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Sit it out or dance: representative bureaucracy contagion effects in health care

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Kenneth Meier highlights the study of representative bureaucracy and traces out multiple organizational and individual-level pathways through which identity-based representation contributes to improvements in bureaucratic processes, outcomes, and legitimacy.

Image courtesy of interviewee. March 25, 2024

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This video video discusses the concept of representative bureaucracy and contagion effects, emphasizing that individuals within organizations, both public and private, make decisions based on their values and experiences. Representative bureaucracy posits that public organizations are more effective when their workforce reflects the demographics of the population they serve, as this can lead to better responsiveness to community needs.

Contagion effects refer to changes in behavior among employees when diverse individuals from underserved populations are hired, impacting the overall organizational culture and decision-making. This video video includes reducing prejudice, enhancing learning, and improving outcomes for disadvantaged groups. Examples are provided, such as the positive effects of same-race teachers on student performance and changes in disciplinary policies that benefit all students.

This video video also highlights research findings that more diverse organizations perform better and suggests that increased diversity among police and medical staff leads to improved outcomes for the communities they serve, like better handling of sexual assault claims or heart attack diagnoses in women.

Moreover, it emphasizes the importance of creating bureaucracies that reflect the community's diversity to leverage varied experiences and perspectives, thereby optimizing performance and addressing disparities effectively. The overarching message advocates for a business case for diversity in the public sector to enhance outcomes and address systemic inequalities.

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Contagion effects are part of a general theory

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of representative bureaucracy.

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And the idea behind representative bureaucracy is that

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organizations in every organization,

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whether it's a public organization

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or a private organization, that individuals in

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that organization have some discretion

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in terms of what they do.

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Either the rules are ambiguous

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or there's more work to do than people can possibly do.

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And so in those cases like that,

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the individuals in the organization make choices.

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And how do they make those choices? They make those choices.

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Like everyone makes choices based on the values

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that they have and their lived experience.

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And this is essentially all representative bureaucracy is,

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which is the idea that public bureaucracies, if they

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look like the people they serve, they're more likely

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to be responsive to the needs of those people.

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It was originally a social class theory, came out

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of England, but it's mostly been applied

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to race and gender.

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Now, contagion effects are one of the ways

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representative bureaucracy might have an impact.

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And it would be good, I think, to sort

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of outline the other four

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or other three ways that it could have an impact.

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The predominant way of looking at this is to look at those

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employees who look like clients

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and see if they make decisions differently in terms of

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that client that is they disadvantage them

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less, et cetera.

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For example, it's widely established that students

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with same race teachers perform better.

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That's been widely established at, so that's one way we call

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that active representation.

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Sometimes what occurs is there's just a major policy change

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as organizations get more diverse again in education.

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We have found in the United States that

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disciplinary problems,

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and of course the major reason students get disciplined in

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the United States is truancy.

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They don't show up for school.

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And so the irony is we punish students who don't show up

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for school by suspending them from school,

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so they can't go to school.

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Okay? This sort of reinforces exactly what they were doing.

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What occurs is, as bureaucracies get more representative,

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that they move away from these punitive policies

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to AME policies.

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You get suspended in school, not out of school.

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You have processes to get you caught up

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with homework, et cetera.

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This benefits disadvantaged students,

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but it actually benefits every student that gets disciplined

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and sometimes policy from outside just forces

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An organization to change.

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An example from the United States involves when Clarence

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Thomas, who was the head

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of the Equal Employment Opportunity Commission,

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was nominated to be the Supreme Court evidence came out

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that he engaged in egregious

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of sexual harassment of employees.

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The impact of these nationally testified hearings on the

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EEOC was dramatic.

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What it did was fundamentally shift the organization

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to focus on sexual harassment, and the number of claims

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and process claims went up dramatically.

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It didn't change what the individual

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bureaucrats did in terms of their, their identity

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and their matchup,

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but everyone now, contagion effects with the topic.

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Here are effects that occur

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because you hire individuals from underserved populations

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and simply hiring them

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and their interactions with the other employees

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changes the behavior of those existing employees.

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Uh, it can occur through a couple of different ways.

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It can occur through prejudice reduction

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and the ability to listen to other people or,

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or think that they're really no different from you

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or it can occur in the cases.

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I like cases where learning occurs,

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different individuals will have different skills,

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different experiences,

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and there's an entire literature on diversity in businesses

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where it argues that in fact,

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more diverse businesses are more profitable

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and they're more successful.

