William J. Mott, Jr., CHE, vice president, Clinical and Support Services, St. John Oakland Hospital, Madison Heights, Michigan

ORGANIZATIONAL INFORMATION
The organization has been serving its suburban community since the early 1960s. It is a 210-bed, acute care, not-for-profit hospital with an active emergency department and more than 7,000 admissions per year. A volunteer board of 13 trustees governs the organization, and its trustees include businesspersons from the community, physicians, and sponsors. The organization serves a community that used to be predominantly middle class and aging; today, that demographic is changing. The community remains predominantly older, but many younger families are moving to the affordable housing it offers, and it is attracting many different ethnicities as well. The organization employs nearly 800 full-time equivalents and has a very large and active medical teaching program, including residencies in general surgery, otolaryngology, neurology, internal medicine, emergency/internal medicine, orthopedics, ophthalmology, family practice, and podiatry. The organization's reach into the community beyond the services of the hospital is facilitated through its medical training programs and other community partnerships.

BRIEF STATEMENT OF THE PROBLEM
The community surrounding the hospital is in transition. Its homogenous, middle class, Caucasian, and aging population is becoming more diverse both in ethnicity and age. The availability of good-quality, affordable housing in the community, combined with the organization's location between the central city and the more affluent suburbs, leads to a change in the patient population-specifically, more Middle Eastern and Asian patients. This challenges the organization to provide the same high-quality care it is accustomed to providing but with more cultural awareness and sensitivity.

DESCRIPTION OF THE PROBLEM
The hospital is located in a suburban community that had changed little in its ethnic makeup over the past 50 years. The community grew significantly after World War II with the building of tract homes to accommodate the baby boom. Later, most of the baby boom children moved away, leaving their aging parents. The good-quality homes, city infrastructure, and aging population are now leading to turnover in the community. The region has been a magnet for certain immigrant populations, including several Middle Eastern and Asian groups.
The organization's need to develop its workforce to be more culturally competent was born from an unfortunate incident. In 1998, a gravely ill elderly woman of Middle-Eastern descent, Mrs. X, was admitted to the hospital. Almost immediately, the hospital had difficulties with Mrs. X's family. The staff was told not to give any information to the patient herself, who did not seem to understand English. The hospital offered a translator, but it was refused by the family. All communication was to happen via Mrs. X's son, as the patient's husband did not speak English either. The throngs of visitors were difficult to accommodate in Mrs. X's semiprivate room, and other families were using the waiting room on the unit. After a short stay, Mrs. X expired.
The hospital culture tries to involve the patient in his or her care and works to protect the patient. In this case, hospital staff was conflicted; they recognized the benefit of family and friends in the healing process, but Mrs. X was gravely ill. Her family minimized her participation in her own care, and the volume of visitors was not seen as supportive but as disruptive. Nonetheless, the staff tried to honor the wishes of the family and accommodate the visitors. When Mrs. X died, several family members and friends began screaming and sobbing, creating quite a disturbance on the unit and for the roommate. Efforts to move the family to the hospital meditation room, thereby separating the family from the deceased, were met with resistance. Finally, hospital security staff was called to remove the family from the unit, leaving only the husband and son with Mrs. X. Three days later, a panel van was parked across the street from the hospital. On its side was a poster stating "[This hospital] killed Mrs. X!" The van was driven by the husband of Mrs. X.
Prior to Mr. X arriving in his van, hospital administrators (including myself) had met to talk about the family and our perception that something went wrong with our handling of the situation. The administrators hoped that they never would again use hospital security to remove a grieving family; also, they agreed that they needed to determine whether this family was unique or if the case called for cultural understanding, which had to be developed and honed.
When word spread that Mr. X was in his van across the street, hospital staff became very upset. How did Mr. X get the idea that the hospital had killed his wife? The administrators wondered how the relationship with Mr. X and his family could be mended, how the staff could be assured that their leaders continue to have confidence in them, and how this episode could teach everyone a lesson.

ADMINISTRATIVE DECISIONS
The administrators could have been satisfied with saying that they acted appropriately in the care of Mrs. X and done nothing further. They could have called the police, asking them to move Mr. X along. They could have simply tried to bury the situation, classifying it as a patient's family behaving badly. Instead, they decided that there was something to be learned from the situation, and the team quickly took the following steps:

1. The spiritual leader of the family's church was contacted for advice and assistance.
2. Mr. X's son was contacted, and a meeting was arranged with him, his father, and a small group of administrators, including the president, vice presidents, and spiritual care director.
3. A director of multilingual education in a neighboring school district was contacted for advice. He is a friend of the hospital and is also of Middle Eastern descent.

These three interventions helped to resolve the immediate issues with Mr. X and his family. Mr. X did not blame the hospital for "killing" his wife, but he did find fault with the treatment of his family and friends, especially immediately after Mrs. X's death. The administrators learned that contacting the spiritual leader with whom Mr. X's family identified would have guided the hospital's earlier actions and helped everyone understand the cultural need for the patient's family and friends to be present at the hospital. This case was resolved in a manner acceptable to the family. More important, the case led the hospital to research and ultimately begin a program to help everyone understand and better serve the changing demographic of the community.
The delivery of healthcare is such an intimate and personal experience, and the world is getting smaller in terms of cultural integration. This incident shows the imperative to understand the cultural norms and traditions of patients. For the hospital, it sparked the development of a Diversity Council, which I chaired.
Following the incident, the Diversity Council researched the demographics of the hospital's service area. Based on our findings, we decided to educate staff on the healthcare expectations of the primary cultures moving into the community. Our charge was to provide enough basic information to the bedside practitioners to sensitize them to other belief systems. We recognized the danger in looking at a person and making cultural assumptions based on the person's appearance alone. For example, not every person who appears to be Indian is a vegetarian; not every person who appears to be Asian is Chinese or Filipino. The hospital's mission statement, which states in part that the organization is "dedicated to spiritually centered, holistic care that sustains and improves the health of individuals and communities," guided us.
The Diversity Council educated itself through reading and attending seminars. We then sought and received a commitment from hospital leadership to make staff available for "cultural diversity enlightenment sessions." These sessions began simply with a review of the culture from a social studies perspective: where is the country; what are its climate, customs, food preferences, economic base, etc. This nonthreatening way of looking at other backgrounds paved the way for the next iteration of education designed to highlight some of the different ways of looking at health-related issues. We wanted to equip our staff with the tools to better serve patients from a variety of backgrounds, not only to satisfy our patients but also to satisfy our associates' desires to serve our patients in the best way possible.

