Professional Documents
Culture Documents
Glossary 429
Index 439
LIST OF FIGURES
Figure 1.1. Systematic Approach to Development of Cultural
Competence 5
Figure 1.2. Systems Approach to Diversity and Cultural Competence 27
Figure 3.1. Model of Factors Affecting Career Advancement of Women
and People of Color 85
Figure 5.1. Grubb Institute’s Transforming Experience Framework 153
Figure 5.2. Lifeline Graph 161
Figure 6.1. The Healing-by-Heart Model for Culturally Responsive
Health Care 203
Figure 10.1. Conceptual Framework for the Impact of Organizational
Behavior on Disparities 340
Figure 10.2. Diversity-Sensitive Orientation and Organizational
Performance 342
Figure 10.3. Relationship Among Diversity, Leadership, and Effective
Communication 348
Figure 10.4. Organizational Behavior to Build Inclusion and Ameliorate
Disparities 352
Figure 11.1. Sodexo’s Ten Key Elements for Inclusion and Systemic
Cultural Change 381
Figure 11.2. Fishbone Diagram: Root Causes of Racial and Ethnic Patient
Satisfaction Gap 396
Figure 12.1. Percent of the US Population in Each Racial and Ethnic
Group, 2000 and 2010 407
Figure 12.2. Percent Change in the US Population Under Age Eighteen,
2000–2010 408
Figure 12.3. Percent of the Population in Each Racial and Ethnic Group by
Age, 2010 409
Figure 12.4. Force Field Analysis 423
LIST OF TABLES
Table 1.1. The Seven Dimensions of Diversity 6
Table 2.1. US Race and Ethnicity Demographics, by Percent 38
Table 2.2. Data Collection Standards for Ethnicity and Race 40
Table 3.1. Comparisons of Labor Force Entrants and Leavers by Race
and Ethnicity 1998–2008 and 2008–2018, Projected 79
Table 3.2. Composition of US Labor Force by Gender, Race, and
Ethnicity, 1998, 2008, 2018, Projected, by Percent 79
Table 3.3. Health Professions Gender, Racial, and Ethnic Demographics and
Representation Relative to Workforce Representation, 2011 81
Table 3.4. Median Weekly Earnings by Gender for Selected Health
Professions, 2010 84
Table 3.5. Educational Attainment for People over Twenty-Five by Gender,
Race, and Ethnicity, 2010, by Percent 88
Table 5.1. Journey of Self-Discovery: Action Plan 166
Table 7.1. Six Prominent Models from Transcultural Nursing 226
Table 9.1. Minority Status Group Identity Development 303
Table 9.2. Majority Status Group Identity Development 304
Table 11.1. DiversityInc Top Five Hospital Systems, 2010–2012 377
Table 11.2. Institute for Diversity in Health Management Benchmarking
Survey 2009: Best in Class Hospitals on Three or More
Dimensions 391
Major changes are occurring in the US population and the nation’s health care
institutions and delivery systems. The population is aging rapidly, with the
proportion of senior citizens to youthful workers becoming larger than it has ever
been. The population is increasingly ethnically and racially diverse, and groups
that were long ignored in health care, such as the LGBT community, are being
recognized as having specific health needs that are not being met. The health care
enterprise, with all its integrated and disparate parts, has been slow to respond to
the needs of our rapidly diversifying population. Millions are uninsured in a
system in which insurance is critical to receiving health care, and enormous
disparities in health status are visible across diverse groups in the nation’s pop-
ulation. Legislation, such as the Affordable Care Act of 2010, is driving change
in the way health care services are delivered. Health care institutions, public and
private, are seeing the need to recognize and respond to the needs of discrete
population groups.
This book was written as an argument for the incorporation of cultural com-
petence and diversity management as important components of the current and
emerging systems of health care in the United States. In this argument, we recognize
that health care in this country is actually the integration of three systems: a pre-
vention and curative treatment system, a workforce system, and a business system.
The book identifies cultural competence and diversity management as integral to all
three systems.
All three authors have worked intimately for more than twenty-five years with
health care systems at all levels: national, state and local governments, professional
associations, and public and private health care delivery organizations. We see cul-
tural competence and diversity management as essential elements of any workable
system organized to meet the needs of all Americans.
as an important strategy of health care is reviewed as are guides and models for cul-
turally competent care.