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So in terms of overall representative bureaucracy,

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we have lots of evidence that it works, right?

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The question is what's the pathway?

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We know, for example, that in education, both same race

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teachers matter and gender matters.

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Girls do better with female math teachers than they do

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with male math teachers,

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and we can demonstrate that in a variety

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of countries throughout the world.

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Uh, this is mostly elementary and secondary,

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but there's some impacts at the collegiate level.

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Also, in the uk we have a wonderful case of,

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fire prevention policies seen to reflect the diversity

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of the fire force as they interact with citizens

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to prevent fires, not to put 'em out, putting 'em out

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as sort of an emergency response.

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And there's, you know, there's no discretion.

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But in terms of convincing people to change behavior,

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to reduce the incidents, it, it, it's, it's there in,

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the case of gender and police.

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We have extensive evidence both in the the US

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and in the uk, that more female police officers,

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we'll generate more, people willing

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to actually file a sexual assault claim

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and it will generate more arrests of those claims.

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Uh, we can find it in places like employment discrimination

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in healthcare in the US and Tanzania

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and child support, juvenile justice.

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It doesn't always work, but it generally works.

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So why would I focus on contagion effects?

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Okay, I think I'm focusing on contagion effects.

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Well, I know I am

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because if you're actually interested in correcting the

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disadvantages, actually trying to equalize outcomes in terms

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of interactions with police

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or interactions with the education system

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or anything, there's always more individuals

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who are not from an underserved group in the bureaucracy

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than from the underserved group.

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Uh, my colleague here, Seth Gerson,

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who studies education says,

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we cannot solve the racial gap in education in the

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United States by hiring more black teachers.

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There aren't more black teachers to hire.

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There just aren't enough individuals, and

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therefore the behavior

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of the others are especially important.

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And so this links really the diversity management literature

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to representative bureaucracy

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and looks at

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how the other people in the organization respond.

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And so we're looking in this case at

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Florida Emergency Groups.

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And the basic concern here, the policy concern is this,

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heart attacks are leading cause

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of death across all age groups in the us

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and the death rate for women who have a heart attack

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show up at a hospital is 20% higher

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than the heart attacks for men.

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The reason because the symptoms of a heart attack

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for women are often different than they are for men.

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Men have chest pains and that's sort of an automatic.

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Women might have fatigue, abdominal discomfort, sweats,

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pain in other parts of their body.

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Now the interesting thing is this is known in the medical

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literature, it's been in existence for 20 years, okay?

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However, it's also documented that women

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physicians are more likely

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to diagnose a heart attack correctly for a woman patient

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that's both in the medical literature

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and my co-author on this paper,

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Austin McCrea has done a a lot of work in this area.

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Now, here's the basic thing. This should not happen, right?

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It's in the medical literature,

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it's been there for a long time.

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Nobody has an incentive to let a patient die,

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not the doctor, not the hospital,

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and clearly not the patient.

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And so it's a case of a problem

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that should have been solved, but hasn't been solved.

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So we're looking at every

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hospital emergency room visit in the state

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of Florida for 12 years.

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These are over, millions of cases.

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There are 37,000 heart attacks that we're looking at,

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massive dataset combined with census data

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to get background information.

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And through some data scraping techniques

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and a lot of scanning of websites

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and checking it out, we can match up,

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we can find the identity of each of the doctors

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that has ever worked in an emergency

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room in the state of Florida.

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And when they're working Florida keeps marvelous records

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and the process of emergency rooms, it's just perfect

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for sort of eliminating any type of selection factor.

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You don't get to pick your doctor, right?

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The next doctor out is the one who treats you

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and they rotate sh shifts

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because nobody likes to work the midnight to 8:00 AM shift

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and they work with different sets of doctors.

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Now, Florida hospitals keep track of all of this.

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So we can match every patient with a specific doctor

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and we can match genders and control for everything else.

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We know the symptoms they have, whether they smoke,

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whether they're overweight, their age, their insurance,

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the workload, everything.

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So when a woman has a male doctor in general, her

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odds of dying at the heart attack, as I said, go up 20%.

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That's not a good figure.

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Uh, men's odds

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of dying actually go up a little bit more.

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If there's a male physician, it's not as big a difference

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as contact and male doctors work

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with female doctors, the odds improve.