RESULTS
The following are some of the initiatives the Diversity Council has undertaken to prepare hospital associates to better meet the needs of patients and their families:

• Developed a booklet entitled "Cultural Diversity in Health Care Delivery Competency." This self-learning module was provided to associates to expand their knowledge of selected cultures that are represented in our patient population. Associates read the information, complete evaluation questions provided in the module, and participate in discussion groups. Because it is nearly impossible to become an expert on the customs of every culture, the module highlights general skills needed to communicate with cultural groups other than one's own. Sections in the module include awareness and assessment, knowledge and communication, nonjudgmental respect, and accommodation. This module is approximately 50 pages and features special sections on Arab Americans; Black/African Americans; Chinese Americans; and people of Hmong, Russian, and Vietnamese descent.
• Followed up the "Cultural Diversity in Health Care Delivery Competency" module with a series of presentations by Gottfried Oosterwal, Ph.D., Litt.D., entitled "Caring for People from Different Cultures: Communicating Across Cultural Boundaries." Dr. Oosterwal is a world-renowned cultural anthropologist who was born in the Netherlands; has lived and worked in Indonesia, New Guinea, Malaysia, Singapore, the Philippines, Taiwan, and Europe; speaks seven languages; and has published ten books and numerous articles on cultural diversity from a healthcare perspective. Dr. Oosterwal's presentations were made to associates and medical staff.
• Hosted a seminar for associates and physicians titled "DEAF Culture: Facilitating Communication with DEAF and Hard of Hearing Patients and Families." It featured a hard-of-hearing specialist from DEAF C.A.N. (Community Advocacy Network).
• Hosted two educational sessions for associates and medical staff that were designed to heighten awareness about Middle-Eastern Americans. The first session featured the director of the Behavioral Health Division of the Arab-American and Chaldean Council, and the second featured an expert in the area of behavioral health.
• Hosted an interfaith unity program. This program featured clergy from the Jewish, Episcopal, Chaldean Catholic, Islamic, and Hindu faiths. The clergy shared the basic tenets of their faith and spoke about their commonalities and differences; they also prayed with attendees. The presentation opened with a short video, "The World as a Village of 100 People" to further emphasize the diversity of our world.
• Hosted a Martin Luther King, Jr. memorial featuring Martin Luther King, III as the special guest speaker.
• Recognized cultural groups monthly via publications and activities such as serving ethnic foods in the hospital cafeteria and celebrating various events such as Black History Month in February, Women's History Month in March, Multicultural Communication Month in April, Asian Pacific American Heritage Month in May, Spanish Heritage Month in October, and Native American Indian and Alaskan Native Heritage Month in November.

These programs not only support the organization's commitment to serving its patients in a culturally competent manner but also support its core values.
In addition to these educational efforts, the hospital has embraced a number of community outreach efforts that recognize the diversity of our communities:

• Food drive for the poor
• Pumpkin carving contest to support the local food bank
• Operation Clean Sweep
• Make-A-Difference Day
• Holiday donations to needy families
• Donation of turkeys to St. Vincent de Paul
• Tree of HOPE (which helps patients financially in emergencies)
• Sponsorship and support of an all-girls school (which is for girls who are at risk of doing poorly in the traditional educational system)
• Community Fall Fest (which focuses on disease prevention and healthy lifestyles)

In addition, our diversity initiatives have also included recruitment, including recruitment at the board and medical staff levels. Because of the racially, ethnically, culturally, and linguistically diverse population the organization serves, a diverse representation at the board and physician levels is necessary. To that end, we have recruited a Middle-Eastern American and an African American to our board. The board of trustees receives regular educational materials, including a Health Governance Report article entitled "Making Diversity a Reality in Your Hospital."
We survey our associates regularly to determine if they feel the organization (1) is sensitive to their family needs and their need to balance work with family life, (2) handles problems fairly, and (3) is open to suggestions. This survey information can be stratified by religious practice and ethnicity or heritage to ensure that all associates are valued equally. We also survey our patients to determine if they feel the organization has met their cultural needs during their visit. The hospital's associates come from a variety of cultural backgrounds, and many speak languages other than English. A list of interpreters is available for our patients, and associates who share the same language/cultural background with patients are encouraged to meet with and talk to these patients to make them feel more at ease. Naturally we also have a cadre of professional language interpreters, including American Sign Language interpreters, who are available on patient request. The hospital has initiated a program that sends volunteer high school students who speak another language to visit with non-English-speaking patients to discuss nonmedical topics.
In summary, the hospital has gone through a horrific experience, learned from it, and turned it into an opportunity to better serve its diverse patients and associates. Diversity education is an ongoing activity, and the Diversity Council continues to reach out. Our efforts were recognized with a Diversity Award from the local county's Employment Diversity Council.

SOURCE MATERIALS
A primary source of information used in the preparation of this case report was the author's first-hand observation.

References
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