Battling Bias: Sustaining inclusion through organizational culture Insight Article - July 28, 2020 Performance Management Leadership Development Culture & Engagement Sign in to save MGMA Staff Members Editor’s note: This is Part 3 of “Battling Bias,” an ongoing series on the role of healthcare executives, administrators, providers and staff in confronting issues of race in their professional lives and their communities. Taking racism seriously and building cultures within healthcare organizations that promote diversity and inclusion requires an honest appraisal of issues of racism and educating ourselves. During a recent presentation, “Stop Killing our Patients: Pandemic, Protest and the Outcry for Justice,”1 Solangel Maldonado, JD, full-time faculty, Seton Hall University School of Law, said there are clear parallels to addressing these topics raised by BIPOC (Black, Indigenous and People of Color) staff to how providers deliver care. “When [BIPOC] tell you that they have experienced racism, believe them … Just like mental health professionals, when a patient comes in and tells you what they are experiencing, you take that seriously,” Maldonado said. “Let's all educate ourselves about the systems of oppression in our society, and how we are complicit in these systems, not necessarily because we as individuals created them, but because we do benefit from them,” Maldonado added. “All of us have a responsibility to recognize our privilege, whether it's race privilege, class privilege, and to use that to fight oppression and racism.” Clues to the culture of a healthcare organization can be seen in the mission statement and other statements of medical practice philosophy, beliefs, and values about “who we are” and “how we do it here.”2 While countless companies have issued statements and posted on social media regarding Black Lives Matter, police brutality and racial inequality in the United States, changes in organizations require more than one-time press releases and leaders talking about the issues. According to Limeade people team senior director Sarah Stevens, SHRM-CP, these efforts “can’t just be an HR initiative or on the leaders” to have longstanding impact.3 What is inclusion? One of the most concise definitions of inclusion comes from Gallup: Inclusion refers to a cultural and environmental feeling of belonging. Employees in inclusive environments feel appreciated for their unique characteristics and are therefore comfortable sharing their ideas and other aspects of their authentic selves. Inclusion also is the extent to which employees feel valued, respected, accepted and encouraged to fully participate in the organization.4 As outlined in Part 2 of this series, the recruitment and hiring process plays a key role in establishing diversity within the organization. For inclusion to exist in conjunction with that diversity, sense of environment should be built into new employee orientation and onboarding programs. As noted in Employee Handbook for Medical Practices, onboarding and orientation is a crucial time for new hires to “learn about practice values and the organizational structure,” and practice leaders should encourage “new employees to ask any questions during the orientation so they better understand all guidelines that affect and govern their employment relationship” with the practice.5 What inclusion looks like Cleveland Clinic CEO and President Tom Mihaljevic, MD, notes in Modern Healthcare that diversity and demographics are the starting points for work on inclusion. “When there is an inclusion imperative, caregivers have a sense of purpose and belonging,” he writes, adding that there is a level of cultural competence for communicating with people of varying backgrounds “in a way that recognizes differences and allows individuals to feel respected and valued.”6 Part of allowing a culture of inclusion to flourish might involve acknowledging the diversity of your staff and communities with social events that highlight or celebrate employees’ culture.7 For some organizations, considering unconscious bias training for employees to help them recognize common biases and avoid decisions based on them can be helpful in building a culture of inclusion.8 Ashley McGirt, MSW, a racial trauma and mental health therapist, recommends making such trainings an ongoing effort, as inclusion requires long-term change to become engrained into the organization’s culture.9 The work isn’t purely internal, either. In noting a commitment to diversity and inclusion, AIS Healthcare announced a review of all its marketing, including its website, to ensure the organization represents the diversity of the communities it serves, as well as make strategic contributions that support nonprofits focused on diversity issues and education.10 Additionally, major initiatives such as an inclusion program need some type of accountability, whether that’s key performance indicators (KPIs) to measure progress or some other method. One tool to engage employees in holding leadership accountable for their stated goals is Rachel Cargle’s template letter (PDF) regarding efforts toward inclusion and racial