Diversity in Healthcare: Time to Get REAL!
Frontiers of Health Services Management, Spring 2010 by
Armada, Anthony A, Hubbard, Marilyn F
Cross-cultural healthcare involves three key issues: racial and ethnic disparities in the quality
of healthcare provided to minority patients; cross-cultural value differences between
immigrant patients and Western medical providers; and providing language access and
assistance to limited English proficient (LEP) and disabled persons. Addressing these key
issues represents a compelling diversity agenda for a new generation of healthcare
executives. This article describes each of these challenges and the cutting-edge strategies that
leading healthcare organizations are using to address them.
RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
From now until the year 2050, over 90 percent of U.S. population growth is expected to come
from people of color. If you think that 2050 is far off, consider that today, 48 of the 100
largest cities in the United States already have minoritymajorities. Five states - California,
Texas, Hawaii, New Mexico, and Florida - also have minority-majorities and five other
states, including New York, are expected to become minority-majority soon.
In 2002, the Institute of Medicine released a report entitled "Unequal Treatment: Confronting
Racial and Ethnic Disparities in Healthcare." The key conclusion from the report was that
people of color receive lower-quality healthcare than whites do, even after adjusting for
insurance status, income, age, and severity of conditions. Major disparities were found across
a wide range of diagnostic areas including cardiovascular disease, cancer, stroke, kidney
dialysis, HIV/ AIDS, asthma, diabetes, mental health and maternal and child health. Given
the fact that over 80 percent of new private health insurance enrollees are people of color, the
implications of disparities research suggests that the healthcare industry's fastest growing
customers are receiving the worst care.
It has now been seven years since the Institute of Medicine issued its clarion call for
improving the quality of healthcare for the nation's minorities. While some strides have been
made, quality gaps continue. A recent Agency for Healthcare Research and Quality (AHRQ;
2008) report notes that over 60 percent of disparities in quality of care have stayed the same
or worsened for blacks, Asians, and poor populations while nearly 60 percent of disparities,
including but not limited to quality issues, have stayed the same or worsened for Hispanics.
In the meantime, new research has demonstrated dramatic difference between whites and
people of color in terms of patient satisfaction. A Harvard School of Public Health/Robert
Wood Johnson Foundation survey (Blendon et al. 2008) compared perceptions of the quality
of physician care among 14 racial and ethnic groups with those of whites. On each measure
examined, the subgroups perceived their care to be significantly worse than care for whites –
often by as much as 15 percentage points.
AHA EFFORTS TO ADDRESS RACIAL AND ETHNIC DISPARITIES
In December 2007, the American Hospital Association (AHA) convened the Special
Advisory Group on Improving Hospital Care for Minorities as part of its ongoing efforts to
ensure equitable treatment for all patients. This group has a dual mission: one, to study how
to improve hospital care and eliminate disparities among minority populations; and two, to
ensure that racial and ethnic minorities have a voice in the national debate on healthcare
reform. The AHA also is bringing together tangible resources to help hospitals navigate the
path toward disparities elimination. Through AHA’s Center for Health Care Governance and
Institute for Diversity in Health Management, the organization has developed trustee training
programs to help hospitals expand the racial and ethnic diversity of their governing boards.
The AHA’s Health Research and Educational Trust (HRET) created the Disparities Toolkit, a
Web-based toolkit to collect race, ethnicity, and primary language data in a uniform way.
Currently, 19 states have state-based mandates to collect race and ethnicity data in hospitals.
While the AHA has not, as yet, taken a policy position on the collection of race, ethnicity,
and language data, others have. In 2009, The Joint Commission, the National Committee on
Quality Assurance, and the National Quality Forum all issued draft statements proposing new
cultural competence standards for hospitals, health plans, and other healthcare organizations.
All three sets of guidelines endorsed the collection of race, ethnicity, and language data.
HOSPITAL COLLECTION OF RACE, ETHNICITY, AND LANGUAGE (REAL) DATA
According to a 2006 study by the Robert Wood Johnson Foundation and the National Public
health and Hospital Institute, more than three-quarters (78.4 %) of non-federal acute care
hospitals collect information on the race of their patients, and half the hospitals that collect
race and ethnicity information do so at the point of registration for both inpatient (96%) and
outpatient (93.5%) services provided at the hospital campus. The majority (89%) also collect
this information in the emergency department and at affiliated same day surgery centers
(79.7%). Only about half (55.6%) of hospitals that collect race and ethnicity information do
so at doctors’ offices or clinics located away from the hospital campus.