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And as the percentage of female doctors they work

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with approaches, 30%,

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there becomes no statistically significant difference.

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In other words, women's outcomes are equal to men's outcomes

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in that situation.

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So what's going on? What's going on?

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It's not prejudice reduction. This is learning.

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And we can document that learning

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because all the improvements in the survival rates

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are from individuals who have atypical symptoms.

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And so it's exactly the case. You would expect improvement.

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It's not the people coming in with chest pains,

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it's the people coming in with other symptoms.

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The other indication this is learning is

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which doctors improve.

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The doctors who improve are the younger doctors

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more recently trained?

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And therefore we think more exposed

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to the scientific literature

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and doctors from better medical schools.

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And in the United States, there's a wide range

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of hiring from medical schools.

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'cause we simply do not produce enough doctors in the

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country and therefore a higher, formula wide variety.

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So those are the indications that this is learning.

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So I'd like to talk a little bit about the implications

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of this and where this can also occur

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and what it all means.

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Uh, basically this reinforces the idea

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that organizational diversity

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is a performance issue, okay?

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It's, it's, it's not a favoritism issue.

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It's about how do you get results

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for the most people in the most positive way.

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The business case for diversity applies to organizations

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where they're either public or private or nonprofit.

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Our data actually shows

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that the government owned hospitals have

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the best record on this.

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Uh, something we're not exactly sure why occurs,

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but we're actually looking at that.

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Where else would we find this?

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I think we're gonna find this in every place.

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In other places where these lived experiences, these sort

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of gender, race, socioeconomic status

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will bring some specific motivation

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to learn about a problem, particularly disparities

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and how to deal with those disparities.

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And those experiences will translate

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into different insights.

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I think there's a very good reason why we often like

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to recruit drug abuse counselors among former addicts.

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They've been through the process,

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they understand the challenges.

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I think this is a reason why,

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our immigration enforcement

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and our police officers in United States have placed a

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premium on hiring Latino police officers.

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They speak the language, they can communicate

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with the individuals,

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and in fact, they appear to be very good at it.

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There's a wonderful case in immigration

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where Latino immigration officers do fewer stops

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of individuals, fewer searches,

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but find dramatically more felons

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who are eligible for deportation.

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In other words, they're more efficient about the problem

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and they're catching the bad cases, the people

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that we really don't want in the community.

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And so it's a function of learning.

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And we found some evidence that white officers who patrol

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with Latino officers actually improve their own results.

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Contagion effects. We think that this will also occur

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where anytime the different lived experiences

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tap into different information sources,

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networks in the community, how the community is organized,

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different approaches to the problem,

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understanding the culture of different communities,

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different research literature.

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I think this is a particularly important in countries

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with large immigration influxes

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because in fact there are always sort

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of policy implementation questions there.

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It's also, I think, gonna be important when outcomes become

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Salient. We

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tolerate lots of inequalities throughout the world.

14:54.715 --> 14:57.205
Sometimes government doesn't care,

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sometimes people don't care.

14:58.725 --> 15:01.245
Sometimes people think, well, that's just the way it is.

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But it'll occur in those cases where it's on the agenda

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and someone cares about it.

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We need in the study to recruit people

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from broadly varied backgrounds

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to create bureaucracies

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that look a lot like the population they serve.

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And this will bring in experiences,

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this will bring in knowledge.

15:24.205 --> 15:26.365
This will bring in factors

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that will improve the overall performance

15:29.065 --> 15:31.685
and the performance of the other people in the organization.

15:32.315 --> 15:36.205
This is essentially the public sector needs to AOR

15:37.165 --> 15:38.165
business case for diversity.

00:00 - Contagion effects are part of a general theory of representative bureaucracy. And the idea behind representative bureaucracy is that organizations in every organization, whether it's a public organization or a private organization, that individuals in

00:18 - that organization have some discretion in terms of what they do. Either the rules are ambiguous or there's more work to do than people can possibly do. And so in those cases like that, the individuals in the organization make choices. And how do they make those choices? They make those choices. Like everyone makes choices based on the values that they have and their lived experience. And this is essentially all representative bureaucracy is,

00:51 - which is the idea that public bureaucracies, if they look like the people they serve, they're more likely to be responsive to the needs of those people. It was originally a social class theory, came out of England, but it's mostly been applied to race and gender. Now, contagion effects are one of the ways representative bureaucracy might have an impact. And it would be good, I think, to sort of outline the other four

01:25 - or other three ways that it could have an impact. The predominant way of looking at this is to look at those employees who look like clients and see if they make decisions differently in terms of that client that is they disadvantage them less, et cetera. For example, it's widely established that students with same race teachers perform better. That's been widely established at, so that's one way we call that active representation.

