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Ensuring equality: Penn develops method to measure and operationalize inclusive culture

August 03, 2018

PHILADELPHIA - The importance of an inclusive workforce culture in health care is key to advancing scientific inquiry, improving the quality of care, and optimizing patient satisfaction. In fact, diverse student bodies and workforces have been shown to improve everyone's cultural effectiveness and address inequities in health care delivery. Now, inclusiveness of workplace culture can be measured by a concrete set of six factors, according to a study published today in JAMA Network Open from researchers at the Perelman School of Medicine at the University of Pennsylvania.

Previous studies have demonstrated how structural bias and a professional's individual implicit and explicit biases in decision-making leads to health disparities, even in places where people of different ethnicities have equal access to care. One of the major ways to mitigate this bias is to foster inclusive environments that ensure equal treatment and advancement of diverse members. Although organizations may aim to be inclusive, many have lacked the structure needed to achieve and measure success.

"This study finds that heath care is not immune to the workplace challenges and inequality experienced by women and minorities, which have taken center stage among discussions in many other industries," said lead author Jaya Aysola, MD, MPH, an assistant professor of General Internal Medicine and assistant dean of Inclusion and Diversity. "This is a pivotal time where there is a growing realization of the importance of inclusion to our collective success and the need for every perspective and voice to matter. While we often use the word "inclusion," there remains a lack of understanding of what exactly it means to health care organizations and how it can be operationalized."

This paper lays out a framework that health care systems can follow to identify, measure, and address the key factors that contribute to inclusive learning and work environments, in an effort to ensure parity among all students and employees.

In June 2016, the team used a novel method developed by Frances Barg, MD, a professor of Family Medicine and Community Health, to gather 315 anonymous stories about experiences with inclusion or lack thereof in response to two open-ended questions posed to employees, faculty, and students of four health science schools and six hospitals, including a children's hospital and a Veterans Affairs medical center. The first question asked for respondents to share a time they witnessed or participated in a situation where they or a colleague was treated in a way that made them feel either included, valued, and welcome or excluded, devalued, and unwelcome. The second asked for comment on how the respondent perceived the general climate at the organization with regards to inclusion and respect.

The narrative responses came from diverse populations across many dimensions representing but not limited to ethnicity, religion, sexual orientations, gender identity, and disability status. The results yielded six key factors that contribute to inclusivity: presence of discrimination; silent witness (in which someone witnesses discrimination but is afraid to take action, and experiences anxiety and lower job performance as a result); effectiveness of organizational leadership and mentors; interplay of hierarchy, recognition, and civility; support for work-life balance (and the perceived or actual gender discrimination that sometimes results) and perceptions of exclusion from inclusion efforts.

The responses also revealed the resulting effects when a workplace is not inclusive. Environments lacking inclusion appeared to impact the wellbeing of those that either experienced or witnessed it alike, and caused stress, anxiety, and feelings of hopelessness, social isolation, and expendability. As one bystander expressed about the department's approach to an injured colleague, "It left me worried about how I would be treated if I were disabled." Narratives often described how micro-aggressions and favoritism eroded participants' sense of value and thereby limited their engagement and contributions to the organization. As one respondent noted, "Needless to say, I felt exceptionally excluded and no longer want to be engaged in [this organization]."

"Inclusion is integral to the health, well-being, productivity, and engagement of a diverse workforce," Aysola said. "When dedicating effort and resources to improve faculty, student, and/or employee wellness, it's shortsighted to leave inclusion out as if it's a separate and distinct entity."

Strategies for fostering an inclusive organizational culture emerged from the narratives in the form of direct recommendations and positive examples of inclusion. The team found most respondents referenced a systemic culture that influenced their group and interpersonal dynamics. Therefore, recommendations centered on system-level interventions, such as providing inclusive skills training to existing leadership, revisiting organizational policies, developing advocacy campaigns (from those who witness discrimination and/or incivility), and expanding professional networks to gain new perspectives and create a greater sense of community.

Although all the responses were compiled from schools, clinics, and hospitals affiliated with one large academic institution, and may not be nationally generalizable, the authors note that prior research in other disciplines supports these results and suggests that this taxonomy for an inclusive organizational culture and methods to measure and operationalize inclusion may be widely applicable.
This study was launched as part of Office of Inclusion and Diversity's mission to chart a course for inclusion here at Penn under the leadership of senior author and Vice Dean for Inclusion and Diversity, Eve Higginbotham, SM, MD.

Penn's diverse study team, in addition to Aysola, included three Summer Undergraduate Minority Research (SUMR) scholars, an a MPH student, and two faculty members, all at Penn at the time of the study. The other authors on the study are Frances K. Barg, PhD, MEd; Ana Bonilla Martinez, BS, CHES; Matthew Kearney, MPH; Kareha Agesa, BA; Carlos Carmona, BA; and Eve Higginbotham, SM, MD.

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $7.8 billion enterprise.

The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $405 million awarded in the 2017 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; Penn Wissahickon Hospice; and Pennsylvania Hospital - the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine, and Princeton House Behavioral Health, a leading provider of highly skilled and compassionate behavioral healthcare.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2017, Penn Medicine provided $500 million to benefit our community.

University of Pennsylvania School of Medicine

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