Accuracy and the Use of Race and Ethnicity Data
The fact that 78 percent of American hospitals collect patient race data sounds impressive but
becomes much less so under closer scrutiny. Research by the AHA and others has found
serious reasons to doubt the accuracy of patient race data (Hasnain-Wynia, Pierce, and
Pittman 2004). While most hospitals reported that the primary source of information about
race/ethnicity is the patient or an admitting clerk obtaining information from the patient
directly, 51 percent of responding AHA hospitals reported that admitting clerks determined
the patient's race/ ethnicity based on observation. (In short, they guess.) The researchers also
asked hospitals to disclose the percentage of cases where data on race or ethnicity were
missing or unavailable. Responses ranged from o to 100 percent.
NPHHI asked hospitals that collect race and ethnicity data whether they used it to assess and
compare quality of care, utilization of health services, health outcomes, or patient satisfaction
across their different patient populations. Sadly, less than 20 percent of surveyed hospitals
collect patient race and ethnicity information and tie it to patient outcomes and quality
Barriers and Concerns Regarding Data Collection
Research by the AHA's HRET shows that among hospitals that collected data on
race/ethnicity, 70 percent did not see any drawbacks to collecting the data. Drawbacks
reported by the remaining 3 o percent included (Hasnain-Wynia, Pierce, and Pittman 2004):
* discomfort on the part of the registrar or admitting clerk asking the patient for the
* problems associated with the accuracy of the data collected;
* a sense that patients might be insulted or offended, or resist answering questions about their
race and ethnicity;
* patients who did not "fit" the categories that were given;
* a fear that data might not be kept confidential; and
* the possibility that collecting data on race and ethnicity might be used to profile patients
and discriminate in the provision of care.
Of these drawbacks, by far the biggest (though rarely discussed) issue is the concern among
white admissions personnel that asking about patients’ race will inevitably upset or offend
people of color. Richard Pride, director of access management for the University of
Mississippi Health Care initially shared these concerns when his organization launched a
race/ethnicity date collection effort. The University of Mississippi launched its data collection
effort after intensive training which offered admissions staff scripted answers to patients most
frequently expressed questions. Prior to launch, Pride gave his staff his pager number and
offered to be ready at a moment’s notice to handle any racial concerns that camp up. No one
called. Pride did not receive one page or phone call during the first few weeks of the
initiative. And the project is clearly generating quality data. According to Pride, the hospital
had 350 Hispanic patients the year before the data collection initiative when race was largely
determined by staff through patient observation. When the admissions staff asked patients
about their race directly, they recorded 450 Hispanic patients the first month (AHA 2009).
HealthPartners based in Bloomington, Minnesota serves 1.25 million medical and dental
health plan members nationwide. Since 2004, HealthPartners has collected race and language
preference data from its patients and members. Today the organization has collected race data
from nearly 90 percent of its primary clinic patients and language preference data on nearly
100 percent of its primary clinic patients. Regions Hospital, which is also part of
HealthPartners, has collected race data on 84 percent of admitted patients and language data
on 92 percent of admitted patients (Walker 2009).
Hospitals in the LeHigh Valley Health Network implemented a mandatory race/ethnicity data
collection effort in October, 2008. Prior to launching the initiative, the organization was
careful to communicate its intentions to minority community leaders and elected officials.
The hospital even wrote an op-ed piece for the local newspaper discussing racial and ethnic
disparities in healthcare and describing the data initiative as one important step to address
them. The result? Minimal disruption in the registration process for hospital staff and
patients, according to Eric Gertner, MD, MPH, a hospital official who worked on the project
The Health Research and Educational Trust asked hospitals (n = 57) that do not collect data
on race and ethnicity to give reasons why. Sixty-one percent stated that it was "unnecessary
to collect data on patients' race and ethnicity." Smaller numbers of respondents stated that
there was no reliable system for data collection (17 percent); there was no good classification
system for race or ethnicity (16 percent); data were too costly to maintain (7 percent); and
that collection of race/ ethnicity data was prohibited by law or external regulation (Hasnain-
Wynia, Pierce, and Pittman 2004).
The National Health Law Program (NHeLP) examined this question and issued a
comprehensive report detailing its findings. In essence, the NHeLP found that the collection
and reporting of data on race, ethnicity, and primary language are legal and authorized under
Title VI of the Civil Rights Act of 1964. No state statutes bar hospitals from collecting race
and ethnicity data, though some states restrict health plans from doing so (Hasnain-Wynia,
Pierce, and Pittman 2004).
