An Ecological Approach to Organizational Cultural Competence
Judith Sabino, MPH; Eric Gertner, MD, MPH; Erica Mahady, MA; Lynn Deitrick, PhD, RN; Jarret Patton, MD; Mary Kay Grim; James Geiger; and Debbie Salas-Lopez, MD, MPH

LehighValley Health Network, Allentown, PA

Lehigh Valley Health Network (LVHN) is an academic-community hospital and the largest regional provider of health services in mid-eastern Pennsylvania. LVHN is composed of nearly 1,000 beds across three hospital sites, eight health centers in four counties, a 400-member physician group with numerous primary and specialty care physician practices, as well as home health services and hospice care. The 1,100-member medical staff includes more than 800 board-certified providers in 95 specialties. A member of the Council of Teaching Hospitals, LVHN is among the largest teaching hospitals in Pennsylvania, providing education and clinical training for 278 residents in 17 programs. LVHN’s medical staff and its nearly 9,800 employees help to make it among America’s Best Hospitals for 15 years (USNews and World Report), one of the 10 Best Hospitals in America in 2009 (Becker's Hospital Review), and a Magnet hospital since 2002.LVHN’s quality outcomes are in the top 5 performers in the University Health System Consortium. Earlier this year, LVHN was the recipient of the Carolyn Boone Lewis Living the Vision Award from the American Hospital Association for efforts to improve the community’s health through actions that go beyond traditional hospital care. In 2010, the network’s CancerCenterwas selected by the National Cancer Institute to join a national network of community cancer centers offering expanded research opportunities and state-of-the-art cancer care, with an emphasis on reducing ethnic/racial disparities.

Serving over 800,000 people living in urban, suburban, and rural communities in east central Pennsylvania, LVHN’s service area is located about 50 miles north of Philadelphia and 80 miles west of New York City. Historically an industrial center, it had been a destination for European immigrants seeking employment since the late 1860’s. In the area’s largest city, Allentown, the Latino population has nearly tripled since 1990 and as of 2006 is 36% of the city’s total population (U.S. Census Bureau 2006-8). Growth in Middle Eastern and Southeast Asian populations is also being seen in the region.

History. A foundation of culturally-competent services (including telephonic interpreter services, translated educational materials and unit-specific cultural sensitivity projects) existed within LVHN for many years, most notably at the most urban hospital site. However, the impetus for a significant organizational culture change to truly embrace diversity and ensure the delivery of culturally and linguisticallyappropriate care began following a patient-centered experience retreat in 2006. Former patients, family members and community representatives spoke honestly about medical encounters in which they believed health providers and staff members were not attentive to their cultural backgrounds and language preferences. This “transformational event” launched a cultural competency project within LVHN’s patient and family-centered care initiative.

Network Cultural Competency Project. Two members of the senior management team were so moved by the passionate pleas of patients and family members that, following the retreat, they assembled a multi-disciplinary team of hospital personnel to strategically plan a system-wide cultural competency project. Assessments[1][2] were conducted to prioritize needs and set strategic direction. These assessments found:

  • Improvements were necessary to ensure the valid collection of patient race, ethnicity and language preference data. Like many other hospitals, LVHN’s collection of these data was not standardized and, subsequently, the data could not be confidently used to describe the racial/ethnic backgrounds of its patients.
  • The demographics of LVHN’s service area were changing over time. More remarkably in the urban areas, but evident across the region, minority populations were growing. In the service area’s largest city (Allentown), the Latino population nearly tripled since 1990 and it comprised more than one-third of the total population by 2006.
  • The racial and ethnic distribution of the employee population was not concordant with the service region demographics.

These assessment findings and the community feedback from the patient-experience retreat were used to identify goals and improvement opportunities that formed LVHN’s first cultural competency strategic plan.

Following the senior management approval of the strategic plan in July 2007, the Cultural Awareness Implementation Team (CAIT) was formed and held its first meeting in September 2007. The 44-member group was assembled with representatives from all levels and parts of the health network that had a strong passion for culturally-responsive care delivery. Through the use of a structured project management process, in a 24-month period, several organizational changes occurred to improve the network’s ability to care for patients from diverse backgrounds. Among these achievements included:

  • standard collection of patient race and ethnicity data,
  • growth in the interpreter program (including the use of video remote interpretation for deaf and hard of hearing individuals),
  • increased attention to recruiting and retaining diverse employees,
  • behavioral expectations regarding acceptance of diversity on annual employee performance appraisals,
  • measurement of employee satisfaction regarding equal opportunity for promotion regardless of race, religion, gender, age, ethnic background or disability,
  • completion of an intercultural sensitivity assessment of network physicians and employees,
  • acquisition of additional staff educational programming, including mandatory instruction on cultural competency,
  • senior management establishment of a network-wide equitable care goal in FY10 and FY11,
  • creation of a small learning collaborative of LVHN physicians, researchers and staff members was formed to strengthen our collective capacities to analyze cultural competency data, publish findings and secure external funding for future projects,
  • publications describing LVHN’s organizational cultural awareness activities in the professional literature.

