Presentation on theme: "My name is Jin My name is Jean My name is Gene My name is Jeanne."— Presentation transcript:
1My name is Jin. My name is Jean. My name is Gene. My name is Jeanne. Do you know me?Improving Patient Satisfaction: From Microinequities to MicroaffirmationsPresented by:David Hunt, J.D.President & CEO(612)
2Agenda Three Demographic Megatrends The “Science of Bias” and Attitudes Towards DifferenceUnderstanding MicroinequitiesThe Implicit Association Test – Pro and ConOther Social Science Evidence for Implicit BiasCan Unconscious Bias Be Controlled?The Role of Microaffirmations
3Three Demographic Megatrends Race and EthnicityImmigration Numbers and PatternsImmigrants Bring New Cultural InfluencesReligionLanguage
4Understanding the New Science of Bias *07/16/96Understanding the New Science of Bias*##
6Two Competing Bias Theories Freudian Psychology - the human mind defends itself against the discomfort of guilt by denying or refusing to recognize those ideas, wishes and beliefs that conflict with what the individual has learned is good or right.Cognitive Psychology – culture (including the media and an individual’s peers, and authority figures) transmits certain beliefs and preferences. Because these beliefs are so much a part of the culture, they are not experienced as explicit lessons. Instead, they seem part of the individual’s rational ordering of the world.
7Awareness: New Research re: Bias *07/16/96Awareness: New Research re: BiasIn the past, bias was regarded as aberrant, conscious and intentional.Today, we understand that bias is normative, unconscious and largely unintentional.Social Cognition Theory establishes that mental categories and personal experiences become “hard-wired” into cognitive functioning.4. As a result, human biases can be seen as evolutionarily adaptive behaviors.*##
8Human Biases are Evolutionarily Adaptive Behaviors We go out in the world every day and make decisions about what is safe or not.Much of this decision-making is automatic and unconscious. Our brains determine whether or not something or someone is safe before we can even begin to consciously make a determination.When the object, animal, or person is assessed to be dangerous, a “fight or flight” response occurs in our Amygdala – a part of the brain that processes alarm.Scientists estimate that we are exposed to as many as 11 million pieces of information at any one time, but our brains can only functionally deal with about 40. So how do we filter out the rest?Answer: we use categories as a form of intellectual short-hand.
10Brain Scans Show Activation of the Amygdala *07/16/96Brain Scans Show Activation of the AmygdalaBrain scans using magnetic resonance imaging techniques has found that white subjects respond with a greater activation of the amygdala – a region that processes alarm – when shown images of black faces than when shown images of white faces. (One of the amygdala’s critical functions is fear-conditioning…) Later studies have shown similar results when black subjects look at white faces. Source: Race and the Brain, Time, October 20, 2008, at p. 59.*##
11What Activates Our Biases? *07/16/96What Activates Our Biases?Our biases are most likely to be activated by fourkey conditions. They are:stresstime constraintsmulti-taskingneed for closure*##
12Attitudes Towards Differences Impact Our Behaviors Towards Others *07/16/96Attitudes Towards Differences Impact Our Behaviors Towards OthersWe tend to behave differently towards “in-groups” than out-groups.Behaviors towards in-groups include…Behaviors towards out-groups include….When we deal with people from other cultures we tend not only to be more judgmental but to make moral judgments…*##
13Antecedent Conditions that Encourage Stereotypes *07/16/96Antecedent Conditions that Encourage StereotypesPsychologists have identified antecedent conditions that encourage stereotyping. Stereotyping is likely to occur when the target has “solo” or near-solo status (i.e., the only person of color among all white colleagues or the only woman among all male colleagues) among an otherwise homogeneous group.Specifically, in the employment context, stereotyping is likely to occur when a member of a previously omitted group (or protected class) assumes a job considered nontraditional for his group. Another condition shown to enable stereotyping in the employment context is the perceived lack of fit between the target’s category (i.e., female, of color, etc.) and occupation. Finally, stereotyping is likely to occur when the criteria used for evaluation of a target are ambiguous, as is the case with subjective evaluations.*##
14What are Microinequities? M. Rowe Microinequities are subtle acts of discrimination which are often covert, unintentional and hard to prove.They are frequently unrecognized by the perpetrator but have a significant impact on the recipient.Microinequities occur wherever people are perceived to be "different“.Microinequities work both by excluding the person of difference and by making that person less self-confident and less productive.Microinequities discourage creativity and risk-taking.
