table 3.3 enumerates these goals for healthcare organizations.

Table 3.3 Diversity management and cultural competence and proficiency goals Organization type Objectives and goals Individual practitioners • Awareness • Empathy • Sensitivity • Sympathy Healthcare organizations • Emphasis on innovation • Improvements in communication • A culture of learning • Awareness of and welcoming diversity – provide employment opportunities – respond to disparity problems – o ffer equal treatment of patients (regardless of ability to pay) American College of Healthcare Executives (ACHE) • Membership • Knowledge • Career advancement • Leadership • Service excellence Source: Adapted from American College of Healthcare Executives (2012). Dimensions of diversity. 2012 annual report and reference guide, p. 2–7.

Culturally proficient organizations and managers pursue these healthcare goals, which orient the organization to the future and help it maintain a positive standing in the community. This, in turn, helps ensure a facility’s growth and survival over time. A healthcare organization’s culture can inspire employees to achieve the goals listed in Table 3.3. Managerial practices, reward sys- tems, and peer influence can become part of the early training and socialization of new members and remain as institutionalized parts of the cultural environment. Connections can also be made among cultural change, diversity management strategies, and cul - tural competence. Just as the “old boy” network must be broken down in order to remove the glass ceiling, steps must be taken to improve the circumstances of other groups served by the health - care system, including patients and nonmedical employees. Healthcare operations that embrace diversity often reach wider networks of patients and potential employees, benefit from innovative ideas from untapped members of society, and perform a social good. Seven key activities, which are described in the sections that follow, are part of a quality diversity management system (Cox, 1993, pp. 225–241; Harvey & Allard, 2002).

Recruit from New Sources Part of the human resource management process that will be described in Chapter 9 involves planning for future personnel needs. Human resource planning programs can be designed to Diversity Management and Cultural Competence Chapter 3 emphasize finding recruits from diverse backgrounds. Doing so involves going beyond tradi- tional sources in order to publicize efforts to attract minority applicants. Internship programs and job fairs can be established to create “pipelines” of minority member applicants. In addition, the power of word of mouth and social media should not be ignored. In essence, part of recruit - ing involves getting the word out that a healthcare facility has a true interest in a more diverse workforce.

Hospitals should seek not only to attract diverse members of a community for employment purposes but also to widen the circle of patients under their care. Programs can specifically target cultural issues for diverse groups of patients, such as women, Hispanics, and those with disabilities.

Unbiased Selection Processes Many major orchestras across the United States employ a unique selection pro- cess. When a finalist plays for the judging committee, the musician plays behind a screen—only the music matters. The judges cannot see the person’s physical appear - ance. Although this technique cannot be applied to many situations, the concept can.

Candidates selected solely for their poten - tial to succeed, without any other biases involved, encourages true diversity. Many organizations use multiple raters to exam - ine an employee’s application or résumé, with the goal of making sure the applicant receives unbiased treatment during the selection process. The same approach may help minority members achieve promotions within healthcare organizations.

Training and Orientation for Minority Group Members Someone from an unusual or different background often experiences a sense of discomfort with a new, unfamiliar organization. This discomfort is often coupled with a potential lack of familiarity with various institutional procedures. Training methods help establish an environment in which a person can remain confident, even while knowing that his or her background may be different.

Proper training helps assure the person that adjustment to the new situation will take place.

Sensitivity by All Employees Many healthcare organizations provide diversity training. These diversity programs encourage employees to embrace the idea that diversity creates an advantage for a facility and to enjoy cul - tural and individual differences. The process should begin at the earliest stages of the recruiting and selection processes. For example, applicants should be notified that the institution intends to build a diverse workforce. Part of the selection criteria could include a statement about accep - tance of or excitement regarding working in such an environment.

