three key demographic megatrends and...• today, people of color are already a majority in 48 of...

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Presented by:

David Hunt, J.D.Jerry BenstonCritical Measures, LLC.

Cultural Competence in Healthcare:Patient Care & Employment Implications

AGENDA

• Three Demographic Megatrends• Patient Care Implications• Employment and Employment Law Implications• The New Science of Unconscious Bias• The Culturally Competent Manager/Provider

Three Key Demographic Megatrends



Changing Demographics –United States

• Between now and the year 2050, almost 90% of U.S. population growth will come from Asian Americans, African-Americans and Hispanic-Americans.

• Today, people of color are already a majority in 48 of the nation’s 100 largest cities.

• Today, five states have “minority majorities.” They include: California, Hawaii, New Mexico, and Texas

• Six other states: Maryland, Florida, Mississippi, Georgia, New York and Arizona have non-white populations over 40%.

Source: “The Emerging Minority Marketplace: Minority Population

Growth 1995-2050.” U.S. Census Bureau September 21, 1999.

Trends in U.S. Immigration

• 1 of 10 global citizens today is a migrant.

• Immigration to the U.S. has tripled in the last 30 years.

• During the 1990s, the U.S. received over 13 million immigrants – the largest number in our nation’s history.

• We broke even that mark during the last decade.

• Significantly, most immigrants today no longer come from Western European nations with whom we have the most in common historically….

Source: The Economics of Necessity: Economic Report of the

President Underscores the Importance of Immigration. American

Immigration Law Foundation

Immigrant - Top 5MexicoPhilippinesChinaIndiaDR

Refugee - Top 5SomaliaRussiaCubaVietnamIran



Immigrants Bring New Cultural Influences

• Religion: Islam is now the fastest growing religion in the U.S.

• Language: 21 percent of Americans 5 years old and older speak a language other than English at home, with nearly half of those claiming to speak English less than "very well."

• America is now more linguistically diverse than Western Europe.

Three Demographic Megatrends –

City, County, State vs US (2014)

City of MilwaukeeCategory Milwaukee County Wisconsin U.S.

People of Color 63% 47% 18% 23%White not Hispanic 37% 53% 82% 77%Hispanic 17% 14% 7% 17%Foreign-Born 10% 9% 5% 13%Language Other Than 19% 16% 9% 21%English Spoken at Home (age 5+)

Notes: City of Milwaukee, Milwaukee County, State of Wisconsin and U.S. Census statistics all derived from U.S. Census Quick Facts (2014).

Patient Care Implications



1. Racial and Ethnic Disparities in Patient Outcomes

2. Providing Language Access to LEP Patients/Families

A. Medical – Quality/Safety IssueB. Legal – Civil Rights Issue (Title VI,

ADA)

3. Medical Disparities Resulting from Globally Mobile Populations

What is Cross-Cultural Healthcare?

Institute of Medicine Report Highlights Racial and Ethnic Disparities

• In 2003, the Institute of Medicine issued a major report entitled: “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”

• The report concluded that, “People of Color receive lower-quality health care than whites, even when insurance status, income, age and severity of conditions are comparable.”

• Major disparities were found in many key diagnostic areas: cardiovascular disease, cancer, stroke, kidney dialysis, HIV/AIDS, asthma, diabetes, mental health, maternal and child health.

Where Are We Today?

• A recent Agency for Healthcare Research and Quality (AHRQ) report notes that over 60 percent of disparities in quality of care have stayed the same or worsened for blacks, Asians and poor populations. Results for Hispanics were only slightly better.

• Racial health disparities cost the U.S. health system more than $57 billion a year, according to a report authored by researchers from Johns Hopkins University and the University of Maryland.

• Less than 23% of American hospitals collect REL data and tie it to patient outcomes to reduce disparities…



Disparities Have Not Improved

AHA Launches #123forEquity ProgramTo Reduce Racial & Ethnic Disparities

AHA’s #123forEquity Pledge to Act



Racial & Ethnic Disparities Are a Major Issue in Wisconsin

DH1

Medical Case for Language Access in Healthcare – Improved Quality, Safety

1. Language barriers are associated with poor quality of care in

emergency departments; inadequate communication of diagnosis,

treatment and prescribed medication; and higher rates of medical

errors.

