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Hospital cultural competency as a
systematic organizational intervention:
Key findings from the national center for
healthcare leadership diversity
demonstration project
Robert Weech-Maldonado
Janice L. Dreachslin
Josue
´Patien Epane
´
Judith Gail
Shivani Gupta
Joyce Anne Wainio
Background: Cultural competency or the ongoing capacity of health care systems to provide for high-quality care to
diverse patient populations (NationalQuality Forum, 2008) has been proposed as anorganizational strategy to address
disparities in quality of care, patient experience, and workforce representation. But far too many health care
organizations still do not treat cultural competency as a business imperative and driver of strategy.
Purposes: The aim of the study was to examine the impact of a systematic, multifaceted, and organizational level
cultural competency initiative on hospital performance metrics at the organizational and individual levels.
Methodology/Approach: This demonstration project employs a preYpost control group design. Two hospital systems
participated in the study. Within each system, two hospitals were selected to serve as the intervention and control
Key words: cultural competency, diversity climate, diversity management
Robert Weech-Maldonado, MBA, PhD, is Professor and L.R. Jordan Endowed Chair, Department of Health Services Administration, University
of Alabama at Birmingham. E-mail: rweech@uab.edu.
Janice L. Dreachslin, PhD, is Professor Emerita of Health Policy and Administration, Penn State Great Valley School of Graduate Professional
Studies, Malvern, Pennsylvania.
Josue´ Patien Epane´ PhD, MBA, is Assistant Professor, Department of Health Care Administration and Policy, School of Community Health
Sciences, University of Nevada, Las Vegas.
Judith Gail, MSOD, is Owner and Principal, Gail Consulting LLC, Washington, DC.
Shivani Gupta, PhD, is Assistant Professor, College for Public Health and Social Justice, Health Management and Policy, Saint Louis University,
Missouri.
Joyce Anne Wainio, MHA, Vice President, National Center for Healthcare Leadership, Chicago, Illionis.
This project was supported by the National Center for Healthcare Leadership (NCHL) with funding from Sodexo and member health systems.
Dreachslin, Weech-Maldonado, Epane´, and Gail were reimbursed by NCHL as consultants to the project.
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.
DOI: 10.1097/HMR.0000000000000128
Health Care Manage Rev, 2018, 43(1), 30Y41
Copyright B2018 Wolters Kluwer Health, Inc. All rights reserved.
30 JanuaryYMarch &2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
hospitals. Executive leadership (C-suite) and all staff at one general medical/surgical nursing unit at the intervention
hospitals experienced a systematic, planned cultural competency intervention. Assessments and interventions
focused on three organizational level competencies of cultural competency (diversity leadership, strategic human
resource management, and patient cultural competency) and three individual level competencies (diversity attitudes,
implicit bias, and racial/ethnic identity status). In addition, we evaluated the impact of the intervention on
diversity climate and workforce diversity.
Findings: Overall performance improvement was greater in each of the two intervention hospitals than in the control
hospital within the same health care system. Both intervention hospitals experienced improvements in the
organizational level competencies of diversity leadership and strategic human resource management. Similarly,
improvements were observed in the individual level competencies for diversity attitudes and implicit bias for Blacks
among the intervention hospitals. Furthermore, intervention hospitals outperformed their respectivecontrol hospitals
with respect to diversity climate.
Practice Implications: A focused and systematic approach to organizational change when coupled with interventions
that encourage individual growth and development may be an effective approach to building culturally competent
health care organizations.
The need for health care organizations to implement
cultural competency practices is supported by demo-
graphic trends and well-documented disparities,
not only in quality of care and patient experience but also
in workforce career outcomes and perceptions of equity and
opportunity in the workplace. The Agency for Healthcare
Research and Quality continues to find disparities in health
as well as in the care delivered to racial/ethnic minorities
when compared to non-Hispanic Whites (Agency for Health-
care Research and Quality, 2014). Similarly, the American
College of Healthcare Executives (2008, 2012) has found
that, despite some improvements, disparities in career ac-
complishment persist even after controlling for human capi-
tal variables, such as education and experience. Furthermore,
racial/ethnic gaps in perceptions of workplace equity and
opportunity remain, with non-Hispanic White men express-
ing the most satisfaction with equity and opportunity in the
workplace compared to racial/ethnic minorities.
Health care organizations_policies and practices are
among the most important factors influencing disparities
in quality of care and workforce career outcomes (Meyers,
2007). As such, cultural competency has been proposed
as an organizational strategy to address such disparities
(Dreachslin, Gilbert, & Malone, 2013). Cultural compe-
tency has been defined as the Bongoing capacity of health
care systems[to provide for high-quality care to diverse
patient populations (National Quality Forum, 2009). Cul-
tural competency is achieved through policies, learning
processes, and structures by which organizations and indi-
viduals develop the attitudes, behaviors, and systems that are
needed for effective cross-cultural interactions (Betancourt,
Green, Carrillo, & Ananeh-Firempong, 2003). Successful
implementation of cultural competency requires an orga-
nizational commitment toward a systems approach so that
the health care organization_s complex structure of inter-
connected people, policies, and practices can work in con-
cert to achieve the common goal ofa culturally competent
organization.