Flexibility in Responding to Worker Requests An effective diversity program recognizes that employee needs vary. Individuals who have chil - dren need time to tend to matters such as doctor’s office visits and parent–teacher conferences. © Digital Vision/Thinkstock ▲ ▲ Recruiting from new sources and unbiased selection processes encourage diversity. Diversity Management and Cultural Competence Chapter 3 Likewise, various cultural backgrounds and religions have different holidays. Senior workers might make requests under unusual circumstances, such as wishing to help out their children or grandchildren in some way. A key element to workplace flexibility is listening to employees.

Managers who pay attention to employee needs are often rewarded with loyalty and extra effort.

Motivation Programs Tailored to Individuals Motivation varies by personal circumstance. A single parent will have motives that are different from those of someone approaching retirement age with an empty nest. Factors such as the cost of health insurance may be highly important to the single parent, whereas the viability of a retire- ment program can be the driving factor for a more senior employee.

Two kinds of motives exist: Extrinsic motives are essentially given by others. Pay raises, pro - motions, positive performance appraisals, and pension plans are all delivered by the healthcare managers. These rewards are tangible and visible. They can be adapted to fit the needs of various organizational members.

Intrinsic motives are internal. Intrinsic satisfaction results from performing at a high level, help - ing others, and taking advantage of one’s own talents and abilities. A person from a minority group, such as an African American, may derive additional satisfaction and motivation from being the first person in his or her category to receive a promotion in an area or department or by being chosen to lead a task force or committee.

A complete diversity program accounts for both extrinsic and intrinsic motives.

Positive Reinforcement of Differences The concept of embracing diversity has begun to appear in basic management textbooks (Robbins, 2005, p. 600). In essence, the idea is to accept the principle of multiculturalism for its own sake.

Doing so takes the form of themed office parties or celebrations, such as Cinco de Mayo or Eid ul Fitr , the end of Ramadan. Allowing workers to decorate their work space with personal items that reflect cultural diversity also expresses the objective of embracing diversity. Managers who take the time to learn a few key phrases that apply to another culture establish a higher level of rapport with employees and with patients.

Barriers to Diversity Management Strategies Healthcare managers who are truly dedicated to diversity understand that a variety of incidents and decisions can detract from a strong program. Encouraging diversity links closely with seek - ing to shape or redefine an institution’s culture. The program may take time, and obstacles can appear along the way. Kinicki and Kreitner (2009, pp. 107–108) listed the following primary forces as potential detractors from a company’s diversity management agenda:

• Continual stereotyping represents a major obstacle to the creation of an accepting and diverse workforce, as well as to diversity in the patient base. Stereotypes regarding women and members of minority groups as managers are common. Overcoming these stereo - types requires that managers pay attention to slurs and generalizations, correcting them as they occur.

• Fears of reverse discrimination , or discrimination against whites or males, are often directed at programs such as affirmative action. Terms such as quota systems are used to resist the implementation of diversity efforts. Management communication processes at all levels can help alleviate these concerns. Diversity Management and Cultural Competence Chapter 3 • Low priority as an organizational activity. When diversity management has a low prior- ity, employees quickly catch on. Members of an organization follow what leaders stress as important. For a diversity program to succeed, top management must buy in and keep the company on course.

• Failure to include diversity efforts in performance appraisal programs indicates that the company only pays lip service to the program. When one-size-fits-all performance criteria are used, some employees may be placed at a disadvantage. Typically, such criteria tend to make it hard for minority group members to succeed.

• Resistance to change of any kind can be found in practically any organization. The term organizational inertia identifies resistance to change as an institutionalized issue. Groups such as the “old boy” network do not dissolve easily. The same holds true for breaking down the glass ceiling as it applies to women and members of other minority groups within hos - pitals and other facilities.

• Poor management training techniques fail to incorporate diversity management in the process. As a result, diversity appears to be a low priority, and managers do not know how to effectively respond to employee needs or discriminatory incidents. Diversity manage - ment begins at the top and must permeate every level of the healthcare organization in order to succeed.