justice.11 How organizational culture matters Organizational culture develops as the personal values of employees shift from individual success to organizational success, in line with the values of the organization. Managers and supervisors are an embodiment of the culture, directing the change process and working to convert the attitudes and habits of their employees to match the strategies of the medical practice. This should be accomplished by setting an example of how the medical practice and its employees should treat other people.12 As detailed in HR Policies & Procedures Manual for Medical Practice, 5th Edition: Before a practice can implement an attitude change, the leaders need to know where to start. Managers and supervisors can survey their employees to determine how open to change they are. ... Practice leaders and supervisors need to know that resistance is a natural response to change. They will need to be prepared for both attitudinal positive and negative phases. These ups and downs are also natural when anyone faces a situation that will require changes in habitual behaviors. Practice leaders should help managers and supervisors identify the rewards related to change and help employees see the “big picture.” They need to point out that change is a reality ... Practice leaders should strive to build employee ownership in the change by engaging them in the strategic planning process. This will also help them see their part in shaping your practice’s future.13 How policies can affect inclusion Practice leaders should be aware of specific areas in which HR policies have a clear, direct effect on the outcomes of diversity and inclusion programs, as well as potentially cause situations in which racial discrimination claims can arise. Ensure a dress code and appearance policy is applied equally to all races and does not disproportionately burden one race over another. Consider carefully before denying a request for reasonable accommodation. As noted in HR Policies and Procedures Manual for Medical Practices, 5th Edition, courts have upheld racial discrimination claims against employers requiring all employees to be clean shaven. For example: Pseudofolliculitis barbae (PFB), an irritation caused by shaving, occurs more often for Black males, and some courts have found no-beard policies to violate Title VII of the Civil Rights Act of 1964.14 There is no one right or correct organizational culture. Especially with respect to diversity and inclusion, practice culture and policies need to reflect the communities served by the practice. Medical practice leaders should account for this when modifying and implementing changes to mission statements, vision and values, especially when engaging in a major new strategic direction, such as a merger or acquisition.15 Additional resources: “A feeling of belonging: An inclusive culture is the foundation for addressing unintentional bias” (MGMA Connection magazine) “Why culture is king in medical practice staff management” (MGMA Insights podcast) “How the COVID-19 pandemic has intensified the conversation around public health and underserved communities” (MGMA Insights podcast) “10 Diversity and Inclusion Trailblazers You Need To Get Familiar With” (Forbes) “A Q&A with new Tulane University Chief Diversity Officer Anneliese Singh” (Tulane University) Editor’s note: Other installments of the “Battling Bias” series include: Part 1: "How intuition and unintentional biases can shape how decisions are made" Part 2: "Building diversity in recruiting and hiring" Part 4: “Racial bias and its effects on patient care” Notes: 1. Seton Hall University. “Stop Killing our Patients: Pandemic, Protest and the Outcry for Justice.” June 19, 2020. Available from: bit.ly/3hATHPu. 2. Price C. HR Policies & Procedures Manual for Medical Practices, 5th Edition. 2014, 287. Englewood, CO. 3. Schiavo A, Webster K. “Employers scrutinize diversity efforts as national protesters demand change.” EBN. June 22, 2020. Available from: bit.ly/3g60Jf0. 4. Washington E, Patrick C. “3 requirements for a diverse and inclusive culture.” Sept. 17, 2018. Available from: bit.ly/2N0gasV. 5. Price C. Employee Handbook for Medical Practices. 2014, 10. Englewood, CO. 6. Mihaljevic T. “Diversity and inclusion in healthcare cannot be left to chance.” Modern Healthcare. May 18, 2019. Available from: bit.ly/3fcY8id. 7. Boggenpoel J. “Leaders Can Make Their Teams More Inclusive.” CEOWorld Magazine. July 2, 2020. Available from: bit.ly/330xuq0. 8. Hines M. “What 4 Companies Are Doing to Promote Inclusivity in the Tech Community.” Builtin. July 7, 2020. Available from: bit.ly/30PmjxO. 9. Robert Y. “4 Ways To Actually Create Diversity And Inclusion In The Workplace.” Forbes. June 11, 2020. Available from: bit.ly/306YIcZ. 10. AIS Healthcare. “Our commitment to diversity and inclusion.” July 10, 2020. Available from: bit.ly/3366wxz. 11. Cargle R. “Template For Holding Your Employer Accountable For Racial Justice.” Patreon. May 31, 2020. Available from: bit.ly/3f5RCcS. 12. Price C. HR Policies & Procedures Manual for Medical Practices, 5th Edition. p 287. 13. Ibid., 197. 14. Ibid. 15. Ibid., 288.