Global Health & Cultural Competencies: Ebbin Dotson


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Providing a Business Case for Leadership Diversity

Ebbin Dotson, University of California at Berkeley

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  • Global Health & Cultural Competencies: Ebbin Dotson

    1. 1. 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
    2. 2. 40 Years of Moving Towards Culturally Competent Care <ul><li>Civil Rights Act of 1964 </li></ul><ul><li>Surgeon General’s Healthy People Initiative 1979 (2000, 2010, 2020) </li></ul><ul><li>1985 Secretary of Health Margaret Heckler Report </li></ul><ul><li>Institute of Medicine Reports </li></ul>
    3. 3. What Has 40 Years Taught Us? <ul><li>Health Disparities exist </li></ul><ul><li>System will not fix itself </li></ul><ul><li>Clinical awareness ≠ reductions </li></ul><ul><li>Culturally Competent Organization Myth </li></ul><ul><li>Financial investments = change??? </li></ul>
    4. 4. Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare Non-Minority Minority The Operation of Health Care Systems Discrimination: Biases, Stereotyping, and Uncertainty <ul><li>Clinical Appropriateness </li></ul><ul><ul><li>and Need </li></ul></ul><ul><li>Patient Preferences </li></ul>Quality of Health Care Health Care Disparity Populations with Equal Access to Health Care Gomes and McGuire, 2001 Difference
    5. 5. Buy or Sell? <ul><li>Financial Pressures </li></ul><ul><li>Clinically Unexplainable Quality Differences (Health Disparities) </li></ul><ul><li>Population Demographic Shift </li></ul><ul><li>Baby Boomer Retirement </li></ul><ul><li>…Investment in Leadership Diversity </li></ul>
    6. 6. Business Case for Leadership Diversity <ul><li>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: </li></ul><ul><ul><li>evaluate the influence of racial and ethnic diversity on decision-making, and </li></ul></ul><ul><ul><li>strategically manage its effect for the benefit of the organization. </li></ul></ul>
    7. 7. Research Aim <ul><li>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 </li></ul>
    8. 8. Research Questions <ul><li>Is leadership diversity related to financial outcomes in hospitals? </li></ul><ul><li>Is leadership diversity related to quality outcomes in the service population? </li></ul>
    9. 9. Study Design <ul><li>Setting </li></ul><ul><ul><li>Integrated Health System </li></ul></ul><ul><li>Sample </li></ul><ul><ul><li>24 Hospitals </li></ul></ul><ul><li>Period </li></ul><ul><ul><li>2003-2007 </li></ul></ul><ul><li>Methods </li></ul><ul><ul><li>Time Series Cross Sectional Approach </li></ul></ul>
    10. 10. Analytic Model Racial Concordance Leadership Diversity Financial Outcomes Quality Outcomes Patient Diversity
    11. 11. Diversity Categories <ul><li>Specified as Racial and Ethnic Diversity: </li></ul><ul><ul><li>African American (non-Hispanic Black) </li></ul></ul><ul><ul><li>Asian or Pacific Islander </li></ul></ul><ul><ul><li>European American (non-Hispanic White) </li></ul></ul><ul><ul><li>Hispanic American (non-White Hispanic) </li></ul></ul><ul><ul><li>African and Hispanic American Combined </li></ul></ul><ul><ul><li>People of Color Combined </li></ul></ul>
    12. 12. Process Variables <ul><li>Leadership Diversity </li></ul><ul><ul><li>A percentage of the number of leaders at senior levels </li></ul></ul><ul><li>Patient Diversity </li></ul><ul><ul><li>A percentage of all patients served by the hospital </li></ul></ul><ul><li>Racial Concordance </li></ul><ul><ul><li>A percent ratio of racially concordant pairs of leadership and patient diversity </li></ul></ul>
    13. 13. Outcome Variable – Financial Success <ul><li>Discharges </li></ul><ul><ul><li>Annual volume of inpatient discharges </li></ul></ul>
    14. 14. Outcome Variable - Quality <ul><li>Acute Myocardial Infarction Composite </li></ul><ul><ul><li>Aspirin at arrival </li></ul></ul><ul><ul><li>Aspirin prescribed at discharge </li></ul></ul><ul><ul><li>Angiotensin converting enzyme inhibitor (ACEI) for left ventricular systolic dysfunction ( LVSD) </li></ul></ul><ul><ul><li>Adult smoking cessation advice/counseling </li></ul></ul><ul><ul><li>Beta blocker at arrival </li></ul></ul><ul><ul><li>Beta blocker prescribed at discharge </li></ul></ul>
    15. 15. Outcome Variable - Quality <ul><li>Heart Failure Composite </li></ul><ul><ul><li>Discharge instructions </li></ul></ul><ul><ul><li>Left ventrical function (LVF) assessment </li></ul></ul><ul><ul><li>Angiotensin converting enzyme inhibitor (ACEI) for left ventricular systolic dysfunction ( LVSD) </li></ul></ul><ul><ul><li>Adult smoking cessation advice/counseling </li></ul></ul>