Each potential barrier to diversity management can be overcome. True diversity often signifies a cultural shift in the organization. The tactics designed to influence or change a culture can play a role in instituting a truly multicultural environment within the healthcare system. Addressing Healthcare Disparity According to Weil (2009), in 1992, the American College of Healthcare Executives (ACHE) com - bined with the National Association of Health Services Executives, which is an association of African American healthcare executives, to address the issue of healthcare disparity. Additional studies in 1997 and 2009 confirmed the continuing disparity problem (Weil, 2009).

Correcting the problem of healthcare disparity involves a series of key managerial practices.

These actions should be designed to influence the culture of specific healthcare organizations, the healthcare system, and the larger population in any given geographic region. Efforts can be made in the following areas:

• Assessment and research • Education and training • Program development • Continuous improvement A systematic approach such as this offers the best chance to reduce disparities among targeted minority groups.

Assessment and Research Each geographic area contains a unique mix of persons from various groups who experience healthcare disparity. Although national statistics are available for identifiable minority popu - lations, local health facilities should first seek to identify groups that are underserved. Then, specific health issues within such a populous should be discovered. In one area, substance abuse may be a greater health risk; in another, it could be diabetes or heart and circulatory problems. Diversity Management and Cultural Competence Chapter 3 The goal should be greater precision in the delivery of effective healthcare diagnoses and treat- ments. The ACHE and other organizations offer assessment tools directed at healthcare facilities (American Hospital Association, 2004). Assessment tools include health statistics from a given area, interviews with employees in the local healthcare community, exit interviews of those who leave healthcare jobs in the community, comments by patients and family members, and inputs from local governmental leaders.

Education and Training Diversity training constitutes one element of healthcare cultural proficiency. A second form of education should be directed at physicians, technicians, employees, and others in the health - care facility in order to expose and respond to disparity concerns. Members can then be taught specific skills that might help in serving an ethnic group. For example, linguistic competency can assist in helping members who speak different languages (most notably Spanish, in many regions). Bilingual employees can be recruited. Programs to teach the basics of a foreign language can be instituted in many healthcare facilities. Other skills include cultural sensitivity, conflict resolution, and decision-making competencies.

Program Development Fully developed programs respond to healthcare disparities at all levels. Personal, group, orga - nizational, and community levels should all receive attention from a program. Many programs begin with personal assessments and attempts to change attitudes and behaviors. From there, groups of physicians, technicians, and other healthcare employees can be incorporated into a more systematic program. Community outreach programs can be designed to improve access to primary care and to create an advocacy system for those who are systematically underserved.

Local, state, and, in some cases, national governments should receive attention from a compre - hensive health disparity program.

Continuous Improvement Continuous improvement is a primary ingredient in a total quality management program. As such, it belongs at the center of a healthcare disparity program. Reassessments focus on shifts in population characteristics; citizen attitudes, healthcare provider responses, and community involvements help ensure that disparity issues remain at the forefront of healthcare managers’ concerns. As new circumstances emerge, those in the healthcare profession can then respond effectively. CASE The Economic Boom Iris Frey never imagined she would end up as the chief operating officer in a small hospital in a rural Nebraska town, but that is exactly what happened. Her husband had obtained employment at the local bank as a loan officer just as she learned of the opening at the hospital. Together, the couple decided Madison would be a great place to raise a family. She was hired, and the move was made.

The Madison Community Hospital housed 45 beds. Two full-time physicians, one part-time semi - retired physician, and a nursing staff consisting of two registered nurses and five licensed nurses tended to patients. Typical occupancy was about 75%. The nonmedical staff consisted of 15 (continued) Diversity Management and Cultural Competence Chapter 3 additional individuals, two of whom provided janitorial services, and four who worked in the food service area. In addition, the hospital operated a small 24-hour emergency care section for persons from Madison and three other small communities in the county. Two additional physicians served in the emergency care room, and each maintained regular shifts and made themselves available for on-call situations when only a nurse was present at the facility.

Iris noted that the individual placed in charge of the nursing staff was the only male in the depart- ment. In the nonmedical staff, all supervisory positions were held by men. Iris wondered how she managed to obtain the job of chief operating officer, given the environment.