Current Efforts. The provision of cross cultural health care enables LVHN to respond to demographic changes in its service area, reduce health disparities among patients with diverse racial, ethnic and cultural backgrounds; assure the delivery of high-quality, patient-centered services; and meet legislative, regulatory and accreditation mandates. Our goal is to assure that cross cultural health care practices are woven into the fabric of our organization and its benefits are experienced by patients, family members and co-workers across the continuum of care. The Cultural Awareness Leadership Council, comprised of senior leaders from across all organizational units, oversee and advocate for the implementation of strategies to meet our overall goals.

Current efforts build upon the foundation of our earlier work with the goal of diffusing cross cultural health care services throughout our organization. Specific strategies are directed to patient centered initiatives, employee initiatives and quality initiatives.

Ensuring effective communication between patients (and their families) with health care providers was an early focus of our efforts. Telephone interpretation (24/7) was enhanced with staff interpreters (and employees cross-trained in language interpretation) in hospital and outpatient sites in 2004. Today more than 17,000 patients have requested interpretation services when they receive health care at our facilities. Extending beyond oral communication, bilingual and bicultural health care services were enhanced when Centro de Salud opened in 2004. All of the services of this primary care practice are delivered in Spanish by health care providers of Latino descent. Health education and disease management services extend beyond the walls of LVHN through the outreach work of several promotoras (or lay health advisors).

Based on the composition of their patient populations, certain network units, such as our AIDS Activities Office, have a long history of cultural and language appropriate care. Unit-wide strategies, including language provision, multi-cultural staff recruitment, continuing education, community outreach, patient advisory groups as well as performance improvement based upon quality outcomes stratified by patient race/ethnicity are often piloted in these departments before being implemented network-wide.

Over the past six years, the total LVHN employee group has become more diverse, as evidenced by the higher proportion growth rates among non-White employee racial/ethnic categories as compared to growth among Whites.Focused efforts in the hospital-based ambulatory practices have resulted in patients interacting with providers who share their language and cultural backgrounds. In addition, expectations regarding fostering and valuing diversity were established for employees and managers through the PRIDEinitiative as well as the addition of behavioral expectations on the annual performance appraisals.

The results of a baseline assessment on employee intercultural sensitivity suggested that network employees have respect for cultural differences and enjoy intercultural encounters, however they seek information and skills to increase their confidence these interactions. These findings have been used to design effective educational programming (including the content, format and facilitation of skill development within programs). Today, LVHN offers more than 15 educational programs on diversity and cross cultural care for staff with varied backgrounds and job responsibilities (including new employee and clinical orientation, management education, and care provider training). In FY11, all staff members are required to take part in at least one of these educational programs. In addition, user-friendly cross cultural information and decision support tools are available to all staff members via our internal Intranet system.

We search out and take advantage of opportunities to link messages about cross cultural health care delivery to existing well-accepted communication venues. For example, the Autumn 2009 issue of LVHN’s patient safety newsletter (which is required reading for all clinical employees) focused on the importance of culturally and linguistically appropriate service delivery on the provision of safe and high quality health care. Likewise, the September 2010 Patient Education newsletter discussed the importance of valid translation processes for multi-lingual educational materials.

Since the standardization of patient race/ethnicity data collection in late 2008, initial efforts have been undertaken to use these data to measure the provision of equitable care. Studies are underway in the Departments of Obstetrics as well as Medicine (with a focus on re-admission rates and diabetes management markers) as well as obstetrics to identify, and then address, any disparities in the quality of care provided for patients and families.

Earlier this year, a question measuring our patients’ satisfaction of staff responses to their cultural needs was added to all of our patient satisfaction surveys. These data will be used to monitor overall patient satisfaction as well as indicate those departments in need to consultation to support improvements.

Current Goals. A new strategic plan was completed in September 2010 based on the National Quality Forum’s (NQF) Framework and Preferred Practices for Cultural Competency.[3] Objectives have been developed the NQF’s seven domains: Leadership Engagement, Management Systems/Operations, Care Delivery, Patient-Provider Communication, Workforce Diversity and Education, Community Engagement and Quality Improvement. Key activities within this work will be the continuing alignment with network initiatives, including the development of accountable care tactics and structures within our organization.

Examples of objectives include:

  • Annual organizational goal related to the delivery of equitable care,
  • Network-wide initiatives related to equitable care ( for example, disparity reduction activities through the NCI National Community Cancer Center Project),
  • Compliance with new Joint Commission requirements,
  • New educational programming on effective interpreter-facilitated interactions,
  • Annual Employee Diversity report to measure concordance between race/ethnicity of staff and patients,
  • Annual staff education on cross cultural care for personnel at all organizational levels and sections (including new medical students),
  • Community representative involvement in Cultural Awareness Leadership Council,
  • Continual monitoring and improvements in REAL data collection,
  • Pilot disparity identification and quality improvement projects,
  • Tracking of responses to patient satisfaction survey question related to patient cultural needs.