01:59 - Sometimes what occurs is there's just a major policy change as organizations get more diverse again in education. We have found in the United States that disciplinary problems, and of course the major reason students get disciplined in the United States is truancy. They don't show up for school. And so the irony is we punish students who don't show up for school by suspending them from school, so they can't go to school.

02:27 - Okay? This sort of reinforces exactly what they were doing. What occurs is, as bureaucracies get more representative, that they move away from these punitive policies to AME policies. You get suspended in school, not out of school. You have processes to get you caught up with homework, et cetera. This benefits disadvantaged students, but it actually benefits every student that gets disciplined and sometimes policy from outside just forces

02:59 - An organization to change. An example from the United States involves when Clarence Thomas, who was the head of the Equal Employment Opportunity Commission, was nominated to be the Supreme Court evidence came out that he engaged in egregious of sexual harassment of employees. The impact of these nationally testified hearings on the EEOC was dramatic. What it did was fundamentally shift the organization

03:25 - to focus on sexual harassment, and the number of claims and process claims went up dramatically. It didn't change what the individual bureaucrats did in terms of their, their identity and their matchup, but everyone now, contagion effects with the topic. Here are effects that occur because you hire individuals from underserved populations and simply hiring them and their interactions with the other employees

03:56 - changes the behavior of those existing employees. it can occur through a couple of different ways. It can occur through prejudice reduction and the ability to listen to other people or, or think that they're really no different from you or it can occur in the cases. I like cases where learning occurs, different individuals will have different skills, different experiences, and there's an entire literature on diversity in businesses

04:29 - where it argues that in fact, more diverse businesses are more profitable and they're more successful. So in terms of overall representative bureaucracy, we have lots of evidence that it works, right? The question is what's the pathway? We know, for example, that in education, both same race teachers matter and gender matters. Girls do better with female math teachers than they do with male math teachers,

04:59 - and we can demonstrate that in a variety of countries throughout the world. this is mostly elementary and secondary, but there's some impacts at the collegiate level. Also, in the uk we have a wonderful case of, fire prevention policies seen to reflect the diversity of the fire force as they interact with citizens to prevent fires, not to put 'em out, putting 'em out as sort of an emergency response. And there's, you know, there's no discretion.

05:27 - But in terms of convincing people to change behavior, to reduce the incidents, it, it, it's, it's there in, the case of gender and police. We have extensive evidence both in the the US and in the uk, that more female police officers, we'll generate more, people willing to actually file a sexual assault claim and it will generate more arrests of those claims. we can find it in places like employment discrimination in healthcare in the US and Tanzania

06:03 - and child support, juvenile justice. It doesn't always work, but it generally works. So why would I focus on contagion effects? Okay, I think I'm focusing on contagion effects. Well, I know I am because if you're actually interested in correcting the disadvantages, actually trying to equalize outcomes in terms of interactions with police or interactions with the education system or anything, there's always more individuals

06:35 - who are not from an underserved group in the bureaucracy than from the underserved group. my colleague here, Seth Gerson, who studies education says, we cannot solve the racial gap in education in the United States by hiring more black teachers. There aren't more black teachers to hire. There just aren't enough individuals, and therefore the behavior of the others are especially important.

07:04 - And so this links really the diversity management literature to representative bureaucracy and looks at how the other people in the organization respond. And so we're looking in this case at Florida Emergency Groups. And the basic concern here, the policy concern is this, heart attacks are leading cause of death across all age groups in the us and the death rate for women who have a heart attack

07:35 - show up at a hospital is 20% higher than the heart attacks for men. The reason because the symptoms of a heart attack for women are often different than they are for men. Men have chest pains and that's sort of an automatic. Women might have fatigue, abdominal discomfort, sweats, pain in other parts of their body. Now the interesting thing is this is known in the medical literature, it's been in existence for 20 years, okay? However, it's also documented that women

08:10 - physicians are more likely to diagnose a heart attack correctly for a woman patient that's both in the medical literature and my co-author on this paper, Austin McCrea has done a a lot of work in this area. Now, here's the basic thing. This should not happen, right? It's in the medical literature, it's been there for a long time. Nobody has an incentive to let a patient die, not the doctor, not the hospital,

08:37 - and clearly not the patient. And so it's a case of a problem that should have been solved, but hasn't been solved. So we're looking at every hospital emergency room visit in the state of Florida for 12 years. These are over, millions of cases. There are 37,000 heart attacks that we're looking at, massive dataset combined with census data to get background information.

