For this week's discussion we have a case study that deals with the good, bad, and ugly of diversity. The topic can be somewhat touchy, but hey, we gotta be real.

As always, there are no right or wrong answers. Let's hear your thoughts or if you prefer you can answer the questions at the end of the case study.

Heritage Valley Medical Center: Are Your Managers Culturally Competent?

Heritage Valley Medical Center was very proud of its reputation for providing quality services for all citizens in the community. Over the last 20 years, the Medical Center had flourished, and both staff and health professionals in the organization were committed to its shared values and its respect for all patients and their families. Services were provided to a community whose residents were 80% Caucasian, 15% African American, and 5% Hispanic.

However, in the last 5 years, the population had gradually changed to 50% Caucasian, 40% African American, and 10% Hispanic and Asian American. The Center's occupancy rates were down to 40%, given that many of its traditional, more affluent, private-pay patients had moved out into the suburbs to escape the urban sprawl that comes with development.

The Medical Center administrator first noticed a change when the patient mix became more diverse. After the State Health Indigent Care Fund was established, Medicaid reimbursement increased, making it comparable to those of managed care organizations.

It was strategically imperative to capture this new market and these potential revenues, particularly since most of the indigent and Medicaid recipients were minorities. Heritage Valley started a major marketing campaign and developed alliances with physicians, community clinics, and public health agencies to increase its referrals of Medicaid and indigent patients to capitalize on this new source of revenue.

By year 3 of this strategic initiative, the increase in minority patients had jumped from approximately 10% to 40% (primarily African American and Hispanics). Many of the Hispanics were immigrants with work permits for the construction boom in the affluent areas of the county and surrounding suburbs. Even though there was an increase in minority patients, the ethnicity of the service providers remained at previous levels. Eighty-five percent of the clinical staff members, including physicians, nurses, laboratory technologists, pharmacists, and therapists, were Caucasian. There were two African American managers and one Hispanic manager.

The executive management team was 100% Caucasian, with one female. The majority of the support and administrative staff (secretaries, human resource technicians, nurse's aides) were African American. In some of the support areas (e.g., dietary or environmental services), the staff was 100% African American. There was little turnover, and the clinical and support staff were like family, since the majority of them had worked at Heritage for more than 15 years, and shared similar values and principles about valuing every patient and treating each patient with respect.

At a management meeting with administrative directors, the vice president of community relations, Ms. Harper, shared the results of a recent patient satisfaction survey, which indicated that while 80% of the Caucasian patients were very satisfied with their care, only 30% of African Americans, 10% of Hispanics, and 20% of Asians were satisfied.

She was very concerned about the reasons for dissatisfaction. At the top of the list for all three ethnic groups was the reason "I don't feel welcomed here." The second was "people talk down to me," and the third was "the nurses don't seem to understand me." When asked for feedback and how to improve these results, the nursing director immediately defended her staff. She made it clear that she had one of the most caring, attentive, and qualified nursing staffs in the county. She could not understand how these minority patients could be so ungrateful.

"These people will never be satisfied unless they can get something for nothing. Half of them can't even speak English and the others mess up the King's English so badly you don't know what they want. We can't help it if these people are uneducated, can't speak the language, and don't know how to communicate with professional people.

My nurses and nurse aides are doing the best they can to work with these people, even when they are too limited to understand basic information." Following this feedback, several other managers also voiced their support for the nursing staff because their employees had complained about these same issues. They wanted to let the vice president know their opinions, of which the following comments were representative:

Most of these patients won't even look us in the eye. We can hardly get any information out of them.

It takes twice as long to deal with Hispanics and Asians because they can barely speak English. They should learn to speak English and get with the program. It's not the employees' fault that these people can't speak the language.

There is absolutely no excuse for those Black patients. They were born here and still cannot speak English. We have done everything for them-given them a free ride for education, jobs, and housing. If anything, they are driving away our few remaining paying patients with their loud conversations and by bringing family members and children with them who are always acting ghetto and foolish.

These patients are not satisfied? Has anybody considered what we have to put up with? These people are just ungrateful complainers!

The two African American managers were asked what they thought about the patients' feedback. Both of them agreed with their colleagues, saying:

"Those Hispanics and Asians need to learn how to speak English. This is America-what do they expect? We can only do so much. As for those Asians, they should speak up and stop being so passive. You can't get them to talk; they bring every family member with them and they speak Chinese or Vietnamese while you're trying to help them. Sometimes I think they are talking about us right in front of our faces. Plus, they think they are better than other minorities; they are cli

quish and they don't want to be a part of anything. How can we ever understand them when they won't talk to us?"

The male Hispanic manager was very upset about the African Americans' and Caucasians' feedback about Hispanics. He felt that Hispanic patients were being unnecessarily targeted because they were the most vulnerable. He knew that they were hard-working people just trying to make a living, doing work no one else would. To blame them for the way they felt about their treatment at the Medical Center was wrong. He went on to say the following:

"How dare the African American managers say anything? They are only here because of affirmative action and diversity initiatives. The only reason they are agreeing with the white managers is because they want to keep their jobs. The Blacks are ashamed of their culture and are afraid to be associated with the low-income Black patients, even though they probably came from the same ghetto neighborhood."

Ms. Harper was completely shocked and dismayed at the responses of these managers. As she left the meeting, she was at a loss as to how to explain these attitudes to the Medical Center's executive team. And more importantly, what could be done to change these managers' beliefs and attitudes about minority patients? Or was it too late?

Possible DISCUSSION QUESTIONS

1. Would you want to work with them on a team? Explain your response.

2. Thinking back to the chapter on teamwork, do you think Ms. Harper is a good team leader? Explain your response.

3. Do you think any of these managers demonstrated cultural proficiency?

4. What should Ms. Harper do about her managers' knowledge about other cultures? Compare and contrast two different approaches to fixing this organization's issues.