Greatest Successes: We have been fortunate to experience many successes in the course of our work. Perhaps the greatest of the successes has been the engagement of our organization’s senior leaders and their endorsement of this work in all parts of our organization. This advocacy has given cultural awareness a priority among many competing initiatives and engaged key individuals that are essential to the implementation of our plans. It was through this leadership that goals related to the provision of equitable health care were included among our network goals in each of the last two fiscal years.

In addition, our ability to accomplish almost all of the goals in our first strategic plan provided a firm foundation and a history of success that launched new initiatives and encouraged additional champions to join our work.

How were successes achieved: Several factors accounted for our success, including:

  • the engagement and passion of our executive sponsors who represented both the administrative and clinical parts of the organization and their influence to bring their leadership colleagues on board,
  • the alignment of cultural awareness with high profile internal initiatives with shared goals (such as new Joint Commission requirements, patient safety, patient satisfaction, patient-centered care, Magnet designation),
  • a solid strategic planning and project implementation process (including change management and project management techniques) that ensured the achievement of goals,
  • finally, engagement of hospital colleagues who share a strong passion for cultural awareness.

How to get leadership on board: The following strategies were used to engage our leadership:

  • maintaining the patient-centered focus of this work (patient-centeredness is already a strong organizational focus),
  • the power of the transformational event (an ideal patient experience retreat) to engage and sustain leadership commitment,
  • tying cultural awareness to established network goals,
  • ongoing communication of cultural awareness achievements in internal and external venues (including organizational goal attainment and external recognition such as the American Hospital Association Institute for Diversity recognition,
  • engagement of national cultural awareness experts (who are respected by leadership) to provide feedback and next steps for our work.

Tips for other organizations:

  • Understand where your leadership stands relative to cross-cultural care delivery. Fully engage leaders who are already advocates and work with them to gain commitment from entire leadership team. Take advantage of “transformational” events that strengthen leadership buy-in and provide a sense of urgency and shared vision among multiple stakeholders.
  • Invest the time and energy into a structured strategic planning and implementation process (with change management and project management methodologies) to ensure the overall success of your initiative.
  • Align and integrate cultural awareness work into existing organizational priorities and initiatives (such as medical student and resident curriculum development, patient safety education, management and leadership development, patient satisfaction surveys). In this way, we seek to have cultural awareness “in the pipes”[4] of our organization.
  • Align with external factors that support your goals, eg New Jersey’s legislation that required cultural awareness education for physician licensure; Joint Commission requirements, etc.
  • Identify and engage a cadre of multi-disciplinary “champions” who have the authority and responsibility to passionately promote cultural awareness in their units and departments.
  • Consider an “operationalization” approach in which cultural awareness is responsibility of all manager/leaders (not the work of a single “office” or “center”). Cultural awareness staff members provide leadership, expertise and consultation to organizational managers and staff members to ensure the delivery of cross cultural health care.

Publications: You can learn more about some of our cultural awareness initiatives in the following publications:

  1. Salas-Lopez, D., Gertner, E., O’Neill, O. (2009). Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Delisser, H., Hark, L. (Eds.), The Case of Isabel Delgado. (chapter 4) Blackwell Publishing: April 2009
  2. Sabino, J., Friel, T., Deitrick, L., Salas-Lopez, D. “Striving for Cultural Competence in an HIV Program: the transformative impact of a microscystem in a larger health network.” Health & Social Work. 34(4): 309-313. November 2009.
  3. Deitrick, L., Paxton, S., Rivera, A., Gertner, E., Biery, N., Letcher, A., Lahoz, L., Maldonado,E., Salas-Lopez, D. “Understanding the Role of the Promotora in a Latino Diabetes Education Program.” Qualitative Health Research. 20(3) 386-399. February 9, 2010.
  4. Salas-Lopez, D., Woodburn, C., Sabino, J., “Seeing Each Patient as a ‘Culture of One’.” Medical Economics. TWISI. Pg. 40. April 9, 2010.
  5. Gertner, E., Sabino, J., Mahady, E., Deitrick, L., Patton, J., Grim, MK., Geiger, J., Salas-Lopez, D. “Developing a Culturally Competent Health Network: A Planning Framework and Guide." Journal of Healthcare Management. May/June, 2010 Volume 55, Number 3; pages 190-205.

Greatest challenges and how to respond to them: Often in today’s health care environment, assuring that we have the resources needed to accomplish our goals can be our biggest challenge. We have used the following strategies to address this issue: 1) Seek and secure external funds for initial and novel efforts (for example, a local philanthropy funded the early phases of our interpreter program, the development of Centro de Salud, unit-based cultural competency programming in the AIDS Activities Office and staff educational resources); 2) align your work to already-funded programs (for example, regulatory affairs offices already have funding to meet Joint Commission requirements); and 3) frame resource requests within the context of existing organizational commitments (such as patient safety, risk management, patient satisfaction, etc.).