2. According to one study, no interpreter was used in 46% of

emergency department cases involving patients with LEP.

3. Few clinicians receive training in working with interpreters; only 23

percent of U.S. teaching hospitals provide any such training and

most make it optional.

17

Medical Case for Language Access in Healthcare – Improved Quality, Safety

4. Glenn Flores conducted research on mistakes by inadequately

trained interpreters. His results showed:

• An average of 31 mistakes per doctor-patient visit

• Two-thirds could have negative consequences for patients

5. According to the Joint Commission, fully half of LEP patients who

reported adverse events experienced some degree of physical

harm – compared to less than a third of English speaking patients.

6. The same report found that the rate at which LEP patients suffered

permanent or severe harm or death was more than twice that of

English-speaking patients.

18

DH1 DAVID HUNT, 12/21/2016



More Hospitals Seeing LEP Patients

1. More hospitals are seeing LEP patients.

A. 80% of American hospitals encounter LEP frequently.

B. Yet less than 30 percent of U.S. hospitals have quality improvement efforts underway to improve the quality of their language access programs.

2. More doctors/clinics are treating LEP patients.

A. 97% of physicians have at least some LEP patients.

B. But only 56% of physicians are in practices that offer

interpreter services…

19

Who Is Entitled to Receive Language Access Services?

• Two major groups have language access rights: LEP under Title VI and Deaf and Hard of Hearing under ADA. New rights under ACA.

• Failing to provide language access is national origin discrimination

• More language access litigation under ADA than Title VI. Typical focus: hospitals.

• No private right of action under Title VI. Alexander v. Sandoval, 121 S.Ct. 1511 (2001).

• Plaintiffs may allege intentional discrimination.

• Do not have to be U.S. citizen to have language access rights under Title VI (“persons”).

• Language access rights not limited to patients.

Legal Issues Associated With

Language Access

• Informed Consent – invalid if not obtained by qualified interpreter. See: Quintero v. Encarnacion, Lexis 30228, 10th Cir. 2000; Snyder v. Ash, 596 N.E.2d 518 (1991)

• Breach of Provider’s Duty to Warn

• Breach of Patient’s Privacy Rights (HIPAA)

• Medical Malpractice – language access violations are civil rights violations which are typically not covered by medical malpractice insurance.

• EMTALA Violations – hospital emergency departments

• State Pharmacy Laws – counseling obligation



With 1 billion people crossing international borders each

year, there is no where in the world from which we are

remote and no one from whom we are disconnected.

Sometimes It Looks Like A….

• Horse …

• And gallops like a horse …

• But it’s a …..

Moral: In A Globally Mobile World,

Today’s Doctors Are Seeing More…



Diseases of Foreign Origin

M.D. Cultural Competence Results

1. 97% of MD’s had LEP patients. (Exactly on par with U.S. avg.)

2. Nearly half felt “less than well prepared” to care for these patients.

3. Primary care MDs often felt least prepared to provide care to LEP patients.

4. 30% did not use qualified interpreters to obtain informed consent. 50% did not record use of interpreter in pt’s medical record.

5. 92% treat immigrants and refugees.+60% = less than well prepared

6. 56% to 70% of MDs did not routinely ask about country of origin or recent travel history .

7. 52% of MDs unfamiliar with Schistosomaisis; 65% unfamiliar with Strongyloides – two of the five most common diseases found in immigrants and refugees to the United States;

Employment and Employment Law Implications



Managing Diversity – Why It Matters

1. Recruitment, hiring and retention

2. Productivity

3. Pro’s and Con’s of a diverse workforce.

4. Roles of managers and employees are culturally relative

5. Employment law is becoming diversity law.

• Nationally, 85% of new labor market entrants will come from three groups: women, people of color and recent immigrants.

• U.S. Bureau of Labor Statistics predicts a shortage of over 10 million workers in the next decade….

• The number one reason workers leave their jobs is…..

• Turnover is costly … on average 1.5 to 3 times the worker’s salary

Recruitment, Hiring and Retention

Susan Boyle – Britain’s Got Talent

– Great talent often doesn’t look and act like you…

– Can you spot great talent no matter how it is “packaged”?