    16. 16. Covariates <ul><li>Bed Size </li></ul><ul><li>Average Length of Stay </li></ul><ul><li>Medical Center Location </li></ul><ul><li>Leadership Gender </li></ul><ul><li>Years worked in Organization </li></ul>
    17. 17. Characteristics of the Sample <ul><li>Leadership Diversity = 34% People of Color </li></ul><ul><li>Patient Diversity = 43% People of Color </li></ul><ul><li>Bed Size = 271 </li></ul><ul><li>Average Length of Stay = 3.83 days </li></ul><ul><li>Leadership Gender = 22% Women </li></ul><ul><li>Seniority = 13 years </li></ul><ul><li>Annual Discharges = 16,310 </li></ul><ul><li>AMI Composite = 88% </li></ul><ul><li>HF Composite = 73% </li></ul>
    18. 18. Hypothesis Testing <ul><li>Hypothesis 1: </li></ul><ul><ul><li>Greater leadership diversity is negatively associated with discharges in a hospital. </li></ul></ul><ul><li>Hypothesis 2: </li></ul><ul><ul><li>Greater leadership diversity is positively associated with quality outcomes in a hospital. </li></ul></ul>
    19. 19. Results – Financial Success <ul><li> Discharges </li></ul><ul><li>African American -10023** </li></ul><ul><li>Asian or Pacific Islander -8080** </li></ul><ul><li>European American 6900** </li></ul><ul><li>African and Hispanic American -7067* </li></ul>(*p<.10; **p<.05; ***p<.001)
    20. 20. Results – Financial Success <ul><li> Discharges </li></ul><ul><li>Average Length of Stay -1164** </li></ul><ul><li>Seniority 151** </li></ul><ul><li>Region -3137** </li></ul><ul><li>Bed Size 46*** </li></ul>(*p<.10; **p<.05; ***p<.001)
    21. 21. Results – Quality of Care <ul><li>Acute Myocardial Infarction Measure </li></ul><ul><ul><li>No main effect </li></ul></ul><ul><li>Heart Failure Measure </li></ul><ul><ul><li>No main effect </li></ul></ul>
    22. 22. Discussion <ul><li>Mixed support for increasing leadership diversity </li></ul><ul><ul><li>Financial Implications </li></ul></ul><ul><ul><ul><li>Strategic Perspective </li></ul></ul></ul><ul><ul><ul><li>Institutional Perspective </li></ul></ul></ul><ul><ul><li>Quality Implications </li></ul></ul><ul><ul><ul><li>Theory or Implementation Failure? </li></ul></ul></ul>
    23. 23. Limitations <ul><li>Available Data </li></ul><ul><ul><li>Financial Success </li></ul></ul><ul><ul><li>Patient and Quality </li></ul></ul><ul><li>Generalizability </li></ul><ul><ul><li>Sample size </li></ul></ul><ul><ul><li>Specific to integrated health system </li></ul></ul>
    24. 24. Research Contributions to Public Health <ul><li>Empirical support for investment in racial and ethnic diversity </li></ul><ul><li>New avenue for cost implications (both savings and resource needs) </li></ul><ul><li>New level of understanding factors associated with health disparities </li></ul><ul><li>Enhancing pathway for cultural competence </li></ul>
    25. 25. Future Research <ul><li>Expanding the potential of a managerial solution to health disparities </li></ul><ul><li>Exploring how various organizational structures address health disparities </li></ul><ul><li>Examining the return on investment of cultural programs </li></ul>
    26. 26. Questions
    27. 27. Organizational Performance <ul><li>Importance of Top-Down Leadership </li></ul><ul><li>Linkage to Leadership Skills </li></ul><ul><li>Environmental Constraints </li></ul>
    28. 28. Evidence of Diversity Performance <ul><li>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 </li></ul><ul><ul><ul><ul><ul><li>Hartenian and Gudmunson, 2000 </li></ul></ul></ul></ul></ul><ul><li>Firms with top management teams composed of persons from different functional backgrounds experience more positive financial returns </li></ul><ul><ul><ul><ul><ul><li>Korn, Milliken, and Lant, 1992 </li></ul></ul></ul></ul></ul><ul><li>Educational training among top management team members has been shown to be positively related to return on investment and sales growth </li></ul><ul><ul><ul><ul><ul><li>Smith et al., 1994 </li></ul></ul></ul></ul></ul>
    29. 29. Evidence of Race-Based Quality Issues <ul><li>Heart Disease: </li></ul><ul><ul><li>Leading cause of death in US </li></ul></ul><ul><ul><li>At the top of health disparities list </li></ul></ul><ul><ul><ul><li>Especially cardiac care </li></ul></ul></ul><ul><ul><ul><li>Linked to many other illnesses </li></ul></ul></ul><ul><ul><li>Issues with access to cardiologists in medically underserved areas </li></ul></ul>
    30. 30. 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
    31. 31. Heart of the Matter Managerial Factors Health Disparities Social Determinants of Health Health Status Quality of Care