Need Response:
When responding to your classmates, evaluate your classmates’ recommendations and suggest additional ways in which the chosen case study’s service could be improved to meet the CLAS standards

Undergraduate Discussion Rubric

Overview

Your active participation in the discussions is essential to your overall success this term. Discussion questions will help you make meaningful connections
between the course content and the larger concepts of the course. These discussions give you a chance to express your own thoughts, ask questions, and gain
insight from your peers and instructor.

Directions

For each discussion, you must create one initial post and follow up with at least two response posts.

For your initial post, do the following:

 Write a post of 1 to 2 paragraphs.

 In Module One, complete your initial post by Thursday at 11:59 p.m. Eastern.

 In Modules Two through Eight, complete your initial post by Thursday at 11:59 p.m. of your local time zone.

 Consider content from other parts of the course where appropriate. Use proper citation methods for your discipline when referencing scholarly or
popular sources.

For your response posts, do the following:

 Reply to at least two classmates outside of your own initial post thread.

 In Module One, complete your two response posts by Sunday at 11:59 p.m. Eastern.

 In Modules Two through Eight, complete your two response posts by Sunday at 11:59 p.m. of your local time zone.

 Demonstrate more depth and thought than saying things like “I agree” or “You are wrong.” Guidance is provided for you in the discussion prompt.

Rubric

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Comprehension Develops an initial post with an
organized, clear point of view or
idea using rich and significant detail
(100%)

Develops an initial post with a
point of view or idea using
adequate organization and
detail (85%)

Develops an initial post with a
point of view or idea but with
some gaps in organization and
detail (55%)

Does not develop an initial post
with an organized point of view
or idea (0%)

40

Timeliness N/A Submits initial post on time
(100%)

Submits initial post one day late
(55%)

Submits initial post two or more
days late (0%)

10

Engagement Provides relevant and meaningful
response posts with clarifying
explanation and detail (100%)

Provides relevant response
posts with some explanation
and detail (85%)

Provides somewhat relevant
response posts with some
explanation and detail (55%)

Provides response posts that
are generic with little
explanation or detail (0%)

30

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Writing
(Mechanics)

Writes posts that are easily
understood, clear, and concise
using proper citation methods
where applicable with no errors in
citations (100%)

Writes posts that are easily
understood using proper
citation methods where
applicable with few errors in
citations (85%)

Writes posts that are
understandable using proper
citation methods where
applicable with a number of
errors in citations (55%)

Writes posts that others are not
able to understand and does
not use proper citation
methods where applicable (0%)

20

Total 100%

Initial Post Completed:

To begin this discussion, introduce yourself to your classmates and instructor. Briefly discuss your background, describe your professional goals, explain what you hope to gain from this course, and share what you enjoy doing in your free time. Then, to continue your initial post, respond to the following:
The Commonwealth Fund’s report Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches provides four brief case study examples of culturally competent healthcare service models. Your textbook outlines the U.S. Department of Health and Human Services’ Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS). The CLAS consists of 15 standards.
Choose one of the case studies in the report and discuss which elements of the CLAS the healthcare service meets. For those standards that the service does not meet, how could the service be improved or changed to meet the additional standards?

Need Response:

When responding to your classmates, evaluate your classmates’ recommendations and suggest additional ways in which the chosen case study’s service could be improved to meet the CLAS standards.

Classmate #1:

Oluwaseun Adeyeri posted Jan 5, 2021 10:55 AM
The case study I decided to focus on and discuss for this class is the “Kaiser Permanente, San Francisco, CA.” After carefully going through the case studies, I found this to be more apt and detailed to meet many of the CLAS standards. First, the CLAS’s Principal Standard was met because the study provides effective, equitable, understanding, and respectful quality care services focused on preferred language, cultural health benefits, and health literacy and communication.
Under the Governance, Leadership, and Workforce CLAS standards, Kaiser Permanente, San Francisco, CA, promotes adequate education and training and recruits internal staff to cater to language deficiency patients. They also provided a cultural advisory board to encourage CLAS and health equity through policies and programs. “A cultural diversity advisory board was also established for oversight and consultation”. (Betancourt et al., 2002). Their Communication and Language Assistance is sufficient because they provide adequate language assistance though they have a specific capacity for Chinese and Latino patients, which I see as not exclusive. They also ensure competent people are employed for the purpose, and adequate information was available for them. The Kaiser Permanente, San Francisco, CA. the case study also provides sufficient engagement, continuous improvement, and accountability. The organization now has six current and future centers of greatness, each with a different mission. It focuses that cut across diverse cultural and ethnic groups to implement and sustain CLAS to all stakeholders. I believe it is necessary to increase the diversity of the language assistance to other tribes and ethnic groups such as the African Americans and other tribes.