However, very few studies have examined the impact of
systematic, organizational level cultural competency interven-
tions on hospital performance metrics. Weech-Maldonado,
Elliott, et al. (2012) found a positive relationship between
hospital cultural competency, assessed as adherence to
the Department of Health and Human Services Office of
Minority Health_s cultural and linguistic appropriate ser-
vices (CLAS) standards and inpatient experiences with
care in California hospitals. This study makes a contribu-
tiontotheliteraturebyusingapreYpost intervention assess-
ment to explore the impact of a systematic, multifaceted,
and organizational level cultural competency initiative on
performance metrics at the organizational and individual
levels among two health systems.
Conceptual Framework
The conceptual frameworkfor this article draws from Burke
and Litwin_s (1992) Model of Organizational Performance
and Change and Cox_s (1994) Interactional Model of
Cultural Diversity. The Model of Organizational Performance
and Change posits that organizational change responds to
the demands of the external environment and that orga-
nizations can proactively facilitate the necessary change
through leadership, management practices, structures, and
policies. These factors can in turn influence work climate,
which can ultimately affect organizational performance.
The Interactional Model of Cultural Diversity highlights the
importance of both organizational context factors (e.g.,
structures and human resource systems) and individual
level factors (e.g., prejudice, stereotypes, and personal iden-
tity) as determinants of diversity climate, whereas diversity
Findings From the NCHL Diversity Demonstration Project 31
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
climate ultimately affects individual career outcomes and
organizational outcomes. Using tenets from both models,
we hypothesize that a systematic, multifaceted, and organi-
zational level cultural competency/diversity intervention
aimed at improving organizational and individual level com-
petencies of diversity can positively affect diversity climate
and workforce diversity (Figure 1).
Systematic Diversity Intervention
Two hospital systems participated in the study. Within
each system, two hospitals were selected to serve as the
intervention and control hospitals. Executive leadership
(C-suite) and all staff at one general medical/surgical nursing
unit at the intervention hospitals experienced a systematic,
planned diversity intervention. The intervention was aimed
at improving organizational level and individual level com-
petencies as described in the following sections. Figure 2
summarizesthe key steps in the intervention. First, a battery
of preassessments was administered for both intervention
and control hospitals. In addition to the survey instruments
and other quantitative assessments, the project team con-
ducted interviews, focus groups, and a website analysis of
the intervention hospitals at baseline. A feedback report
was developed for each intervention hospital document-
ing the results of the quantitative and qualitative data
analysis. Then, a diversity coach discussed the preassess-
ment results with the CEO and leadership team of each
intervention hospital. On the basis of this feedback, the
diversity coach in collaboration with the intervention
hospital_s CEO and leadership team developed an organi-
zational level action plan that determined the interventions
in the next phase. Interventions included infrastructure
development, executive coaching, training, individual level
action plans, and other interventions determined by each
intervention hospital. After the intervention phase, the
quantitative assessment battery was repeated to determine
preYpost intervention change.
Organizational Level Competencies
Organizations that follow a systems approach integrate
cultural competency practices throughout their management
and clinical subsystems. Three organizational level compe-
tencies were the focus of the systematic change initiatives
in the intervention hospitals: diversity leadership, strategic
human resource management, and patient cultural com-
petency. We hypothesize that the intervention hospitals
will experience more improvement on each of the three
organizational level competencies than their respective con-
trol hospitals.
Diversity leadership is described as top management
commitment toward cultural competency and includes
(a) integrating cultural competency into strategic plan-
ning and throughout all the management systems of the
organization, (b) having dedicated staff and resources to
achieve diversity goals, (c) implementing proactive human
resources practices to ensure recruitment and retention of a
Figure 1
Conceptual framework
32 Health Care Management Review JanuaryYMarch &2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
diverse workforce, (d) diversity training, and (e) commu-
nity engagement in decision-making (Weech-Maldonado,
Dreachslin, et al., 2012).
Strategic human resource management represents a Bstrate-
gic deployment of a highly committed and capable work-
force[using an array of personnel practices (Storey, 2001,
p. 6). Strategic human resource management practices
include (a) recruitment and selection (process of attract-
ing and choosing candidates for employment), (b) job
design/work systems (specification and allocation of tasks
and responsibilities), (c) learning and development (edu-
cational activities or learning experiences to enhance
employee performance), (d) performance management (pro-
cess used to define, measure, and provide feedback on
strategic goals), (e) reward and recognition (formal or in-
formal programs to acknowledge good performance or
goal attainment), and (f) succession planning (formal pro-
cess to identify and develop individuals to fill key leadership
roles). Strategic human resource management practices
are likely to result in a more diverse workforce, greater
minority representation in leadership, and higher retention
of minorities.