The community of Madison had begun to experience significant changes. The availability of the Internet, coupled with a town consisting of many people with a strong work ethic, had led an Internet firm to relocate its operations in Madison. The firm built a shipping warehouse and hired nearly 60 people to fulfill orders. The influx of money in wages led to a strong local economy.

At the same time, Madison retained its rural farming base. As was the case with many small family farms across the country, many found it difficult to survive. Farmers in the area held considerable resentment toward a corporate farm located in the next county. The resentment extended to per - sons employed by the farm.

Many farmers were able to continue operations due to an influx of individuals of Mexican descent.

Most of those individuals spoke a small amount of English, but their primary language was Spanish.

At first, suspicion of these new citizens had been the norm; however, over time, some farmers rec - ognized that these immigrants were willing to work long hours for lower wages without complaint.

Many friendships had emerged as a result.

The local Catholic Church experienced major growth with the addition of new Hispanic mem - bers. The church had maintained positive relationships with the other major denomination of the region— Lutherans. The Evangelical Lutheran Church of America maintained a nursing home in Madison.

Iris felt it would be wise to understand the community to as great a degree as possible. What she discovered was troubling: Only 60 percent of citizens currently had health insurance policies. The majority of these were employed by the Internet company and the corporate farm. Many other farmers and members of the Hispanic population did not have health insurance. She was told that some of the Hispanic population consisted of undocumented workers, which meant buying health insurance was not even possible. Iris was not sure how the 2014 implementation of the Affordable Care Act would impact the problem in Madison.

Iris was also concerned by the lack of preventive care in the area. Problems of obesity were com - mon. Life expectancy was lower than in many other nearby counties. The hospital also did not pro - vide a great deal of prenatal care. Iris took a deep breath. She knew her organization had several obstacles to overcome.

1. Is the hospital, as it currently operates, culturally competent? Why or why not? 2. What type of culture would be most likely in the hospital: clan, hierarchy, adhocracy, or market? What factors would cause the culture to take that form? 3. Describe the health disparity issues present in this scenario. 4. Outline a plan to overcome the diversity and healthcare disparity issues this hospital faces. Key Terms Chapter 3 Chapter Summary The term culture can be defined in several ways. Each definition notes a different set of publics or level of analysis. Cultural competence or proficiency adheres to a defined set of values and principles and demonstrates behaviors, attitudes, policies, and structures that enable persons in the organization to work effectively and cross-culturally. Such an organization is culturally com - petent. Cultural competence at all levels of analysis involves awareness of diversity, identification of cultural disparities in healthcare, the creation of programs designed to address disparities, and individual behaviors associated with cultural sensitivity and proficiency. Cultural competence is of unique importance in healthcare for individuals, groups, and the larger society.

A close relationship exists between cultural proficiency with increasing diversity and the impact diversity has on an organization’s culture over time. Diversity describes a spectrum of differences among people. Diversity concepts apply to individuals, groups, and organizations. In the world of healthcare, groups that can be used to describe diversity include race and nationality, gender, religion, age, sexual orientation, and people with physical disabilities. Stereotyping and subse - quent discrimination can influence the quality of healthcare. Culturally competent organizations seek to reduce discrimination in employment opportunities for minorities, facilitating movement into managerial ranks, while combating problems associated with stereotyping of patients and employees.

Organizational culture consists of a set of shared meanings and values held by a set of members in an organization. This culture distinguishes the organization from other organizations and determines how it perceives and reacts to the larger environment. Culture makes an organiza - tion distinct, creates a sense of identity, builds a strong social system, and helps employees “fit in.” Three levels of culture interact with one another and influence behaviors in organizations:

observable artifacts, espoused values, and enacted values. The four forms of culture are clan, hierarchical, adhocracy, and market patterns.

Diversity management programs include setting quality goals, recruiting from new sources, offering unbiased selection processes, training and orientating minority members, increasing sensitivity of all organizational members, being flexible in helping employees cope with unique circumstances, providing quality motivation programs, and reinforcing in positive ways. These efforts help overcome the barriers to diversity programs. Addressing healthcare disparity prob - lems involves four activities: assessment and research, education and training, program develop - ment, and continuous improvement.