15Why Are Microinequities Harmful? Because the victim can’t foresee them, stop them or prevent them from recurring.Because they are a form of punishment for being different (inequities) and occur in the context of work without regard to performance or merit.Because they undermine the effectiveness of the recipient.Because they lead to the Pygmalian effect (expectations predict results).Because they take up workplace time and energy and undermine interpersonal trust and relationships.
16Workplace Incivility – DRI’s Studies have found that over 71 percent of the workforce has experienced some form of workplace incivility in the last five years. Incivility is evidenced by disrespectful behavior. Source: Don Zander, Brookings Institution, 2002Of the reported incidents of workplace-related DRI’s: 32% were related to gender; 28% were related to race; 20% were related to age; 14% were related to sexual orientation and 6% were related to religion.
17Workplace Incivility – DRI’s Fiscal Impact of Workplace Incivility:Of those who experienced work-place related DRI’s:28% lost work time avoiding the instigator of the incivility;53% lost time worrying about the incident/future interactions;37% believe their commitment at work declined;22% have decreased their effort at work;10% decreased the amount of time that they spent at work;12% actually changed jobs to avoid the instigator.Source: The Sparticus Group: 2003.
18Picker – Inpatient Satisfaction with Doctors By Race, CLIENT 2003-2005 Question/Statement White Of Color Signif?Didn’t always have confidence/trust 14.5% 26.1% Yesin my doctors.Doctors talked as if I wasn’t there % 23.2% YesCourtesy of doctors “fair” or “poor” 2.5% 5.5% YesDoctors/nurses gave conflicting info. 21.5% 26.5% Yes* Scores over 20% are considered “problems” by Picker.
19Picker – Inpatient Satisfaction with Nurses By Race, CLIENT 2003-2005 Question/Statement White Of Color Signif?Didn’t always have confidence/trust 24.8% 34.7% Yesin my nurses.Nurses talked as if I wasn’t there % 22.9% YesCourtesy of nurses “fair” or “poor” 3.5% 5.6% YesNurses answers to questions % 29.6% Yesweren’t always understood.* Scores over 20% are considered “problems” by Picker.
20Picker – Treated with Courtesy, By Race, CLIENT 2003-2005 Question/Statement White Of Color Signif?Courtesy of admissions staff rated 2.0% 5.9% Yesfair or poor.Courtesy of people who took blood 2.8% 8.8% Yessamples rated fair or poorCourtesy of people who brought food 5.0% 8.8% Yesrated fair or poor.Courtesy of people bringing to and from 1.2% 6.2% Yesroom rated fair or poor.Courtesy of people taking x-rays rated 1.4% 7.6% YesCourtesy of people who cleaned room 3.3% 8.6% Yesrated fair or poor
21Picker – Other Key Indicators of Care By Race, CLIENT 2003-2005 Question/Statement White Of Color Signif?Not always treated with respect and 13.1% 21.6% Yesdignity.Didn’t always get help in time going 20.4% 30.8% Yesto the bathroom.After using call button, had to wait > % 4.3% Yesminutes for help.Staff definitely did not do everything 19.7% 26.3% Yesthey could to control pain.Didn’t have enough say about pain 26.1% 38.4% Yescontrol during delivery.Probably would or would not % 28.8% Yesrecommend to family/friends.
22The Implicit Association Test *07/16/96The Implicit Association Test*##
23What is Project Implicit? Yale University, 1998Now at Harvard, Virginia & Washington Universities2003 – took off with research grant from National Institute of Mental Health4.5 million tests since 1998Now averaging 15,000 per week
27*07/16/96Key IAT Findings - AgeAge: Around ninety percent of Americans mentally associate negative concepts with the social group "elderly"; only about ten percent show the opposite effect associating elderly with positive concepts. Older people do not, show an automatic preference for their own group. Remarkably, the preference for “young” is just as strong in those in the over-60 age group as it is among 20-year-olds.*##
28Key IAT Findings - Gender *07/16/96Key IAT Findings - GenderGender: Seventy-five percent of men and women do not associate female with career as easily as they associate female with family. (Women show an implicit attitudinal preference for females over males, but they nonetheless show an implicit stereotype linking females closer to family than career.)*##
29*07/16/96Key IAT Findings - RaceRace: White participants consistently show a preference for White over Black on the IAT – a substantial majority of White IAT respondents (75% to 80%) show an automatic preference for White over Black. Data collected from this website consistently reveal approximately even numbers of Black respondents showing a pro-White bias as show a pro-Black bias.Other key race findings: younger people are just as likely to display an implicit race bias as older adults, women are as likely to display an implicit race bias as men and educational attainment appears to make no difference with respect to implicit race bias.*##
30Summary: Key IAT Trends *07/16/96Summary: Key IAT TrendsImplicit biases are pervasive.People are often unaware of their implicit biases.Implicit biases predict behavior.People differ in levels of implicit bias.Educational attainment makes no difference with respect to implicit biases.*##
31Other Social Science Research Regarding Implicit Bias *07/16/96Other Social Science Research Regarding Implicit Bias*##
32The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization 720 physicians viewed recorded interviewsReviewed data about a hypothetical patientThe physicians then made recommendations about that patient's careSource: Schulman et.al. NEJM 1999;340:618.