Patient cultural competency represents the processes of care
aimed at delivering quality of care for diverse populations
(Weech-Maldonado, Dreachslin, et al., 2012). This includes
(a) patientYprovider communication (provision of inter-
preter services and translated materials for limited English
proficient patients) and (b) care delivery and supporting
mechanisms (delivery of care, physical environment, and
links to supportive services and providers).
Individual Level Competencies
Three individual level competencies were the focus of the
systematic intervention: diversity attitudes, implicit biases,
and racial/ethnic identity. We hypothesize that the inter-
vention hospitals will experience more improvement on
each of the three individual level competencies than their
respective control hospitals.
Diversity attitudes, implicit bias, and racial/ethnic iden-
tity status have been shown to influence behavior and
decision-making (Carter, Helms, & Juby, 2004; Gawronski,
Ehrenberg, Banse, Zukova, & Klauer, 2003; Richeson &
Shelton, 2003). Therefore, a necessary goal of diversity
Figure 2
Diversity demonstration project intervention flow diagram
Findings From the NCHL Diversity Demonstration Project 33
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
training and related strategic diversity management initia-
tives is to move leadership, staff, and the organization to
increasingly more evolved or sophisticated ways of experienc-
ing diversity and to enhance their awareness of and ability
to manage their own diversity attitudes, implicit biases, and
racial/ethnic identity.
Greenwald and Banaji (1995) define attitudes as Bfavor-
able or unfavorable dispositions toward social objects such
as people, places, and policies.[Attitudes toward diversity
include four key constructs (Inscape Publishing, 1994): (a)
knowledge(stereotypes and information about differences),
(b) understanding (empathy), (c) acceptance (tolerance and
respect), and (d) behavior (patterns of interactions, flexi-
bility, and openness). Although explicit bias refers to the
attitudes that individuals are consciously aware of, implicit
bias consists of attitudes that operate outside of conscious
awareness.
Racial/ethnic identity development describes the process
through which individuals become aware of and experience
the social reality of their racial group identity and that of
others (Helms, 1995). Helms_model of racial identity de-
velopment consists of a series of statuses, each of which is
more emotionally, cognitively, and behaviorally sophisti-
cated than the previous status. The maturation or develop-
ment process that results in dominance and accessibility of
increasingly more sophisticated statuses is driven by need,
with new statuses evolving as the individual discovers that
his or her current status is inadequate given what he or she
knows and is experiencing now. Movement among statuses
is indicative of a shift in worldview that occurs in response
to experiences, self-reflection, and conscious decisions.
Organizational Outcomes
In this article, we focus on two organizational level out-
comes for the intervention: diversity climate and workforce
diversity. Diversity climate has been conceptualized as the
perception of the value of diversity in a work environment
(Kossek & Zonia, 1993); these include perceptions of
organizational fairness and inclusion. Diversity climate has
been associated with human resource outcomes (McKay
et al., 2007). Leaders and organizations must provide a con-
text in which diverse groups can realize their full potential.
Hospital staff and leadership at all levels of the orga-
nization should reflect the community diversity (The Lewin
Group, 2002). Racial/ethnic and language concordance
between patient and provider has been associated with
better patient experiences with care and satisfaction (Ngo-
Metzger et al., 2006). Similarly, leadership diversity increases
the likelihood that the needs of a diverse workforce and
patient population are taken into account in organizational
decision-making processes (Weech-Maldonado, Dreachslin,
et al., 2012).
On the basis of our conceptual framework, we expect
that the hypothesized greater improvement in organiza-
tional and individual competencies will result in greater
improvement in organizational outcomes, such as diversity
climate and workforce diversity for the intervention hospi-
tals as compared to their respective control hospital.
Methods
Sample and Design
This study design consisted of pretestYposttest control group
design, which allows for within-group pretestYposttest
comparisons. A purposeful national sample of 25 hospital
systems was invited by mail to participate in the National
Center for Healthcare Leadership (NCHL) Diversity De-
monstration Project. An overview of the project was included
with the invitation, and follow-up calls were made to en-
courage project participation. Two health systems located
on the U.S. East Coast agreed to participate.
Within each system, two hospitals were selected to serve
as the intervention and control hospitals. The intervention
and their respective control hospital for each system served
the same metropolitan area. The participating health sys-
tems were located in similar metropolitan areas in terms of
the population_s racial/ethnic and education profile, but
one health system was located in a metropolitan area with
lower unemployment rate and higher per capita income
compared to the other. Assignment to intervention or
control status was at random, with the executive leadership
(C-suite) at each intervention hospital receiving the diver-
sity interventions and the control not. In addition, a ver-
tical slice of the intervention hospital_sstaff,consistingof
one general medical/surgical nursing unit, experienced the
diversity intervention. This included support staff, direct
caregivers, supervisors, managers, and directors. A matched
nursing unit in the control hospital served as an additional
control group and participated in selected preYpost assess-
ments but did not experience the diversity interventions.
