The mission of most not-for-profit hospitals is ultimately to improve the health of the communities they serve. For many hospitals across the country, the racial and ethnic diversity of communities is changing, and cultural disparities in health care are becoming more and more evident. It is trustees' role and responsibility to ensure the hospital knows what the community's health needs are, and how to best deliver care that meets the needs of those who live in the community.
The Health Disparity Gap
Diversity has the potential to cause a number of disparities and inequities in health care. This is driven by differences in socioeconomic status, language barriers, varying consumer health behaviors when seeking care, as well as adhering to treatment guidelines, discrimination and stereotying by providers, lack of cultural knowledge and sensitivity by providers, lack of a culturally representative health care workforce, and differences in insurance coverage.
In November 2013, the Centers for Disease Control and Prevention released its second agency report on health disparities and inequalities in the United States. CDC Director Thomas R. Frieden observed that four findings bring home the enormous personal tragedy of health disparities, including:
- "Cardiovascular disease is the leading cause of death in the United States. Non-Hispanic black adults are at least 50 percent more likely to die of heart disease or stroke prematurely (i.e., before age 75 years) than their non-Hispanic white counterparts.
- The prevalence of adult diabetes is higher among Hispanics, non-Hispanic blacks, and those of other or mixed races than among Asians and non-Hispanic whites. Prevalence also is higher among adults without college degrees and those with lower household incomes.
- The infant mortality rate for non-Hispanic blacks is more than double the rate for non-Hispanic whites. Rates also vary geographically, with higher rates in the South and Midwest than in other parts of the country.
- Men are far more likely to commit suicide than women, regardless of age or race/ethnicity, with overall rates nearly four times those of women. For both men and women, suicide rates are highest among American Indians/Alaska Natives and non-Hispanic whites."
The combined cost of health disparities and subsequent deaths due to inadequate or inequitable care in the United States is $1.24 trillion, according to the U.S. Department of Health and Human Services.
Defining the Community's Health Care Disparities and Needs
Improving the health of a community begins first with understanding what the community is and what the needs are. Establishing additional ways to identify and address health disparities was one factor behind the Patient Protection and Affordable Care Act requirement that not-for-profit hospitals regularly conduct community health needs assessments. In carrying out the assessment, hospitals must seek input from representatives or members of the community's medically underserved populations, low-income populations, minority populations and the public health department. Identifying the community's health care needs should include digging deeply enough to identify its health disparities and inequities. As an additional resource, the ACA also requires federally-funded health programs and population surveys to collect and report data that will help to identify and analyze health disparities including information on race, ethnicity, and primary language among other demographic data. The Secretary of HHS is required to analyze, monitor and report trends in health disparities to federal agencies and the public.
Trustees are responsible for ensuring the hospital has a sound understanding of the community's health needs and its disparities. They also are responsible for determining the strategies and resources their organizations will use to address health needs, and evaluate the impact of those programs.
Developing Cultural Competency – A Governance Accountability
As a part of their accountability for mission fulfillment and for the leadership of hospitals and health systems, trustees are being called upon to address their community's health care disparities and strengthen cultural competency. With oversight responsibility for the hospital's strategic plan, trustees committed to reducing and eliminating inequities in health care must ensure their plan takes into account cultural competency. This includes setting appropriate strategic goals for strengthening the organization's measures of cultural competency as well as goals for meeting the health care needs of all populations in the community.
The Office of Minority Health, U.S. Department of Health & Human Services, first published the National Standards for Culturally and Linguistically Appropriate Services in Health Care (National CLAS standards) in 2000. Revised in 2010, the 15 national CLAS standards are designed to advance health equity, improve quality and help to eliminate health care disparities by establishing a guide for health and health care organizations. In addition to the principal standard to "provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs," the remaining 14 standards address governance, leadership and workforce; communication and language assistance; and engagement, continuous improvement, and accountability. The Joint Commission and other legal and regulatory entities look to the CLAS standards when considering their own oversight requirements. The board, too, should take these standards into account as it seeks to fulfill its responsibilities to the community. However, standards cannot replace the value of first-hand insights, understanding and information available by ensuring a diverse board membership, leadership and workforce, and a comprehensive community health needs assessment.
Actions the Board Can Take
Steps the board can take to strengthen the hospital's cultural competency include:
- Ensure the board's composition represents the diversity of the community;
- Ensure the organization's leadership and workforce represents the diversity of its community;
- Include cultural competency training in new trustee orientation and on-going governance education;
- Ensure cultural competency is an active component of the organization's workforce training program;
- Promulgate policies and practices that set a tone of leadership and support for cultural competency;
- Monitor conduct of periodic comprehensive community health needs assessments;
- Identify strategic plan goals that will strengthen the organization's cultural competency and address the community's health care needs, disparities and inequities; and
- Allocate the resources needed to achieve the plan's goals of cultural competency and eliminating health care disparities.
Special thanks to The Walker Company for use of: Ensuring the Best Care for All. Additional trustee resources from KHA are available in the Trustee Section of the KHA website. Additional resources from Larry Walker can be found at www.walkercompany.com.