Chapter Five describes the complex processes underlying personal biases
toward others, both implicit and explicit. It discusses the nature of professional
resistance to training in cultural competence. A framework for transforming the
role of the health care professional to explicitly include the perspectives of cultural
competence is presented. Chapter Six emphasizes training modalities that include
general and specific kinds of knowledge and skills needed by health care man-
agers, clinicians, and frontline workers in order to be culturally competent in the
work they do.
The chapters in Part Three, “Cultural Competence and Health Care Delivery,”
address specific issues in cultural competence as they relate to interactions between
health care providers and diverse patients. Chapter Seven focuses our attention on
the most fundamental element in health care: the patient-provider interaction.
The chapter describes several conceptual models that can assist clinicians in pre-
paring for crosscultural transactions. Chapter Eight introduces the critical issue of
language access in the United States, where 8 percent of the population has no or
limited proficiency in English. It examines the severity of issues that can arise in
a health care setting when interpretation and translation are not available, the
legislation and regulation that have developed around the provisions of lang-
uage services, as well as several model programs and practices that health care
organizations have devised to reduce language barriers. Chapter Nine examines the
process of group identity development and the role that group identity plays in
the delivery of health care services. The operation of in-group–out-group behavior
and relationships are described and their effect on health care delivery is explored.
Part Four, the last section of the book, is devoted to cultural competence as it
relates to and is expressed in diversity management, organizational behavior, and
policy. Chapter Ten explains why organizational behavior is essential to a systems
approach to cultural competence. It describes the practices that create a culture of
inclusion in which people can perform to their highest potential, providing a
motivating context for culturally competent health care. Chapter Eleven makes
the business case for culturally competent health care organizations by pointing to
improvements in productivity, patient satisfaction, health outcomes, and market
expansion that accrue to diversity management of the workforce and the provi-
sion of culturally competent health care. Chapter Twelve explores the future of
diversity and cultural competence in health care with emphasis on the continuing
When a book is the product of three people each spending over twenty years
working in complementary fields such as diversity management and cultural
competence, there are many, many people who have provided important insights,
education, counsel, and support along the way. We are particularly grateful for the
long-term, pioneering inspiration and collaborative support of Julia Puebla-Fortier
of Diversity Rx; Robert C. Like, MD, of the Center for Healthy Families and
Cultural Diversity; Tawara Goode of the National Center for Cultural Compe-
tence; Guadalupe Pacheco of the Office of Minority Health; Joseph Betancourt,
MD, of the Disparities Solutions Center; Beatriz Solis of L.A. Care; Fred Hobby of
the Institute for Diversity in Health Management; and Rob Weech-Maldonado
of the University of Alabama. Without their innovation, collegial spirit, and, yes,
dogged persistence, the fields of cultural competence and diversity management
would not have developed as fully as they have!
Jan Dreachslin owes special thanks to Portia Hunt of Temple University, her
treasured mentor, colleague, and friend, whose love, guidance, and encouragement
were key to her development in the field of diversity management over the last
thirty-plus years. She is grateful to the American College of Healthcare Executives
for the 1999 Health Management Research Award that was instrumental in
launching her exploration of the role that leadership behavior and organizational
practices play in the delivery of culturally and linguistically appropriate care.
Subsequent and ongoing support from the National Center for Health Care
Leadership and Sodexo ensured that her work in the field would continue to
evolve.
Jean Gilbert owes special thanks to the many doctors and managers of Kaiser
Permanente who willingly embraced the concepts of cultural competence and
taught her much about patient care and the structuring of health care delivery.
She benefitted from learning about medical interpretation and translation from
colleagues Gayle Tang and Cindy Roat and is thankful for the insights they shared.
The California Endowment is also gratefully acknowledged for the strong support
they provide for culturally and linguistically appropriate health care services in
general and also for the specific support they provided for Gilbert’s research on
medical interpretation in clinical settings and the development of the Principles and
Standards for the Cultural Competence Education of Health Care Professionals.
Bev Malone is indebted to Drs. Hattie B. Bessent and Gloria Smith, who lived
a commitment to diversity and inclusion in their clinical and organizational work.
Dr. Bessent, with the wisdom of those over eighty years old, is still developing
creative strategies to include minority professionals as leaders in the care of others.