Ke y Te r m s cultural competence organizations that follow “a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable [persons in the organiza - tion] to work effectively cross-culturally” culturally competent healthcare organization an organization that is “vigilant for ethnic disparities in screening, prescriptions, procedures, and health outcomes and has policies and procedures in place to address any disparities found” culture (a) “the act of developing the intellectual and moral faculties especially by educa - tion”; (b) “the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations”; (c) the set of Critical Thinking Chapter 3 values, conventions , or social practices associated with a particular field, activity, or societal characteristic” diversit y a spectrum of differences between people as individuals, groups, and organizations health disparity a circumstance in which a distinct populous encounters a significant or great difference in the overall rates of disease incidence, morbidity, or mortality when compared with the health status of the general population organizational culture a set of shared meaning and values held by a set of members in an organization that distinguish that organization from other organizations and that determine how the organization perceives and reacts to the larger environment role clarity what exists when a person has a clear understanding of his or her function in the organization and how to complete all assigned tasks stereotyping occurs when someone applies assumed (and often inaccurate) averages or char - acteristics to every individual in a group Additional Resources American College of Healthcare Executives http://w w Americans with Disabilities Act Asian Healthcare Leaders Association h t t p : //w w Cultural Competence Diversity Toolkit ht t p://w w w. a h a .org /c ont ent /0 0 -10/d i ver sit y t o ol .p d f Equity of Care http://w w Health Research and Educational Trust Disparities Toolkit Health Resources and Services Administration: Cultural, Language, and Health Literacy http://w w Institute for Diversity in Health Management h t t p : // National Association of Health Services Executives (African American) h t t p : // National Center for Cultural Competence National Forum for Latino Health Care Executives h t t p : // Office of Minority Health U.S. Census Bureau h t t p : // U.S. Equal Opportunity Employment Commission http://w w Critical Thinking Review Questions 1. Define cultural competence. 2. Define health disparity . Critical Thinking Chapter 3 3. Why is cultural competence or proficiency in healthcare important? 4. Define diversity and stereotyping . 5. What ethnic groups create diversity in the healthcare system with regard to patients and employees? 6. How does discrimination affect healthcare organizations? 7. Define organizational culture . 8. Describe the functions organizational culture provides in healthcare and other organizations. 9. What three layers of culture exist in healthcare organizations? 10. What forms of culture are present in various healthcare organizations? 11. What steps can managers take to build quality diversity management programs? 12. What barriers stand in the way of designing quality diversity management systems? 13. What steps are involved in combating healthcare disparity problems? Analytical Exercises 1. Some sources explain cultural competence as the extreme of a continuum, with competence at one end and cultural destructiveness and blindness at the other. Do you think this is an accurate portrayal? What alternative descriptions could be used to portray individuals and organizations that are not culturally competent? 2. Explain the relationship between cultural competence and increasing diversity in the patient population. Explain the same relationship in the recruiting and selection of employees to work in a healthcare facility. 3. Of the various forms of diversity described in this chapter, which is most likely to experience healthcare disparity? Which is least likely? What role does health insurance play in this?

Explain your answers. 4. What types of stereotyping, discrimination, and healthcare disparity problems have people in your community encountered? Are these activities highly overt or subtle? What steps would you take to resolve these problems? 5. Consider a local hospital you attend. Could you identify the organization’s observable artifacts? From any previous visit or time in the hospital, report on your observations of the organization’s espoused and enacted values. Explain how they help or hinder quality healthcare. 6. For a patient with a rare and highly contagious disease, which form of culture would be likely to provide the best care: a clan, hierarchy, adhocracy, or market culture? Explain your reasoning. 7. How would a diversity management program in a hospital differ from the same program in a for-profit company, such as a retail store? How would the programs be the same? Explain your responses. 8. What role should the government play in addressing healthcare disparity problems? What role should a healthcare manager play? What role should patients play? How would each be able to have an impact on the problem?