09:09 - And through some data scraping techniques and a lot of scanning of websites and checking it out, we can match up, we can find the identity of each of the doctors that has ever worked in an emergency room in the state of Florida. And when they're working Florida keeps marvelous records and the process of emergency rooms, it's just perfect for sort of eliminating any type of selection factor. You don't get to pick your doctor, right?

09:39 - The next doctor out is the one who treats you and they rotate sh shifts because nobody likes to work the midnight to 8:00 AM shift and they work with different sets of doctors. Now, Florida hospitals keep track of all of this. So we can match every patient with a specific doctor and we can match genders and control for everything else. We know the symptoms they have, whether they smoke, whether they're overweight, their age, their insurance, the workload, everything.

10:12 - So when a woman has a male doctor in general, her odds of dying at the heart attack, as I said, go up 20%. That's not a good figure. men's odds of dying actually go up a little bit more. If there's a male physician, it's not as big a difference as contact and male doctors work with female doctors, the odds improve. And as the percentage of female doctors they work with approaches, 30%,

10:41 - there becomes no statistically significant difference. In other words, women's outcomes are equal to men's outcomes in that situation. So what's going on? What's going on? It's not prejudice reduction. This is learning. And we can document that learning because all the improvements in the survival rates are from individuals who have atypical symptoms. And so it's exactly the case. You would expect improvement. It's not the people coming in with chest pains,

11:13 - it's the people coming in with other symptoms. The other indication this is learning is which doctors improve. The doctors who improve are the younger doctors more recently trained? And therefore we think more exposed to the scientific literature and doctors from better medical schools. And in the United States, there's a wide range of hiring from medical schools.

11:38 - 'cause we simply do not produce enough doctors in the country and therefore a higher, formula wide variety. So those are the indications that this is learning. So I'd like to talk a little bit about the implications of this and where this can also occur and what it all means. basically this reinforces the idea that organizational diversity is a performance issue, okay? It's, it's, it's not a favoritism issue.

12:12 - It's about how do you get results for the most people in the most positive way. The business case for diversity applies to organizations where they're either public or private or nonprofit. Our data actually shows that the government owned hospitals have the best record on this. something we're not exactly sure why occurs, but we're actually looking at that. Where else would we find this?

12:40 - I think we're gonna find this in every place. In other places where these lived experiences, these sort of gender, race, socioeconomic status will bring some specific motivation to learn about a problem, particularly disparities and how to deal with those disparities. And those experiences will translate into different insights. I think there's a very good reason why we often like to recruit drug abuse counselors among former addicts.

13:13 - They've been through the process, they understand the challenges. I think this is a reason why, our immigration enforcement and our police officers in United States have placed a premium on hiring Latino police officers. They speak the language, they can communicate with the individuals, and in fact, they appear to be very good at it. There's a wonderful case in immigration

13:40 - where Latino immigration officers do fewer stops of individuals, fewer searches, but find dramatically more felons who are eligible for deportation. In other words, they're more efficient about the problem and they're catching the bad cases, the people that we really don't want in the community. And so it's a function of learning. And we found some evidence that white officers who patrol with Latino officers actually improve their own results.

14:14 - Contagion effects. We think that this will also occur where anytime the different lived experiences tap into different information sources, networks in the community, how the community is organized, different approaches to the problem, understanding the culture of different communities, different research literature. I think this is a particularly important in countries with large immigration influxes because in fact there are always sort

14:44 - of policy implementation questions there. It's also, I think, gonna be important when outcomes become Salient. We tolerate lots of inequalities throughout the world. Sometimes government doesn't care, sometimes people don't care. Sometimes people think, well, that's just the way it is. But it'll occur in those cases where it's on the agenda and someone cares about it. We need in the study to recruit people

15:11 - from broadly varied backgrounds to create bureaucracies that look a lot like the population they serve. And this will bring in experiences, this will bring in knowledge. This will bring in factors that will improve the overall performance and the performance of the other people in the organization. This is essentially the public sector needs to AOR business case for diversity.

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