Cultural Competence Honors Human Dignity

July-August 2015


Nancy Stahl

Anna, a fair-skinned little girl, was experiencing dizziness, fatigue, headaches and trouble breathing. Her mother brought her to the hospital, where doctors ran tests and found nothing wrong. They prescribed fluids and an antibiotic, then sent Anna home.

Anna's condition got worse, and her parents rushed her back to the hospital. This time, in the presence of Anna's mother and father, hospital staff recognized a crucial oversight they had made during the child's previous visit. No one had checked her ethnic background. Due to her light complexion, hospital staff had assumed Anna was white. However, Anna's father is black, and Anna is biracial. Because of Anna's light complexion, the doctors did not check her for sickle cell anemia, a disease found primarily in African-Americans. Upon realizing the mistake, doctors made a correct diagnosis, treated Anna appropriately and then released her.

A culturally competent provider might have inquired about Anna's ethnicity upon first examining her. A hospital system that systematically collects race, ethnicity and language (REAL) data could have instantly communicated her African-American heritage to the care team. Unfortunately, neither occurred and, as a result, the health care system failed both Anna and her parents.

Trinity Health, based in Livonia, Michigan, is one of the many health care organizations hard at work to provide culturally competent health care. As vice president of the Office of Inclusion and Collaboration at Trinity Health, I am committed to this goal. As an individual deeply affected by two tragic life events, I have made it my life's work.

In 2005, my husband suffered a massive heart attack while walking home from his job as a high school educator. A passerby saw him collapse on the side of the road and informed a county sheriff. I eventually was notified and rushed to the hospital, only to discover that my husband had passed away. Then, just one year later, my son was enjoying the birthday celebration of his 2-year-old daughter when he was shot by an occupant of a car cruising down the street. I pleaded with the doctor to do everything possible to save my son but, sadly, he too passed away.

In both instances, I wondered whether every available option had been used to save the lives of these two upstanding African-American men. Is it possible that unconscious bias could have played a role in the level of care they received? Were there any other assumptions made? Could these deaths possibly have been prevented?

Upon further, deeper reflection, these events fueled my passion for ensuring that all human beings receive equitable health care, and that we all try to eliminate undesirable treatment outcomes that result from cultural incompetence.

I learned there are many books, articles and research studies that have reported on the existence of health disparities among systems of care. The Institute of Medicine's 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, was published a year before the Agency for Healthcare Research Quality issued the first national comprehensive report on disparities, with guidance from the IOM. Data and analysis show that not only do racial and ethnic minority groups receive inequitable care, but so do women, children, low-income people and those requiring end-of-life care.

Soon after arriving at Trinity Health, I was assigned to lead a system-wide team of subject-matter experts, a group called the Equity of Care team. The goal was to collect our health ministries' patient demographic data in a standardized manner. We reviewed our patient information systems for the ability to collect patients' preferred language, religion, ethnicity and race categories as defined by the U. S. Office of Management and Budget. We designed and delivered educational material on why we were asking these questions and how patient registrars should ask them. The team also developed a communication strategy to inform internal colleagues and the communities we serve about why we were collecting REAL data.

Finally, the team designed a policy template to standardize collection of patient demographic data. An important point: The policy required patient registrars to ask the patient to self-identify, as opposed to simply performing a visual assumption of a patient's race or ethnicity.


Trinity Health has a moral imperative for fostering an inclusive environment. You see it in our core value of reverence — we honor the sacredness and dignity of every person. This applies to our patients and our employees. Just recently, my department changed its name from the Office of Diversity and Inclusion to the Office of Inclusion and Collaboration. I believe this new terminology more accurately represents the transformational and strategic way we strive to address the needs of the people we serve and of those with whom we work. When we changed the name, we wanted to create an engaged workforce that recognized our existing colleagues' diverse skills, talents and backgrounds.

Our office does this through our mentoring program and our colleague-led business resource groups, which are affinity groups. We partner with human resources in various functions, that is, in talent development, talent acquisition and succession planning. We must collaborate to ensure that diversity and inclusion are considered in their strategic planning to build a people-centered system together.

We are driven by our guiding principles, formed by the spirit of the Gospel and the heart of Catholic health care, which compel us to:

• Serve all persons who are in need of healing

• Recognize and celebrate the dignity of the human person and honor each person's culture, spirituality and faith tradition

• Foster a culture that attracts a diverse global community that welcomes neighbor and stranger alike

Inspired by these guiding principles, our leadership created a strategic plan called People-Centered 2020. Currently being implemented, the plan contains six focus areas: people-centered care; engaged colleagues; operational excellence; physicians and clinicians; leadership nationally; and effective stewardship. The initiatives and milestones associated with the plan drive all our activities. Our inclusion and collaboration efforts fall neatly into the focus areas of people-centered care and engaged colleagues.