See Table 1 for participant characteristics.
Preassessment interviews revealed that both interven-
tion hospitals had diversity committees, limited diversity
training, and racial and gender diversity in the leadership
team. The project timeline consisted of approximately
6 months for preassessments, 2.5 years for the interven-
tion phase, and 6 months for postassessments with comple-
tion in December 2013. The study was approved by the
Pennsylvania State University Institutional Review Board.
Measures
Preassessments and postassessments were completed by par-
ticipantsinbothhealthsystems.Bothorganizationaland
individual level measures were aggregated at the hospital
level. Following is a description of how each competency and
organizational outcome was operationalized and assessed.
34 Health Care Management Review JanuaryYMarch &2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Organizational level competencies. 1. Diversity Leadership.
Two survey instruments were used to assess the diversity
leadership competency: NCHL Diversity Leadership and
Cultural Competence Assessment and the Cultural Com-
petency Assessment Tool for Hospitals (CCATH). The
NCHL Diversity Leadership and Cultural Competence
Assessment was completed online by executive leadership
at each intervention and control hospital. The 68-item
survey instrument was adapted from the Racial/Ethnic
Diversity Management Survey (Dreachslin, 1998; Weech-
Maldonado, Dreachslin, Dansky, De Souza, & Gatto, 2002).
The instrument measures anorganization_salignmentwith
diversity management best practices in five key areas: (a)
Diversity Leadership (10 items): leadership_s commitment
to cultural competence and diversity management; (b)
Strategic Orientation (15 items): the role of cultural compe-
tence and diversity management in determining the orga-
nization_s strategy; (c) Diversity Infrastructure (14 items):
an organization_s routine practices in support of cultural
competence and diversity management; (d) Professional
Development (14 items): organizational supports for training
and development of a culturally competent workforce, of
clinical and nonclinical staff at all levels; and (e) Culture/
Climate (15 items): the extent to which the organization_s
image and behavior reflect a strong and visible commitment
to diversity and cultural competence. Each survey item has
a 7-point response scale (1 = strongly disagree to 7 = strongly
agree). Composite scores are obtained byaveraging the item
scores within each scale.
One CCATH survey was completed by each interven-
tion and control hospital in consultation with the human
resources team, nursing manager, and diversity leaders as
needed. The CCATH has been shown to have adequate
psychometric properties (Weech-Maldonado, Dreachslin,
et al., 2012). The CCATH scales relevant to Diversity
Leadership are Leadership and Strategic Planning (6 items),
Data Collection on Inpatient Population (2 items), Data
Collection on Service Area (7 items), Performance Manage-
ment Systems and Quality Improvement (3 items), Human
Resources Practices (8 items), Diversity Training (3 items),
and Community Representation (2 items). Each item as-
sesses the presence or absence of cultural competency prac-
tices. CCATH composite mean scores were obtained by (a)
linear transformation of each item to 0Y100 range and (b)
averaging the items within each composite.
2. Strategic Human Resource Management. The NCHL
Healthcare Leadership Questionnaire assessed the strategic
human resource management practices of the organization
and was completed by the CEO of each hospital and sub-
mitted via e-mail. The survey questionnaire was developed
based on empirical evidence and a review of current litera-
ture. The questionnaire was used nationally in 2007 and
2010 for the purpose of developing a national health care
leadership database (NCHL, 2011). Elements of the sur-
vey include Recruitment and Selection (15 items), Job
Design/Work Systems (4 items),LearningandDevelopment
(15 items), Performance Management (8 items), Reward
and Recognition (3 items), Succession Planning (10 items),
Governance (8 items), and Leadership (2 items) compe-
tencies. Each item has a 7-point response scale (1 = not at all
to 7 = a great deal). Composite scores are obtained by aver-
aging the item scores within each scale.
3. Patient Cultural Competency. The CCATH referenced
above was used to assess the two subdomains on patient
cultural competency: patientYprovider communication, and
care delivery and supporting mechanisms. The relevant
CCATH scales were Availability of Interpreter Services
(4 items), Interpreter Services Policies (4 items), Quality
of Interpreter Services (3 items), Translation of Written
Materials (6 items), and Clinical Cultural Competency
Practices (4 items).
Individual level competencies 1. Diversity Attitudes.