Diversity and Productivity

• Effective diversity programs are associated with higher productivity (+18%). (National Urban League)

• Gallup found that 24.7 million U.S. workers, or 19%, are actively disengaged. Another 56% of workers were not engaged, while only 25% of workers were actively engaged. Result: 75% of workers are not fully engaged.

• “Actively disengaged" employees -- those fundamentally disconnected from their jobs -- cost the U.S. economy between $450 billion and $550 billion a year. (Gallup)

• What causes workers to disengage at work? One notable cause is DRI’s – Diversity Related Incident’s of Disrespect.

Workplace Incivility – DRI’s

• Studies have found that over 71 percent of the workforce has experienced some form of workplace incivility in the last five years. Incivility is evidenced by disrespectful behavior. Source: Don Zander, Brookings Institution, 2002

• Of the reported incidents of workplace-related DRI’s: 32% were related to gender; 28% were related to race; 20% were related to age; 14% were related to sexual orientation and 6% were related to religion.

Workplace Incivility – DRI’s

Fiscal Impact of Workplace Incivility:

Of those who experienced work-place related DRI’s:

• 28% lost work time avoiding the instigator of the incivility;

• 53% lost time worrying about the incident/future interactions;

• 37% believe their commitment at work declined;

• 22% have decreased their effort at work;

• 10% decreased the amount of time that they spent at work;

• 12% actually changed jobs to avoid the instigator.

Source: The Sparticus Group: 2003.



What is Workplace Bullying?

1. Workplace bullying is hard to define. Nevertheless:

2. Bullying is usually seen as acts or verbal comments that could 'mentally' hurt or isolate a person in the workplace.

3. Bullying may (or may not) involve negative physical contact.

4. Bullying usually involves repeated incidents or a pattern of behaviour that is intended to intimidate, offend, degrade or humiliate a particular person or group of people.

5. It has also been described as the assertion of power through aggression.

How Extensive Is Workplace Bullying In The United States?

How Does Race/Ethnicity Affect Workplace Bullying in the U.S.?



How Extensive Is Workplace Bullying In The Nursing Profession?

1. Researchers say that at least 85 percent of nurses have been verbally abused by a fellow nurse. Worldwide, experts estimate that one in three nurses quits her job because of bullying and that bullying—not wages—is the major cause of a global nursing shortage. (In the U.S., the Bureau of Labor Statistics projects that by 2022, there will be a shortfall of 1.05 million nurses.)

2. The Workplace Bullying Institute now receives more calls from nurses than from workers in any other field (36 percent vs. 25 percent from educators, the next-most-frequent callers).

3. The American Nurses Association adopted a new national policy position on workplace bullying in July 2015.

Communication and Teamwork

• Research shows that diverse work teams outperform homogenous work-teams.

• Diverse work-teams have many advantages:

– Superior problem-solving ability

– Innovation/creativity = new product/process ideas

– Unique insights into diverse patients/markets

• However, diverse work-teams also face several key challenges:

– Diverse teams take longer to “gel”. Decisions take longer

– Trust is a bigger issue.

– More conflict and different conflict styles

Managing Across Cultures

Egalitarian Societies Hierarchical Societies

Manager is objective, third-party neutral. (A resourceful democrat.)

Manager is paternal head of workforce family. (A benevolent autocrat.)

Hierarchy is tolerated, established for convenience.

Hierarchy valued as reflecting existential inequality between higher and lower classes.

Decentralized – fewer supervisory personnel.

Centralized – more supervisory personnel.

Managers rely on their own experience and subordinates.

Managers rely on superiors and on formal rules.

Subordinates expect to be consulted.

Subordinates expect to be told what to do.



Managing Across Cultures

Egalitarian Societies Hierarchical Societies

Subordinate-superior relations are pragmatic, objective.

Subordinate-superior relations are emotional and subjective.

Subordinates tend to their tasks. Subordinates tend to their superiors.

Privileges and status are tolerated but frowned upon.

Privileges and status symbols are expected, normal and popular.

Manager’s role is to be an informed generalist.

Manager’s role is to be a technical expert.

The New Science of Unconscious Bias

Unconscious Bias: How Does It Work?

• The problem? Too much information to process. Scientists estimate that we are exposed to as many as 11 million pieces of information at any one time, but our brains can only functionally deal with about 40.

• The solution? Mental short-cuts.

– The brain seeks to conserve energy.

