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Delivering high-quality health care equally to all patients may be a matter of common decency, but unfortunately, it’s not always common practice. Discrimination in health care can open organizations to serious legal problems and cause patient satisfaction scores to plummet.
It’s hard to know exactly how widespread the problem is, but studies conducted in individual health care markets paint an alarming picture. Most recently, the Seattle and King County (WA) public health department released a study that showed fully one in 10 people of color reported discrimination in health care episodes.
But you can take action — whether you know you have a problem or simply suspect you might. You can start by gathering what data you have:
• Make sure patient satisfaction surveys contain a component on discrimination and differential treatment. "I think it’s hard for people to talk about their differential treatment," says Michael Smyser, MPH, an epidemiologist with the Seattle and King County public health department. "They want to move beyond it, and the reluctance increases if the environment isn’t perceived as friendly." Special training for interviewers can help. But Smyser says that for many there will be a fear of retaliation. "They might worry that their care will be compromised further, and they will hold back."
• Check the racial and ethnic data you already maintain on your own computer systems, says Lisa Evans, JD, research analyst at the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) in Washington, DC. Ethnic data also often are provided to the state by hospitals and health plans. You can use these data to determine where patients come from and what treatment they receive.
"I don’t think very many hospitals collect these kind of data on their own," says Evans. "And if they do, it’s more than likely that a disenfranchised group has approached them with concerns, and they are responding to that. But it can provide a wealth of information."
For instance, in New York state, hospital discharge data that include racial identification were instrumental in showing that certain minorities didn’t go to certain hospitals for treatment. "They showed this graphically," Evans explains. "You could see clearly where they lived and where they went."
• Consider using the federal government as a resource. Evans says the OCR isn’t just there to respond to complaints; it also can be used as an investigative tool if you are interested in looking at racial and ethnic data. "If you come to us and say we have a problem or we want to look at this, that is part of what we are charged with doing," she says. "We are charged with helping facilities obtain voluntary compliance, not terminating federal funding if you do something wrong."
Should you wait for data to take action? Tom Lonner, PhD, research manager at the Cross Cultural Health Care Program in Seattle, contends very little gets done in this area without some evidence proving you have a problem. "Advances are made in competition with other compelling choices," he says. "And the evidence for these investments must be sound and, often, specific to the institution or agency making the decision. More generic conditions of the world’ will not move folks to action."
Evans disagrees. "Data are helpful because they focus your attention," she says. "But most of the time when action is taken, it isn’t the result of complaints being filed but about people who are interested in getting together to address the perception and reality of differentiation in health care."
If you are moved to act immediately, there are some simple actions you can take:
• Make sure consumers know their rights and what actions they can take to make sure grievances are addressed, says Smyser. Publicize and post your policies.
• Provide interpreter services where needed. You can formally hire people, keep them on-call on a contract basis, use volunteers, or have an ad-hoc program that utilizes staff, patients’ family members, or even strangers from the waiting room. But Evans warns that this should not be your only action.
• Recruit, hire, and retain a diverse work force, and make sure you maintain, enforce, and publicize a nondiscriminatory workplace policy that is known and understood by all staff.
According to a recent literature review on cultural competency,1 having more minority staff can create a more welcoming environment to minorities. Among the programs a hospital can try are setting up minority residency or fellowship programs, having senior executives mentor minority employees, and tracking staff satisfaction by racial and ethnic groupings.
According to Mike Carter, Region II manager for the OCR, who you hire should largely mimic who you serve. "If your staff don’t look like who you market to, you may have a problem."
• Provide cultural competency training. "This is something you have to continually work on," Smyser says. Although 90% of the discriminatory events reported in the King County study were attributed to a physician, nurse, or other provider, all staff should be involved in cultural competency training. "And this has to be worked into a person’s evaluation," he says. But note that a literature review found that shorter courses and didactic approaches are not as effective as other methods.1
• Coordinate with traditional healers. Native American healers, acupuncturists, holistic medi-cine providers, and others should be included in caring for patients who use them so there is a continuity of care. Patients whose providers exhibit knowledge and are nonjudgmental in questioning are more likely to give honest responses about herbal or other remedies they are using.
• Make use of community health workers to provide outreach and liaison services between patients and providers.
• Make your health promotion materials culturally competent. Take into account different beliefs among races about diseases, such as breast cancer, where minority women are much less likely to get mammograms and often present much later with breast cancer.
• Include family and community members where appropriate. In many cultures, the patient isn’t the focus, but rather the family. Mexican-Americans and Korean-Americans are more likely to prefer that family members be involved in decision making, and such family members are crucial to ensuring compliance.
There are assessments you can do yourself to determine how culturally competent you are. Carter, who worked on the New York project that found disparities between where minority patients lived and where they went for health care, worked with New York health care providers and organizations to develop an assessment tool that anyone can use. (For sample tool, see "Do you discriminate? An internal self-assessment tool," in this issue.)
Alternatively, you can ask for assistance from your regional OCR office or one of the numerous private organizations that work in minority health care.
1. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review 2000; 57:187-217.
[For more information, contact:
• Michael Smyser, MPH, Epidemiologist, Public Health — Seattle & King County, Wells Fargo Center, Suite 1200, 999 Third Ave., Seattle, WA 98104. Telephone: (206) 296-6817.
• Tom Lonner, PhD, Research Manager, Cross Cultural Health Care Program, 1200 12th Ave. S., Seattle, WA 98144. Telephone: (206) 326-4161.
• Lisa Evans, JD, Senior Civil Rights Analyst, Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington, DC 20201. Telephone: (202) 260-7645.
• Mike Carter, Regional Manager, Office for Civil Rights, U.S. Department of Health and Human Services, Region II, Jacob Javits Federal Bldg., 26 Federal Plaza, Suite 3312, New York, NY 10278. Telephone: (212) 264-3313.]
• The Department of Health & Human Services Office for Civil Rights (OCR): www.dhhs.gov/ocr/. Includes news, office newsletters, regulations, and contact information for every regional OCR office.
• The Cross Cultural Health Care Program: www.xculture.org/. Conducts cultural competency training. Web site includes a comprehensive list of on-line and hard-copy resources.
• The Center for Cross-Cultural Health: www.crosshealth.com/. A Minneapolis-based training and resource organization that also lists web links and other resources for visitors.
• The Agency for Healthcare Research & Quality: www.ahrq.gov/. The agency’s web site has a minority health subindex that includes research findings and initiatives, as well as articles on the topic of racial disparity.