The Discovering Diversity Profile, which was completed
by leadership and staff onsite, is an 80-item questionnaire
that was used to assess four aspects of diversity attitudes:
knowledge (stereotypes, information), understanding (aware-
ness, empathy), acceptance (receptiveness, respect), and
behavior (self-awareness, interpersonal skills). Items consist
of a 4-point response option (1 = strongly disagree to4=
strongly agree). Composite scores (range, 10Y40) for each
Table 1
Characteristics of study participants at
baseline (N = 287)
Gender
Male 13.2%
Female 86.8%
Race/ethnicity
White 67.7%
Black 25.1%
Hispanic 1.8%
Other 5.4%
Career stage
Early (G5 years) 30.6%
Mid (5Y10 years) 18.1%
Late (910 years) 51.2%
Education
Some high school 2.1%
High school or GED 11.5%
Some college or 2-year degree 44.9%
College graduate 28.9%
Master_s or above 12.5%
Role in organization
Nonclinical staff 6.7%
Clinical support staff or licensed clinicians 12.9%
Nursing 64.3%
Medicine 1.6%
Administration 14.5%
Findings From the NCHL Diversity Demonstration Project 35
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
subscale were obtained by adding the individual item scores.
Prior research has shown face/content validity and internal
consistency of the scales (Mendez-Russell, Wilderson, &
Tolbert, 1994; Moore & Frank, 2013).
2. Implicit Bias. Provided by Harvard_s Project Implicit,
the Implicit Attitude Test (IAT) is a computer-based test
that measures people_s unconscious attitudes, therefore
addressing limitations related to social desirability of self-
reported measures of bias (Greenwald, McGhee, & Schwartz,
1998; Nosek, Hawkins, & Frazier, 2011). The IAT, which
was completed online by leadership and staff, measures
the strength of associations between concepts (e.g., older
people, Black people) and evaluations (e.g., good, bad) or
stereotypes (e.g., athletic, clumsy). The IAT asks respon-
dents to categorize two target concepts with an attribute,
measures reaction time, and calculates a score accordingly.
IAT scores range from no preference to a slight, moderate,
or strong preference for one group versus the other (e.g.,
Whites vs. Blacks). Overall, the IAT has been shown to
be both reliable and valid at detecting an individual_slevel
of implicit bias (Nosek et al., 2011). Three IATs are used in
this project: Race, Gender/Having a Professional Career,
and Age.
3. Racial/Ethnic Identity. The Black Racial Identity Attitude
Scale (BRIAS) and the White Racial Identity Attitude
Scale (WRIAS) were completed onsite by leaders and staff
who self-identified themselves as Black or White, respec-
tively (Helms, 1990). The BRIAS is a 60-item scale that
measures five statuses of Black racial identity development:
Conformity (17 items), Dissonance (8 items), Immersion
(14 items), Emersion (8 items), and Internalization (13 items).
The WRIAS is a 50-item scale and assesses six statuses of
White racial identity development: Contact, Disintegration,
Reintegration, Pseudoindependence, Immersion/Emersion,
and Autonomy. Each item has a 5-point response scale (1 =
strongly disagree to 5 = strongly agree), and there are 10 items
in each subscale. Item scores are added to determine the
subscale scores. Prior research has shown the validity of the
scale, and the internal consistency estimates ranged from
0.55 to 0.74 for the subscales (Helms & Carter, 1990).
Participants with other race/ethnicity completed the People
of Color Racial Identity Attitudes Scale; however, given the
small number of participants (n= 7 for postassessment), this
group was excluded from the analysis.
Organizational outcomes. 1. Diversity Climate. The
Diversity Perceptions Scale, which was completed online
by leadership and staff, is a 16-item questionnaire that
assesses employees_perceptions about diversity climate
(Barak, 2013). Each item in the scale uses a 6-point response
option (1 = strongly disagree to 6 = strongly agree). The scale
consists of two domains (organizational and personal dimen-
sions) and has been found to have appropriate construct
validity and adequate internal consistency (Barak, Cherin,
& Berkman, 1998). We focus on the organizational dimen-
sion, which refers to perceptions of management_spolicies,
procedures, and practices affecting diversity. This dimension
has two subscales: organizational fairness (Items 1Y6) and
organizational inclusion (Items 7Y10). An average score was
obtained for each subscale.
2. Workforce Diversity. UsingdatafromtheEqualEm-
ployment Opportunity_s Employer Information Report
(EEO-1), we compare workforce diversity for each interven-
tion and control hospital pre- and postintervention. Di-
versity is assessed in terms of percentage of women and
percentage of non-White minorities and is reported for the
following occupational categories: Executive/Senior Man-
agement, First/Mid Managers, Professionals, Technicians,
Administrative Support, and Service Workers.
Analysis
Descriptive statistics (means and standard deviations) were
calculated for all the measures used in this study both pre-
and postintervention. All hypotheses involving multiple
observations were evaluated by conducting ttests and chi-
square tests of the preYpost score differences and to test
whether the preYpost change score was significantly different
when comparing the intervention to the control hospital
within each system. Hypotheses involving single observa-
tions at the hospital level were evaluated descriptively by
comparing the change scores (before and after the inter-
vention) for intervention and control hospitals.