– Decision-making, ambiguity, novelty and problem solving all take heavy cognitive reserve.

– We’ve evolved to have mental short cuts that save time and usually yield reliable results.



• The brain acts as a prediction-machine

• Wired for threat identification

• Seeks the simplest path to

conclusions

• 98% of mental processes are unconscious. Only 2% are conscious.

Race and the Brain

Perceptions of “Groupness” Distort Perception and Behavior

1. Experiments by Tajfel and others showed that, as soon as people are divided into groups – even on trivial or random bases –strong biases resulted.

2. Subjects perceived members of their group as more similar to them and members of other groups as more different.

3. Subjects saw in-group members highly differentiated individuals and out-group members as largely homogenous.

4. Subjects were better able to recall undesirable behavior of outgroup members than similar behavior of ingroup members.

5. Ingroup members failures were attributed to situational factors while outgroup failures were attributed to innate characteristics.

6. Subjects permitted to allocate monetary rewards maximized rewards to their own group and minimized rewards to outgroups.



Awareness: New Research re: Bias

1. In the past, bias was regarded as aberrant, conscious and intentional.

2. Today, we understand that bias is normative, unconscious and largely unintentional.

3. Social Cognition Theory establishes that mental categories and personal experiences become “hard-wired” into cognitive functioning.

4. Take the Implicit Association Test on the Web at: http://implicit.harvard.edu

Awareness: Bias Impacts Decisions

5. Unconscious biases are mostly triggered by primary factors such as race, gender and age.

6. Biases most likely to be activated by:

� stress

� time constraints

� multi-tasking

� need for closure

7. Question: to what extent do implicit biases impact physicians clinical decision-making?

https://implicit.harvard.edu



Key IAT Findings - Race

• Race: White participants consistently show a preference for White over Black on the IAT – a substantial majority of White IAT respondents (75% to 80%) show an automatic preference for White over Black. Data collected from this website consistently reveal approximately even numbers of Black respondents showing a pro-White bias as show a pro-Black bias.

• Other key race findings: younger people are just as likely to display an implicit race bias as older adults, women are as likely to display an implicit race bias as men and educational attainment appears to make no difference with respect to implicit race bias.

The “Big Five” Orchestras

• Chicago and Boston

– None of the Big Five employed more than 12% women until the 1980’s

– Blind auditions• Improved the chances that a woman would ultimately be hired

• Female musicians in the Big Five increased five-fold from 1970 to 2000

Orchestrating Impartiality: the Impact of “Blind” Auditions on Female Musicians, 94 Am. Econ. Rev. 715 (2000).



Are Emily & Greg More Employable than

Lakisha & Jamal?

• Study of actual racial hiring bias in Chicago and Boston

– Resumes sent to actual want ads

• 4 resumes per position – 2 “high” quality and 2 “low” quality

• African American sounding names assigned to one high quality and one low quality

– Primary measurement was the “callback” rate

– Results: people with "white-sounding" names are 50 percent more likely to get a response to their resume than are those with "black-sounding" names.

Marianne Bertrand and Sendhil Mullainathan, Are Emily and Greg More Employable Than Lakisha and Jamal? Field Experiment on Labor Market Discrimination, 94 Am. Econ. Rev. 991 (2004).

The Effect of Race and Sex on Physicians'

Recommendations for Cardiac Catheterization

• 720 physicians viewed recorded interviews

• Reviewed data about a hypothetical patient

• The physicians then made recommendations about that

patient's care

Source: Schulman et.al. NEJM 1999;340:618.

Battling Bias – As Individuals

1. Use tools to explore your own unconscious biases (IAT, ICS)

2. Slow down, shift from “think fast” brain systems (amygdala) to “think slow” brain systems (pre-frontal cortex). (Daniel Kahneman)

3. In particular, there are several strategies that appear to make a difference:

A. Information – re: the psychological basis of bias

B. Motivation - internal (vs. external) motivation to change

C. Individuation – learning to see diverse others as individuals rather than as members of groups.

D. Direct contact with members of other groups.

E. Working together on teams, as equals, in pursuit of common goals.

F. Context/environment – display positive images of leaders from diverse groups

3. Obtain 360 degree feedback from diverse employees/colleagues. Reverse mentoring processes can also help.



UCSF Doctors, Students ConfrontTheir Own Unconscious Biases

1. First year medical students, nursing students, pharmacy and dental students at the University of California San Francisco are learning about unconscious or implicit bias as part of their medical school curriculum.