Incorporating inclusion and collaboration into our strategic plan was a very deliberate act. We feel that it's more than just the right thing to do — it's also good business. Demographically, we are becoming a more diverse nation. Today's workforce and consumer marketplace is a dynamic mix of different cultures, ages, races, lifestyles, genders and more. Statistics emerging from recent U.S. and Canadian census and labor force reports confirm that our consumer base and talent pools are shifting. These demographic shifts, as well as emerging market realities, continually create new demands and opportunities. We must be flexible enough to respond to these factors in an increasingly competitive environment. An inclusive, collaborative and diverse workforce enables us to do this.


Trinity Health founded what is now named the Office of Inclusion and Collaboration in 2007 with the primary goal of advancing the collection of REAL data. The cautionary tale about Anna underscores the importance of this effort. The office also is responsible for diversity and inclusion consulting across the system that may result in targeted training, coaching, program design and implementation as it relates to colleague recruitment, development, retention, communication, commitment and accountability. My team works very closely with talent acquisition to ensure that we recruit from the widest possible net of potential colleagues.

In May 2013, Trinity Health and Catholic Health East officially came together, and one result was the launch, led by Clayton Fitzhugh, Trinity Health's executive vice president and chief human resource officer, of the Leadership Advisory Council.

The council is designed as a catalyst for achieving diversity and inclusion objectives by creating accountability and purposeful action at the leadership level. The council advises Trinity Health executive leadership, governing boards and the Office of Inclusion and Collaboration on opportunities and challenges associated with creating an inclusive workplace. The council also gives strategic direction to executive leadership on ways of addressing health disparities.

Collaborative initiatives are another way the Office of Inclusion and Collaboration works across the organization. Already underway are partnerships with several of our regional health ministries to deliver targeted diversity initiatives via consulting. For example, the inclusion and collaboration office developed a cultural proficiency plan to capture all improvement efforts aligned with one regional health ministry's community health needs assessment and other regulatory requirements.

For another regional health ministry, the Office of Inclusion and Collaboration is recommending a strategy for employed physician diversity training. In addition, the office started a diversity management series, a quarterly training course open to middle management and above. The topic of its first training series will be unconscious bias.


The 2013 Health Disparities and Inequalities Report from the Centers for Disease Control and Prevention noted that health disparities among minority populations are widespread. The African-American, Hispanic, Asian-American, American Indian and Alaska Native populations suffer from higher mortality rates than other populations, and disease is detected at a later stage — and is not always well treated. There are higher rates of diabetes among African-Americans, American Indians and Alaska Natives than in the white population. The Asian-American and Pacific Islander populations suffer from higher than average rates of illnesses including heart disease, liver and cervical cancer, as well as diabetes.

Barriers to equitable care range from social determinants, to access, to unconscious bias. Various factors contribute, but we know that improving cultural competency will make us better health care providers. When health care providers are less diverse and lack cultural awareness, the opportunities for health care disparities rise, as there is generally a lesser degree of cultural competency between provider and patient. The Office of Inclusion and Collaboration offers education to help foster cultural proficiency.

Recently, I completed the Disparities Leadership Program (DLP) at Massachusetts General Hospital in Boston, a year-long, hands-on executive education program focused on helping health care leaders deliver equitable, quality care. The program is designed to help attendees translate the latest understanding of disparities into realistic solutions they can take back and adopt within their organizations. Using what I learned in the program, I helped create an accountability plan for Trinity Health to address disparities in health care. This was in alignment with our diversity and collaboration efforts, in that disparities are closely linked with culturally incompetent health care practices.

The plan's key components include a standardized methodology for assessing initiatives, a standardized plan to address identified disparities in care, and embedding disparities analysis and interventions into all clinical care improvement activities.


At Trinity Health, accountability for inclusion, collaboration and diversity starts at the top. President and CEO Richard Gilfillan, MD, is our chief inclusion officer. The strategy, which cascades down through the entire organization, recognizes that diverse colleagues can bring different ideas, perceptions and problem-solving abilities to the table.

The board of directors strongly supports inclusion and the value it brings to an organization. Trinity Health board member Joseph Betancourt, MD, is an expert in cross-culture care and communication. He often advises the government, health care systems and the public and private sectors on strategies to improve quality of care and eliminate disparities.

Trinity Health embraces the concept that being an inclusive, collaborative and diverse organization is a source of strength. By creating a diverse environment, we are creating an organization that is better equipped to achieve our mission of being a compassionate and transforming healing presence within our communities — a presence that delivers equitable, people-centered care to everyone, including the next little girl like Anna who comes through our doors.

ANTOINETTE GREEN is vice president, Office of Inclusion and Collaboration, Trinity Health, Livonia, Michigan.


For more information on the Disparities Leadership Program, please visit the Disparities Solutions Center at Massachusetts General Hospital at www.massgeneral.org/disparitiessolutions.

Cultural Competence Honors Human Dignity

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