References:
Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). CULTURAL COMPETENCE IN HEALTH CARE: EMERGING FRAMEWORKS AND PRACTICAL APPROACHES [PDF]. The Commonwealth Fund. Retrieved from https://www.commonwealthfund.org/publications/fund-reports/2002/oct/cultural-competence-health-care-emerging-frameworks-and

CLAS Standards. (2019). Retrieved from https://www.thinkculturalhealth.hhs.gov/clas/standards

Classmate #2

Amber Larue posted Jan 5, 2021 3:54 PM
I found the four different sites visited to report highly fascinating after an initial analysis of the Cultural Competency in Health Care. I was more fascinated by how distinct site studies would apply to the same four categories and 15 subcategories in order to review the National CLAS Standards. Moving on to making my decision of what case study I would choose for this week’s discussion, I decided, Kaiser Permanente Managed Care (Kaiser) located in San Francisco, CA. My reasoning for picking Kaiser is because I feel they met all four of the CLAS Standard categories.
Kaiser seems to have done an exceptional job of representing their society by following the principal standard in all four categories. Kaiser took the initiative to provide language and communication assistance rapidly to the main standard. As Kaiser has Chinese and Latino patients, Kaiser has put in place a multi-lingual Chinese and a bilingual Spanish module to provide all patients with advanced cultural resources and treatment. Kaiser also supplies the patients with their published information in the chosen language of the patient. Since Kaiser has high expectations for the quality treatment of its patients, Kaiser has eliminated any language barrier they might be facing when serving their group. To be able to accept this need and to go forward diligently and to allow Kaiser to meet additional CLAS standards. In my discussion I discussed two of Kaiser’s CLAS principles, but I agree that they have accomplished more than just these two as they also reflect dedication, quality improvement and transparency. Through the Kaiser organization the continuous growth has helped Kaiser, while serving those who are already challenged, to effectively prepare the community’s needs.

While I believe that Kaiser fulfills all four standards, I also see where its quality can be enhanced. The case study focuses on groups that might be the highest in their group. They are particularly interested in developing facilities by means of a quality of contact and language support; maybe they should look at their societies’ smaller cultures. This change may be aimed at certain individuals who are unable to speak (mute), hard to hear or deaf. This community has huge barriers to communication. Kaiser may use sign-language, brail, or useful listening techniques to capture certain patients no matter how decent.

References:

U.S. Department of Health & Human Services, (n.d.), Culturally and Linguistically Appropriate Services, (CLAS), (n.d.), Retrieved from https://www.thinkculturalhealth.hhs.gov/clas/what-is-clas, on March 2, 2019

Information:

Kaiser Permanente, San Francisco, CA
In the early 1990s, studies showed that Asian populations were the least satisfied with their
health care within Kaiser Permanente’s Northern California Region. As a result, many
Chinese American–owned and –operated companies were exploring health care contracts
with smaller managed care organizations that were marketing services targeted to Chinese
American consumers. To understand this issue better, the San Francisco Medical Center
embarked on the “Chinese Initiative.” Based on findings of this initiative, Kaiser
Permanente established a department of multicultural services that provides on-site
interpreters for patients in all languages, with internal staffing capability in 14 different
languages and dialects. A Chinese interpreter call center is also available to help Chinese
speaking patients make appointments, obtain medical advice, and navigate the health care
system. A translation unit assures that written materials and signs are translated into the
necessary languages. A cultural diversity advisory board was also established for oversight
and consultation.
In addition, Kaiser has developed modules of culturally targeted health care
delivery at the San Francisco facility. The multilingual Chinese module and the bilingual
Spanish module provide care and services to all patients but have specific cultural and
linguistic capacity to care for Chinese and Latino patients. Both modules are multispecialty
and multidisciplinary. They include, for example, diabetes nurses, case managers, and
11
health educators, with the entire staff chosen for its cultural understanding and language
proficiencies.
Much of the stimulus for this work came from the large purchasers of Kaiser health
care services, who wanted culturally competent care for their employees. Not only had it
become clear that culturally competent services made good business sense for Kaiser, but
there was also a need to comply with Title VI of the Civil Rights Act and the Culturally
and Linguistically Appropriate Services (CLAS) Standards.d