Bev also wants to extend a special thank-you to Dr. David Satcher, former surgeon
general and assistant secretary for health during the Clinton administration, who
provided supervision, mentoring, and inspiration to her as she took up the role of
deputy assistant secretary for health. Finally she wishes to extend kudos to her
British colleagues, Bruce Irvine, Jean Reed, and John Bazalgette, who believe in co-
creation when working with organizations, differences, and others honoring the
person in their role in the system.
We are all indebted to the health care managers, clinicians, and consultants
who work every day to ensure that diverse patients receive culturally and lin-
guistically appropriate care and that health care organizations and their leaders
engage in best practices in diversity management.
233
Thomas Lloyd. The Trial of Alexander Addison, Esq.,
Lancaster, 1803, pp. 1–168.
234
William Hamilton. Report of the Trial and Acquittal of
Edward Shippen, Chief Justice, and Jasper Yeates and
Thomas Smith, Assistant Justices of the Supreme Court
of Pennsylvania, on an Impeachment before the Senate
of the Commonwealth, January, 1805, Lancaster, pp. 1–
587.
235
The Commonwealth, August 28, 1805.
236
The Commonwealth, December 25, 1805.
237
Onward Bates. Bates et al. of Virginia and Missouri,
Chicago, 1914, p. 45.
238
Onward Bates. Bates et al. of Virginia and Missouri,
Chicago, 1914, pp. 43–52.
239
The Commonwealth, January 8, 1806.
240
Collinson Read. Abridgement of the Laws of
Pennsylvania, Philadelphia, MDCCCI, p. 383.
241
The Commonwealth, January 15, 1806.
242
The Commonwealth, January 8, 1806.
243
Onward Bates. Bates et al. of Virginia and Missouri,
Chicago, 1914, p. 57.
244
William G. Johnston. Life and Reminiscences, Pittsburgh,
MCMI, p. 36.
245
Pittsburgh Gazette, December 22, 1798.
246
Major Ebenezer Denny. Military Journal, Philadelphia,
1859, pp. 21–30; ibid., pp. 29–30.
247
Pittsburgh Gazette, August 2, 1794.
248
Pittsburgh Gazette, June 14, 1794.
249
Pittsburgh Gazette, May 20, 1803.
250
Tree of Liberty, May 15, 1802.
251
Pittsburgh Gazette, September 6, 1794.
252
Pittsburgh Gazette, October 24, 1800; Tree of Liberty,
October 18, 1800.
253
Pittsburgh Gazette, March 30, 1799.
254
Pittsburgh Gazette, May 21, 1802.
255
Isaac Harris. General Business Directory of the Cities of
Pittsburgh and Allegheny, Pittsburgh, 1841, p. 6.
256
Pittsburgh Gazette, April 6, 1799.
257
Pittsburgh Gazette, July 1, 1799.
258
Pittsburgh Gazette, May 21, 1802.
259
H. M. Brackenridge. “Pittsburgh in the Olden Time,” The
Literary Examiner and Western Monthly Review,
Pittsburgh, Pa., 1839, pp. 27–29.
260
Centennial Volume of the First Presbyterian Church of
Pittsburgh, Pa., 1784–1884, Pittsburgh, 1884, p. 152.
261
Pittsburgh Gazette, October 10, 1800; ibid., December 16,
1802.
262
Pittsburgh Gazette, August 16, 1800.
263
Pittsburgh Gazette, October 17, 1800.
264
William G. Johnston. Life and Reminiscences, Pittsburgh,
MCMI, p. 68.
265
Pittsburgh Gazette, May 15, 1801.
266
Pittsburgh Gazette, October 13, 1798.
267
H. M. Brackenridge. “Pittsburgh in The Olden Time,” The
Literary Examiner and Western Monthly Review,
Pittsburgh, Pa., 1839, pp. 27–29; William G. Johnston.
Life and Reminiscences, Pittsburgh, MCMI, pp. 67–68.
268
Pittsburgh Gazette, February 1, 1800.
269
Pittsburgh Gazette, November 14, 1800; ibid., July 2, 1802.
270
Pittsburgh Gazette, August 28, 1801; ibid., August 5, 1803.
CHAPTER VIII
ZADOK CRAMER