Lack of Executive Leadership
David Hunt is the president and CEO of Critical Measures, a leading consulting and training
firm addressing racial and ethnic disparities in healthcare. Hunt believes that a key factor for
the failure of some hospitals to collect race and ethnicity data is the lack of executive
leadership. "It starts from the top," he says. "We've worked with a number of our hospital
clients to stratify patient satisfaction data by race and language." Doing so showed dramatic
differences in patient satisfaction rates. Patients of color were "twice as likely as whites not to
have confidence in their doctors, two to three times as likely to rate the courtesy of doctors,
nurses, and other staff as 'fair or poor' and substantially more likely to say that they were not
treated with dignity and respect than white patients." Significantly, patients of color were also
substantially more likely to say that they did not receive care in a timely manner and that staff
did not do all they could to control their pain. Hunt notes that when he has presented this data
to hospital CEOs during marketing presentations (with client's names deleted of course)
"their reaction was - that data will never come out at my hospital as long as I'm the CEO"
(Hubbard and Hunt 2009).
HOSPITAL CASE STUDY: HEALTHEAST CARE SYSTEM, ST. PAUL, MINNESOTA
It takes real courage and leadership for hospital executives to take on the lawyers, risk
managers, and naysayers and demand that this data be examined. One hospital CEO who did
just that is Tim Hanson, president and CEO of the HealthEast care system located in Saint
Paul, Minnesota. With leadership from Hanson and the organization's Board of Directors,
HealthEast (Anderson 2009):
* Conducted a cultural competence organizational assessment based on the DHHS CLAS
* Took immediate steps to address issues identified in the assessment. In particular,
HealthEast hired substantial numbers of qualified interpreters (including a full-time American
Sign Language (ASL) interpreter); improved written translated materials and hospital signage
and way-finding resources; trained physicians and nurses to work with interpreters and to
comply with federal and state language access laws; and began collecting patient race,
ethnicity and language data.
* Trained over 800 leading HealthEast executives, physicians, nurses, managers, and
employees on the business, medical, and legal "cases" for diversity and cultural competence
* Conducted a system-wide employee opinion survey on diversity issues (a Diversity
Workforce Assessment); stratified the results by race, gender, and location; and took
appropriate corrective action.
* Trained emergency room physicians and nurses on Quality Interactions, the nation's first e-
learning program on providing culturally competent medical care.
* By becoming more intentional about providing high quality, culturally responsive patient
care, HealthEast increased its inpatient Hmong market share by nearly 33 percent and saw
ED usage by Hmong patients at one of its hospitals double within a six-month period. (The
Twin Cities is home to one of the nation's largest communities of Hmong - people from the
hills of Laos who fought on the American side during the Vietnam war.)
* Finally, culturally responsive care has been positioned under the HealthEast Quality
Institute; a new system director for cross cultural service has been hired who reports directly
to HealthEast's chief medical officer; and leading HealthEast physicians are participating in a
national program on reducing racial and ethnic disparities sponsored by Harvard's Disparities
Hospitals can learn a lot from HealthEast's example. First, diversity at HealthEast has not
been a simple "program" or "initiative." Rather, it has been embedded into the very fabric of
the organization and institutionalized with its own staff and budget. Second, diversity has
been tied to the achievement of larger organizational goals such as patient quality and safety
and employee engagement and productivity rather than being an end in itself. Finally, paying
attention to diversity factors played a significant part in accomplishing HealthEast's strategic
goal of being the benchmark for quality in the Twin Cities by 2010. In 2009, HealthEast was
named one of the top ten hospital systems in the United States, according to a study by
Thomson Reuters. The study ranked hospitals based on their clinical performance.
HOSPITAL EQUITY REPORTS
The Disparities Solutions Center at Massachusetts General Hospital is a national thought
leader in addressing disparities in healthcare. The Center has urged hospitals to create
hospital equity reports. A hospital equity report is a tool that allows a hospital's executives,
physicians, and staff to examine inequalities in the care provided to patients from different
racial, ethnic, language, and socioeconomic groups. It can identify areas that are going well
and those that could be improved, whether across the hospital, within a specific department,
or for a specific patient group. The report can also help leaders monitor progress toward
eliminating inequalities and providing the highest quality of care to all patients, regardless of
their race, ethnicity, language, or socioeconomic status (Weinick, Flaherty, and Bristol 2008).