MANAGED CARE:

Kaiser Permanente, San Francisco, CA
In the early 1990s, studies showed that Asian populations were the least satisfied with their
health care within Kaiser Permanente’s Northern California Region. As a result, many
Chinese American–owned and –operated companies were exploring health care contracts
with smaller managed care organizations that were marketing services targeted to Chinese
American consumers. To understand this issue better, the San Francisco Medical Center
embarked on the “Chinese Initiative.” Based on findings of this initiative, Kaiser
Permanente established a department of multicultural services that provides on-site
interpreters for patients in all languages, with internal staffing capability in 14 different
languages and dialects. A Chinese interpreter call center is also available to help Chinese
speaking patients make appointments, obtain medical advice, and navigate the health care
system. A translation unit assures that written materials and signs are translated into the
necessary languages. A cultural diversity advisory board was also established for oversight
and consultation.
In addition, Kaiser has developed modules of culturally targeted health care
delivery at the San Francisco facility. The multilingual Chinese module and the bilingual
Spanish module provide care and services to all patients but have specific cultural and
linguistic capacity to care for Chinese and Latino patients. Both modules are multispecialty
and multidisciplinary. They include, for example, diabetes nurses, case managers, and
health educators, with the entire staff chosen for its cultural understanding and language
proficiencies.
Much of the stimulus for this work came from the large purchasers of Kaiser health
care services, who wanted culturally competent care for their employees. Not only had it
become clear that culturally competent services made good business sense for Kaiser, but
there was also a need to comply with Title VI of the Civil Rights Act and the Culturally
and Linguistically Appropriate Services (CLAS) Standards.
Today, San Francisco Medical Center is recognized as a center of excellence for linguistic and
cultural services.
On a national level, Kaiser Permanente has a director of linguistic and cultural
programs. The California Endowment recently awarded Kaiser a grant to assess the
outcomes of these programs and validate model programs for linguistic and cultural
services. Kaiser Permanente’s Institute for Culturally Competent Care now has six current
and future centers of excellence, each with a different mission and focus: African
American Populations (Los Angeles), Latino Populations (Colorado), Linguistic & Cultural
Services (San Francisco), Women’s Health, Members with Disabilities, and Eastern
European Populations. Each center can be used as a model and site of distribution for
materials, such as the culturally specific provider handbook, to other Kaiser Permanente
programs.

Key Lessons Learned

• Use publicity, market influences (including strategies to increase market share in
diverse communities), and health care purchasers to stimulate the development of
culturally competent services.
• Be careful in mandating cultural competence initiatives as this may lead to
resentment, poor adherence to policies, and superficial responses.
• Employ multicultural managers to reflect the diversity of the staff and patients and
to emphasize diversity throughout the organization.
• Focus the entire organization on the opportunity to improve services and business
as a whole, including improvement in patient satisfaction.
• Implement systemic changes such as establishing a linguistically appropriate patient
call center to help patients navigate the health care system.
The federal Office of Minority Health developed the Culturally and Linguistically Appropriate
Services Standards project. See www.omhrc.gov/clas.
• Establish a cultural diversity board that includes administrators as well as a
multidisciplinary group of providers (i.e., doctors, physician assistants, nurse
practitioners, and registered nurses) and community representatives to help guide
the delivery of culturally competent care.

Classmate #2

CULTURAL COMPETENCE IN HEALTH CARE:

EMERGING FRAMEWORKS AND PRACTICAL APPROACHES

Joseph R. Betancourt

Massachusetts General Hospital–Harvard Medical School

Alexander R. Green and J. Emilio Carrillo

New York-Presbyterian Hospital–Weill Medical College

of Cornell University

FIELD REPORT

October 2002

Support for this research was provided by The Commonwealth Fund. The views

presented here are those of the authors and should not be attributed to The Commonwealth

Fund or its directors, officers, or staff.