33IAT Finds Unconscious Bias in M.D. Decision-making Emergency room doctors in the study were told two men, one white and one African-American, were each 50 years old and complained of chest pain. The patients were not actually real people, but rather computer-generated images seen by the doctors only on a monitor.After the doctors in the study evaluated the two simulated patients, they were then given an implicit association test examining unconscious racial biases.The result was most of the doctors were more likely to prescribe a potentially life-saving, clot-busting treatment for the white patients than for the African-American patient.The study, by the Disparities Solutions Center, affiliated with Harvard University and Masschusetts General Hospital, is the first to deal with unconscious racial bias and how it can lead to inferior care for African-American patients. It was published in the online edition of the Journal of General Internal Medicine in June, 2007.
34Are Emily & Greg More Employable than Lakisha & Jamal? Study of actual racial hiring bias in Chicago and BostonResumes sent to actual want ads4 resumes per position – 2 “high” quality and 2 “low” qualityAfrican American sounding names assigned to one high quality and one low qualityPrimary measurement was the “callback” rateResults: people with "white-sounding" names are 50 percent more likely to get a response to their resume than are those with "black-sounding" names.Marianne Bertrand and Sendhil Mullainathan, Are Emily and Greg More Employable Than Lakisha and Jamal? Field Experiment on Labor Market Discrimination, 94 Am. Econ. Rev. 991 (2004).
35The “Big Five” Orchestras Chicago and BostonNone of the Big Five employed more than 12% women until the 1980’sBlind auditionsImproved the chances that a woman would ultimately be hiredFemale musicians in the Big Five increased five-fold from 1970 to 2000Orchestrating Impartiality: the Impact of “Blind” Auditions on Female Musicians, 94 Am. Econ. Rev. 715 (2000).
36Racial Discrimination Among NBA Referees Price, Joseph and Wolfers, Justin, "Racial Discrimination Among NBA Referees," NBER Working Paper Series, Vol. w13206 (2007). Available at
37Racial Discrimination Among NBA Referees Unique dataset - over a quarter million player-game observationsFrom seasonsEach season - about 60 NBA referees - ref in 3 person crews - each ref works games per seasonRichness of data allowed for control of a plethora of non-race related relevant factors in foul callingBlack/White players receive fewer fouls when more of the referees present in the game are of the same raceBias in foul calling large enough -probability of team winning affected by racial composition of refereeing crew
38Does Unconscious Racial Bias Affect Trial Judges? This article reports the results of the first study of implicit racial bias among judgesJeffrey J. Rachlinski, Sheri Lynn Johnson, Andrew J. Wistrich & Chris Guthrie, Does Unconscious Racial Bias Affect Trial Judges?, 84 Notre Dame L. Rev (2009)
39Study ResultsThe results of this study are both alarming and heartening:Judges hold implicit biases.* Strong white preference among White judges.* No real preference among Black judges* Black judges comparable IAT scores as Blacks onthe internet* White judges statistically stronger White preferencethan Whites on the internetThese biases can influence their judgment
40IAT and Judicial Behavior In both shoplifter and robbery cases, judges with White preference on IAT somewhat more likely to impose harsher sentences when primed with Black-associated words than White associated or neutral wordsJudges who expressed a Black preference on IAT reacted in opposite fashion.3. Judges can, at least in some instances, compensate for their implicit biases.
