Global Health & Cultural Competencies: Ebbin Dotson

Providing a Business Case in Leadership Diversity Ebbin Dotson, Ph.D., M.H.S.A. Global Health and Cultural Competencies Global Health Education Consortium Conference April 5, 2009

40 Years of Moving Towards Culturally Competent Care
Civil Rights Act of 1964
Surgeon General’s Healthy People Initiative 1979 (2000, 2010, 2020)
1985 Secretary of Health Margaret Heckler Report
Institute of Medicine Reports

What Has 40 Years Taught Us?
Health Disparities exist
System will not fix itself
Clinical awareness ≠ reductions
Culturally Competent Organization Myth
Financial investments = change???

Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare Non-Minority Minority The Operation of Health Care Systems Discrimination: Biases, Stereotyping, and Uncertainty
Clinical Appropriateness
and Need
Patient Preferences
Quality of Health Care Health Care Disparity Populations with Equal Access to Health Care Gomes and McGuire, 2001 Difference

Buy or Sell?
Financial Pressures
Clinically Unexplainable Quality Differences (Health Disparities)
Population Demographic Shift
Baby Boomer Retirement
…Investment in Leadership Diversity

Business Case for Leadership Diversity
Defined as a business decision that is uniquely tied to an organization’s institutionalized practices, the business case for leadership diversity calls for executive leadership to:
evaluate the influence of racial and ethnic diversity on decision-making, and
strategically manage its effect for the benefit of the organization.

Research Aim
To explore the relationship between the racial and ethnic diversity of hospital leadership and whether it impacts financial and quality outcomes of hospitals and the patients served

Research Questions
Is leadership diversity related to financial outcomes in hospitals?
Is leadership diversity related to quality outcomes in the service population?

Study Design
Setting
Integrated Health System
Sample
24 Hospitals
Period
2003-2007
Methods
Time Series Cross Sectional Approach

Analytic Model Racial Concordance Leadership Diversity Financial Outcomes Quality Outcomes Patient Diversity

Diversity Categories
Specified as Racial and Ethnic Diversity:
African American (non-Hispanic Black)
Asian or Pacific Islander
European American (non-Hispanic White)
Hispanic American (non-White Hispanic)
African and Hispanic American Combined
People of Color Combined

Process Variables
Leadership Diversity
A percentage of the number of leaders at senior levels
Patient Diversity
A percentage of all patients served by the hospital
Racial Concordance
A percent ratio of racially concordant pairs of leadership and patient diversity

Outcome Variable – Financial Success
Discharges
Annual volume of inpatient discharges

Outcome Variable - Quality
Acute Myocardial Infarction Composite
Aspirin at arrival
Aspirin prescribed at discharge
Angiotensin converting enzyme inhibitor (ACEI) for left ventricular systolic dysfunction ( LVSD)
Adult smoking cessation advice/counseling
Beta blocker at arrival
Beta blocker prescribed at discharge

Outcome Variable - Quality
Heart Failure Composite
Discharge instructions
Left ventrical function (LVF) assessment
Angiotensin converting enzyme inhibitor (ACEI) for left ventricular systolic dysfunction ( LVSD)
Adult smoking cessation advice/counseling

Covariates
Bed Size
Average Length of Stay
Medical Center Location
Leadership Gender
Years worked in Organization

Characteristics of the Sample
Leadership Diversity = 34% People of Color
Patient Diversity = 43% People of Color
Bed Size = 271
Average Length of Stay = 3.83 days
Leadership Gender = 22% Women
Seniority = 13 years
Annual Discharges = 16,310
AMI Composite = 88%
HF Composite = 73%

Hypothesis Testing
Hypothesis 1:
Greater leadership diversity is negatively associated with discharges in a hospital.
Hypothesis 2:
Greater leadership diversity is positively associated with quality outcomes in a hospital.

Results – Financial Success
Discharges
African American -10023**
Asian or Pacific Islander -8080**
European American 6900**
African and Hispanic American -7067*
(*p<.10; **p<.05; ***p<.001)

Results – Financial Success
Discharges
Average Length of Stay -1164**
Seniority 151**
Region -3137**
Bed Size 46***
(*p<.10; **p<.05; ***p<.001)

Results – Quality of Care
Acute Myocardial Infarction Measure
No main effect
Heart Failure Measure
No main effect

Discussion
Mixed support for increasing leadership diversity
Financial Implications
Strategic Perspective
Institutional Perspective
Quality Implications
Theory or Implementation Failure?

Limitations
Available Data
Financial Success
Patient and Quality
Generalizability
Sample size
Specific to integrated health system

Research Contributions to Public Health
Empirical support for investment in racial and ethnic diversity
New avenue for cost implications (both savings and resource needs)
New level of understanding factors associated with health disparities
Enhancing pathway for cultural competence

Future Research
Expanding the potential of a managerial solution to health disparities
Exploring how various organizational structures address health disparities
Examining the return on investment of cultural programs

Questions

Organizational Performance
Importance of Top-Down Leadership
Linkage to Leadership Skills
Environmental Constraints

Evidence of Diversity Performance
Small firms with more culturally diverse work forces were found to have a greater positive percent change in revenue, net income, and CEO income than small firms with less culturally diverse work forces
Hartenian and Gudmunson, 2000
Firms with top management teams composed of persons from different functional backgrounds experience more positive financial returns
Korn, Milliken, and Lant, 1992
Educational training among top management team members has been shown to be positively related to return on investment and sales growth
Smith et al., 1994

Evidence of Race-Based Quality Issues
Heart Disease:
Leading cause of death in US
At the top of health disparities list
Especially cardiac care
Linked to many other illnesses
Issues with access to cardiologists in medically underserved areas

Environmental Pressures Clinical Guidelines Changing Demographics Business Case for Leadership Diversity Business Case for Leadership Diversity Business Case for Leadership Diversity Cultural Competency Competition Increasing Costs Economy Technology Employers Reimbursement Workforce Shortages Retirement Diversity Technology Legal Governmental External Environment Internal Environment

Heart of the Matter Managerial Factors Health Disparities Social Determinants of Health Health Status Quality of Care

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Global Health & Cultural Competencies: Ebbin Dotson

by UWGlobalHealth on Apr 15, 2009

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