Findings
All eight hypotheses were supported or partially supported
for Intervention Hospital X, but only six of eight were sup-
ported or partially supported for Intervention Hospital Y.
The intervention hospitals outperformed their respective
control hospitals within each health system for change in
diversity leadership, strategic human resource management,
diversity climate, and all three individual level competen-
cies: diversity attitudes, implicit bias, racial/ethnic iden-
tity. Results were mixed for patient cultural competency
and workforce diversity. Results by competency and organi-
zational outcomes are presented in Table 2 and discussed
below.
Organizational Level Competencies
Diversity Leadership (Hypothesis 1a). Differences were observed
across the two systems in the NCHL Diversity Assessment
scores. Intervention Hospital X experienced greater positive
change in their total scores across all five dimensions,
whereas Hospital Y experienced a declinein all five dimen-
sions compared to the control hospitals. However, inter-
vention hospitals at both systems experienced higher change
scores in most CCATH diversity leadership dimensions,
compared to their respective control hospitals.
36 Health Care Management Review JanuaryYMarch &2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Table 2
Hypotheses and summary of findings
Hypotheses Measure Intervention
Hospital X vs. Control Intervention Hospital Y vs. Control
Hypothesis1a: Intervention
hospitals will experience
an increase in diversity
leadership compared to
the control hospitals.
NCHL Diversity
Assessment
Supported
Increase in total scores that
ranged from 1.0 (20.4%) for
Diversity Infrastructure to 0.4
(8.3%) for Diversity Leadership.
Increase in three dimensions
(out of 6): Data Collection on
Service Area (14.3, 23.4%);
Human Resources Practices
(14.3, 20%); and Leadership and
Strategic Planning (0.1, 8.5%)
Partially supported
Decrease in total scores that ranged
from 1.3 (27.6%) for Strategic
Orientation to 0.2 (3.4%) in
Diversity Leadership.
CCATH Increase in four dimensions (out of 6):
Leadership and Strategic Planning
(33.3 points, 199%); Data Collection
on Service Area (25, 25%);
Performance Management Systems
(25, 25%); and Human Resources
Practices (14.3, 25%).
Hypothesis 1b: Intervention
hospitals will experience
an increase in strategic
human resource
management compared
to the control hospitals.
Supported Supported
NCHL Healthcare
Leadership Index
Increase in scores that ranged
from 1.9 (41.3%) for
Governance to 0.2 (4.9%) for
Recruitment and Selection.
Increase in scores that ranged from
3.0 (54.9%) for Recruitment and
Selection to 0.2 (j5.0%) for Job
Design/Work System.
Hypothesis 1c: Intervention
hospitals will experience
an increase in patient
cultural competency
compared to the control
hospitals.
Partially supported Not supported
CCATH Increase in four dimensions
(out of 5): Clinical Cultural
Competency Practices (75,
97.5%); Interpreter Services:
Written Policies (50; 58.3%);
Quality of Interpreter Services
(33.3, 33.3%); and Translation
Services (20, 28.6%). Decrease
in availability of interpreter
services (j30 point, j50%).
Decrease in four dimensions (out of 5):
Translation Services (j30, j40%);
Interpreter Services: Written Policies
(j25, j25%); Quality Of Interpreter
Services (j33.4, j50.1%); and
Availability of Interpreter Services
(j10, j10%). Increase in one
dimension (out of 5): Clinical
Cultural Competency Practices
(25, 33.3%).
Hypothesis 2a: Participants
in intervention hospitals
will experience an
improvement in diversity
attitudes compared to
participants in control
hospitals.
Supported Supported
Discovering
Diversity
Assessment
Increase in seven dimensions
ranging from 2.1 (7.4%) for
Information to 0.25 (0.6%) for
Respect.
Increase in six dimensions ranging
from 1.3 (4.6%) for Stereotypes to
0.3 (1.0%) for Self-Awareness.
Hypothesis 2b: Participants
in intervention hospitals
will experience a
reduction in implicit bias
compared to participants
in control hospitals.
IAT scores for
age, gender,
and race
Supported
Greater reduction in the strong
preference for both young and
Whites. Significant shift from
neutral toward preference for
womenwithcareers.
Partially supported
Improved scores only for race. Shift
from preference for Whites to the
neutral and preference for Blacks.
Shift toward greater preference
for young and preference for men
with career relative to the control.
Hypothesis 2c: Participants
in intervention hospitals
will experience a greater
development in their
racial/ethnic identity
status compared to
participants in control
hospitals.
Partially supported
WRIAS
Partially supported
Whites experienced deterioration
in their racial identity profile
as evidenced by lower WRIAS
scores in the higher-order
dimensions (Immersion/
Emersion and Autonomy).
Whites experienced deterioration in
their racial identity profile as
evidenced by lower WRIAS scores
in the higher-order dimensions
(Immersion/Emersion and
Autonomy).