41Can Implicit Bias Be Controlled? *07/16/96Can Implicit Bias Be Controlled?*##
42Can Implicit Bias Be Controlled? *07/16/96Can Implicit Bias Be Controlled?Researchers long believed that because implicit associations develop early in our lives, and because we are often unaware of their influence, they may be virtually impervious to change.But recent work suggests that we can reshape our implicit attitudes and beliefs or at least curb their effects on our behavior.In particular, there are several strategies that appear to make a difference:A. Information – re: the psychological basis of biasB. Motivation - internal (vs. external) motivation to changeC. Individuation – learning to see diverse others as individuals rather than as members of groups.D. Direct contact with members of other groups.E. Working together on teams, as equals, in pursuit of common goals.F. Context/environment – images of leaders from diverse groups helps4. In sum, one can either “think one’s way into a new way of behaving or behave one’s way into a new way of thinking.” Why? Humans do not like cognitive dissonance.*##
43Using the IAT With Teachers *07/16/96Using the IAT With Teachers1. Two professors at Ball State University recently produced a white paper describing attempts to reduce teachers implicit biases by having them take the IAT and then proceeding with varying types of interventions depending upon their reactions to their scores. See: Using the IAT With Teachers to Affect Change, Dr. Eva Zygmunt-Fillwalk and Dr. Patricia Clark, Ball State University.Over a four-year period, the researchers had over 500 practicing teachers take the Race IAT “in order to begin a dialogue on issues of race, power, privilege, and education for social justice.”Teachers’ responses tended to fall into one of five categories:A. Disregard for the resultsB. Disbelief in the resultsC. Acceptance of the resultsD. Discomfort with the resultsE. Disclosure*##
44Reducing Bias In Physicians *07/16/96Reducing Bias In PhysiciansRacial and ethnic disparities in the quality of medical outcomes are widely documented.A. Institute of Medicine report “Unequal Treatment” (2002)B. Research indicates that little progress has been made since 2002.Michelle van Ryn of the University of Minnesota and colleagues recently published some evidence-based recommendations for combating bias among health care providers. See: Burgess, D., van Ryn, M., et. al. Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology, 22 Journal of General Internal Medicine (2007).Their conceptual model (depicted on the next slide), recognizes the importance of motivation, information and skills as key ingredients for successful interventions.The next slide discusses the approach advocated by van Ryn.*##
45Can Implicit Bias Be Controlled? *07/16/96Can Implicit Bias Be Controlled?*##
46Battling Bias – New Tools *07/16/96Battling Bias – New Tools*##
47Battling Bias – Individual Actions *07/16/96Battling Bias – Individual ActionsEnhance understanding of the psychological basis of bias.Replace negative mental images of the target group with positive mental images.Increase positive contacts with socially dissimilar groups .Increase affective empathy and perspective taking toward outgroups.Work with target group members to achieve common tasks/goals.Replace tolerance behaviors with acceptance and appreciation behaviors. (Shift from micro-inequities to micro-affirmations.)Analyze personal patterns of privilege and privation in light of the Set Up to Fail Syndrome. (Who do you micro-manage?)Get 360-degree diversity feedback from diverse members of your work-team.*##
49INTERCULTURAL CONFLICT STYLE MODEL 21DIRECTENGAGEMENTDISCUSSION34INDIRECTACCOMMODATIONDYNAMICEMOTIONAL RESTRAINTEMOTIONAL EXPRESSIVENESS
50What are Micro-affirmations? Micro-affirmations are tiny acts of opening doors to opportunity, gestures of inclusion and caring, and graceful acts of listening which occur wherever people wish to help others to succeed.Micro-affirmations lie in the practice of generosity, in consistently giving credit to others—in providing comfort and support when others are in distress.Micro-affirmations include the myriad details of fair, specific, timely, consistent and clear feedback that help a person build on strength and correct weakness.
51How Do Micro-affirmations Help? Affirming people and their work helps them do well.Consistent, appropriate affirmation of others can spread from one person to another—potentially raising morale and productivity. It helps everyone.Micro-affirmations are particularly helpful for department heads, and anyone who is senior to another person, to “model” affirming behavior.It may be hard for a person to “catch” himself or herself unconsciously behaving inequitably. But if I try to affirm others in an appropriate and consistent way, I have a good chance of blocking behavior of mine that I want to prevent.
52Battling Bias – Organizational Actions *07/16/96Battling Bias – Organizational ActionsConduct a Diversity Workforce Assessment.Collect patient race, ethnicity and language data and connect it to patient outcomes. Less than 20% of U.S. hospitals do both.Collect patient satisfaction data and stratify it by race, language and other key variables such as national origin.Collect patient complaint data and stratify it by race, national origin, language etc.Stratify “critical incident” data by each of the variables above.Look for patterns in these data sets.Provide personalized feedback.Key: these data sets are like the smoke detectors in our homes. You’ll never hear the alarms if the smoke detectors are turned off…*##