2. Dr. Rene Salazar conducts the instruction on unconscious bias. Before class, students are asked to take various versions of the IAT (race, gender, age, weight, religion, color, etc.)

3. Only about a dozen medical schools in the U.S. are currently teaching students about unconscious bias.

Source: UCSF Doctors, Students Confront Their Own Unconscious Biases, April Dembosky, KQED News, State of Health, August 4, 2015. Online at: http://ww2.kqed.org/stateofhealth/2015/08/04/ucsf-doctors-students-confront-their-own-unconscious-bias/

Perspective-Taking

1. Another strategy to mitigate the impact of implicit bias is perspective-taking. Perspective taking is a conscious attempt to envision another person’s viewpoint.

2. Drwecki et. al. applied perspective-taking in a clinical setting.

3. Nurses were shown pictures of either Black or White patients with genuine expressions of pain and asked how much pain medication they recommended. Nurses told to use their best judgment recommended significantly more pain medication for White than Black patients, whereas Nurses instructed to imagine how the patient felt recommended equal analgesic treatment regardless of race. Drwecki BB, Moore, CF Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective taking. Pain. 2011:152(5):10001-6.

Battling Bias – Within Hospitals

1. Collect patient race, ethnicity and language (REL) data.

2. Tie patient REL data to patient outcomes. (



Cultural Competence – New Skills For Managers

Cultural Competence

Culturally Competent Leaders

Cultural

AwarenessCultural Sensitivity, Cultural Biases

Cultural

KnowledgeCultural World Views,

Theoretical & Conceptual Frameworks

Cultural SkillsCultural Assessment

Tools

Cultural

EncounterCultural Exposure, Cultural Practice

Ten Core Cross-Cultural Issues

1. Orientation: Individualistic vs. Collectivistic

2. Status: Achieved vs. Ascribed

3. Focus: Task vs. Relationship (Univ. Rules vs. Partic.)

4. Communication: High Context vs. Low Context

5. Time: Clock Time vs. Cyclical Time

6. Mental Processes: Linear vs. Lateral

7. Affect: Neutral vs. Emotional

8. Conflict Style: Harmony vs. Confrontation

9. Locus of Control: Internal vs. External (Fate)

10. Power: Egalitarian vs. Hierarchical.



The Culturally Competent Manager: Skills

• Culturally inquisitive, manages own biases

• Capable of perspective shifting

• Hires, retains, manages and mentors diverse workforce

• Trust building with diverse employees

• Cross-cultural communication

• Teambuilding

• Cross-cultural conflict resolution

• Issue-spots diversity-related employment matters that could create liability

• Masters the art of complaint handling

New Skills for the Clinically Competent Global Physician

1. How to conduct a culturally competent patient examination/history using the LEARN Model (Listen, Explain, Acknowledge, Recommend, Negotiate)

2. How lack of knowledge of epidemiological and pathophysiological differences may lead to unintended iatrogenic consequences.

3. How to work with patients using qualified medical interpreters & ASL

4. Understanding the Law of Language Access (implications for informed consent, medical malpractice and other legal issues)

5. Given the increase in globally mobile populations, physicians should know their patients national origin and travel history and be mindful of diseases endemic to other parts of the world that might share symptoms with diseases commonly seen in the U.S.

6. Health care providers should be aware of at least the five most common infectious diseases most commonly encountered in refugee populations.

New Skills for the Clinically Competent Global Physician

7. Cross-Cultural Medical Ethics (examples: cultural differences around death and dying, blood beliefs, surgery, organ transplants, mental health etc.)

8. Ethnopharmacology and its implications for current clinical practice

9. Understand the New Science of Unconscious Bias and its implications for clinical decision-making.

10. Be able to take a competent sexual history.

11. Be able to take a competent patient history from immigrant and/or refugee patients.



Questions? Contact Information

For Further Information:

David B. Hunt

President and CEO

Critical Measures, LLC.

(612) 746-1375

[email protected]

Website:

www.cmelearning.com

Website:


three key demographic megatrends and...• today, people of color are already a majority in 48 of...

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