(continues)
Findings From the NCHL Diversity Demonstration Project 37
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Strategic Human Resource Management (Hypothesis 1b).
Intervention hospitals at both systems experienced greater
positive change scores across the dimensions of the Na-
tional Healthcare Leadership Index, compared to their
respective control hospitals.
Patient Cultural Competency (Hypothesis 1c). Differences
were observed across the two systems in the CCATH patient
cultural competency scores. Intervention Hospital X experienced
higher positive change scores across four dimensions (out of five),
whereas Hospital Y experienced a score decline in four CCATH
dimensions, compared to their respective control hospitals.
Individual Level Competencies
Diversity Attitudes (Hypothesis 2a). Intervention hospitals at
both systems experienced higher positive change scores in
most dimensions of the Discovering Diversity assessment,
compared to their respective control hospitals.
Implicit Bias (Hypothesis 2b). Differences were observed
across the two systems for the IAT scores for age, gender,
and race. Compared to its control, Intervention Hospital X
experienced greater reduction in the strong preference for
both young and Whites. Similarly, Intervention Hospital X
experienced a significant shift from neutral toward pref-
erence for women with careers. On the other hand, Inter-
vention Hospital Y experienced improved scores only for
race relative to the control hospital. Intervention Hospital Y
experienced a shift from preference for Whites to the
neutral and preference for Blacks. However, there was a
shift at Intervention Hospital Y toward greater preference
for young and preference for men with career relative to
the control.
Table 2
Hypotheses and summary of findings, Continued
Hypotheses Measure Intervention
Hospital X vs. Control Intervention Hospital Y vs. Control
BRIAS Blacks experienced
improvements in their
racial identity profile
postintervention, as
evidenced by the shift in the
BRIAS scores from the
lower-order to higher-order
dimensions
Blacks experienced improvements
in their racial identity profile
postintervention, as evidenced by
the shift in the BRIAS scores from
the lower-order to higher-order
dimensions
Hypothesis 3a: Intervention
hospitals will experience
greater improvement in
diversity climate
compared to the control
hospitals.
Supported Partially supported
Diversity Climate Positive increase in both
Organizational Inclusion (0.4,
8.9%) and Organizational
Fairness (0.1, 2.2%).
Both intervention and control had
negative change scores. However,
intervention hospital experienced
lower negative scores.
Hypothesis 3b: Intervention
hospitals will experience
a greater increase in the
diversity of their
workforce compared to
the control hospitals.
Partially supported Not supported
Workforce
Diversity
Human Resources Outcomes: Human Resources Outcomes:
Increase in racial/ethnic diversity
at the management level (for
both intervention and control
hospitals). Greater
improvement (16.4%) at
the intervention hospital.
Slight increase in the diversity of
service workers (both intervention
and control hospitals).
Percentage of women
decreased, 44.8% for
Management and 0.5%
among the Technicians.
Decrease in the racial/ethnic diversity
at the management level (both
intervention and control hospitals).
Increase in percentage of
women among Service
workers (3.3%), Professionals
(2.7%) and Administrative
support (1.1%).
Increase in percentage of women
in the Administrative support
category (4.0%).
Note. NCHL = National Center for Healthcare Leadership; CCATH = Cultural Competency Assessment Tool for Hospitals; WRIAS = White Racial
Identity Attitude Scale; BRIAS = Black Racial Identity Attitude Scale.
38 Health Care Management Review JanuaryYMarch &2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Racial/Ethnic Identity Status (Hypothesis 2c). Whites at
the intervention hospitals at both systems experienced
deterioration in their racial identity profile as evidenced
by lower WRIAS scores in the higher-order dimensions
(Immersion/Emersion and Autonomy) compared to their
respective control hospitals postintervention. However,
Blacks at the intervention hospitals at both systems expe-
rienced improvements in their racial/ethnic identity pro-
file postintervention, compared to their respective control
hospitals.
Organizational Outcomes
Diversity Climate (Hypothesis 3a). Differences were observed
across the two systems in the Diversity Perceptions scores.
Compared to its control, Intervention Hospital X experi-
enced more positive change for both Organizational Inclu-
sion and Organizational Fairness. In the case of Health
System Y, both intervention and control hospitals had
negative change scores; however, Intervention Hospital Y
experienced lower negative scores than the control hospital.
Workforce Diversity (Hypothesis 3b). Findings were mixed
with respect to the recruitment of non-White minorities.
Both control and intervention hospitals in Health System
X experienced increased racial/ethnic diversity at the man-
agement level, although Intervention Hospital X had a
greater improvement (16.7%) compared to its control. Both
control and intervention hospitals in Health System Y ex-
perienced a decrease in the racial/ethnic diversity at the
management level; however, there was a slight increase in the
diversity of service workers at both hospitals. With respect to
percentageof women, there was a decrease in the interven-
tion hospitals at both systems, particularly at the manage-
ment level, compared to their respective control hospitals.
Practice Implications and Discussion
Results of the demonstration project contribute to the
evidence base for adoption of the systems approach to
sustainable change in diversity and cultural competence
practices in hospitals. Overall performance improvement
was greater in each of the two intervention hospitals than
in the controlhospital within the same health care system.
Both intervention hospitals experienced improvements in
the organizational level competencies of diversity leader-
ship and strategic human resource management. Similarly,
improvements were observed in the individual level com-
petencies for diversity attitudes and implicit bias for Blacks
among the intervention hospitals. Furthermore, interven-
tion hospitals outperformed their respective control hospitals
with respect to diversity climate. As such, results suggest that
a focused and systematic approach to organizational change
when coupled with interventions that encourage individual
growth and development may be an effective approach to
building culturally competent health care organizations.
The hypothesized evolution in racial/ethnic identity
status for individual respondents in the intervention hos-
pitals as compared to the control hospitals was evident
only for Black respondents. In fact, White respondents_
racial identity status devolved to less developed statuses.
Blacks may have responded to the change to a more
diversity-focused context in the intervention hospitals with
personal growth, which may help explain these findings.
The early stages of a diversity initiative may produce back-
lash among Whites, which could explain the devolution
to lower-order White racial identity statuses observed in
this study postintervention.
Intervention Hospital X experienced an increase in the
racial/ethnic diversity of its management compared to the
control hospital; however, female representation in lead-
ership declined. This may have been a result of turnover
and male minorities being recruited to leadership positions
that were previously occupied by White women.
Intervention Hospital X had stronger performance im-
provement than Intervention Hospital Y across most
metrics of the study. Although both hospitals experi-
enced the same intervention, contextual differences may
have impacted the implementation of the intervention.
For example, qualitative analysis shows that Hospital X
was more successful than Hospital Y in the implemen-
tation of their organizational action plan as part of the
intervention. Postassessment interviews suggest that health
system factors, such as Hospital X having more direct con-
trol over the planning domains compared to Hospital Y,
may have impacted the implementation ofthe action plans.
The relatively long intervention period of over 2 years
may have limited the potentialimpact of the project in the
two participating hospitals. A shorter, more focused inter-
vention period may have produced better outcomes but
was precluded by competing priorities in the health system.
A strategic diversity initiative needs to be actively aligned
with other hospital and health system initiatives for it to
be effective.
One limitation of this study is that change in individual
level competencies was compared at the hospital level
because of turnover from pre- to postassessment. The
percentage of respondents who completed both the pre-
and postassessment ranged from a low of 7% to a high of
24%, so that specific individual_spreYpost intervention
change scores were not calculated. Anecdotal evidence
from leadership team postintervention group interviews
and observations by the diversity coach, however,
indicates that some of the turnover was due to the
project itself, which resulted in some departures by
individuals who were not supportive of the enhanced
organizational focus on diversity as well as the addition of
new staff who joined the hospital because of the diversity
focus. As such, the preYpost improvement in diversity
attitudes and preYpost reduction in implicit bias at both
intervention hospitals, relative to their control hospital,
Findings From the NCHL Diversity Demonstration Project 39
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
may be indicative of a more culturally competent workforce
postintervention.
Another study limitation is that the original demon-
stration project design called for preYpost collection of
additional outcomes measures. These included hospital-
level operating and total profit margins and nursing unit
level readmissions and mortality data. However, one health
system_s data were only available at the system level, not at
the hospital level, and patient outcomes data, including
HCAHPS, were not available at the nursing unit level in
either health system. As a consequence, although results
do lend support to the systems approach as a strategy to
implement best practices in diversity management as well as
build cultural competence in hospitals, no clear connection
can be drawn as to the impact of improved diversity man-
agement practices and cultural competence on financial or
patient outcomes.
The demonstration project involved control hospitals
and assessed change on a wide array of measures at the
organizational and individual levels. Despite these positive
aspects of the study design, only two health systems par-
ticipated in the project, and this small sample limits the
generalizability of the findings. Future research that also
employs a preYpost design with an intervention and control
hospital but involves more health systems and analyzes
additional outcome measures is needed to build on the
demonstration project_sfindings.
In summary, far too many health care organizations still
do not treat diversity management as a business imperative
and driver of strategy, and we have yet to achieve full
inclusion in the health care workplace and amelioration of
disparities in health and health care. The current focus on
population health calls for a strategic approach to diversity
management and organizational cultural competency. Sys-
tematic, multifaceted, and organizational level cultural com-
petency initiatives show promise in improving diversity
performance metrics and in aligning health care organiza-
tions with the opportunities and challenges of an increas-
ingly diverse population. However, these initiatives should
be aligned with other health system strategic priorities for
them to be effective.
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Findings From the NCHL Diversity Demonstration Project 41
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