Copies of this report are available from The Commonwealth Fund by calling our toll-free

publications line at 1-888-777-2744 and ordering publication number 576. The report

can also be found on the Fund’s website at www.cmwf.org.

iii

CONTENTS

About the Authors ……………………………………………………………………………………………. iv

Acknowledgments ……………………………………………………………………………………………. iv

Executive Summary…………………………………………………………………………………………… v

Introduction ……………………………………………………………………………………………………..1

Findings……………………………………………………………………………………………………………3

Defining Cultural Competence ……………………………………………………………………….3

Barriers to Culturally Competent Care……………………………………………………………..3

Benefits of Cultural Competence …………………………………………………………………….6

Models of Culturally Competent Care …………………………………………………………………..7

Academia …………………………………………………………………………………………………….7

Government ………………………………………………………………………………………………..8

Managed Care……………………………………………………………………………………………. 10

Community Health…………………………………………………………………………………….. 12

Key Components of Cultural Competence …………………………………………………….. 14

Framework for Culturally Competent Care…………………………………………………….. 14

Strategies for Implementation……………………………………………………………………….. 15

Summary of Recommendations and Practical Approaches: Linking Cultural

Competence to the Elimination of Racial and Ethnic Disparities in Health Care………… 17

Organizational Cultural Competence …………………………………………………………….. 17

Systemic Cultural Competence …………………………………………………………………….. 17

Clinical Cultural Competence………………………………………………………………………. 18

Appendix I. Methodology ………………………………………………………………………………… 20

Appendix II. Key Informants …………………………………………………………………………….. 22

Notes…………………………………………………………………………………………………………….. 24

LIST OF FIGURES

Figure 1 Demographic Projections: Growing Diversity………………………………………….1

Figure 2 Minorities Are Underrepresented Within Health Care Leadership ………………4

Figure 3 Minorities Are Underrepresented Within the Health Care Workforce …………4

iv

ABOUT THE AUTHORS

Joseph R. Betancourt, M.D., M.P.H., is senior scientist at the Institute for Health

Policy and program director of multicultural education at Massachusetts General Hospital–

Harvard Medical School.

Alexander R. Green, M.D., is assistant professor of medicine and associate director of

the primary care residency program at New York-Presbyterian Hospital–Weill Medical

College of Cornell University.

J. Emilio Carrillo, M.D., M.P.H., is assistant professor of medicine and public health

at Weill Medical College of Cornell University and medical director of the New York-

Presbyterian Healthcare Network.

Research Coordinators

Owusu Ananeh-Firempong II is research associate at the Institute for Health Policy,

Massachusetts General Hospital.

Chinwe Onyekere, M.P.H., is program associate at the Robert Wood Johnson Foundation.

Research Staff

Elyse Park, Ph.D., is senior scientist at the Institute for Health Policy and instructor in

the department of psychiatry at Massachusetts General Hospital.

Ellie MacDonald is research associate at the Institute for Health Policy, Massachusetts

General Hospital.

ACKNOWLEDGMENTS

The authors would like to thank all of the key informants for their participation and

insights. In addition, they would like to thank those individuals who were kind enough to

coordinate and facilitate the model practice site visits.

Visit www.massgeneral.org/healthpolicy/cchc.html for a more detailed report that

includes further information about the authors, interviews with key experts, and site visits;

links to websites focused on cultural competence and racial/ethnic disparities; an

autosearch engine for recent literature on cultural competence and racial/ethnic disparities;

a guest book; and a searchable database of models of culturally competent care.

v

EXECUTIVE SUMMARY

As the United States becomes a more racially and ethnically diverse nation, health

care systems and providers need to respond to patients’ varied perspectives, values, and

behaviors about health and well-being. Failure to understand and manage social and cultural

differences may have significant health consequences for minority groups in particular.

The field of cultural competence has recently emerged as part of a strategy to

reduce disparities in access to and quality of health care. Since this is an emerging field,

efforts to define and implement the principles of cultural competence are still ongoing. To

provide a framework for discussion and examples of practical approaches to cultural

competence, this report set out to:

• Evaluate current definitions of cultural competence and identify benefits to the
health care system by reviewing the medical literature and interviewing health care

experts in government, managed care, academia, and community health care

delivery.

• Identify models of culturally competent care.

• Determine key components of cultural competence and develop recommendations
to implement culturally competent interventions and improve the quality of health

care.

DEFINING CULTURAL COMPETENCE

Cultural competence in health care describes the ability of systems to provide care to

patients with diverse values, beliefs and behaviors, including tailoring delivery to meet

patients’ social, cultural, and linguistic needs. Experts interviewed for this study describe

cultural competence both as a vehicle to increase access to quality care for all patient

populations and as a business strategy to attract new patients and market share.

BARRIERS TO CULTURALLY COMPETENT CARE

Barriers among patients, providers, and the U.S. health care system in general that might

affect quality and contribute to racial/ethnic disparities in care include:

• Lack of diversity in health care’s leadership and workforce.

• Systems of care poorly designed to meet the needs of diverse patient populations.

• Poor communication between providers and patients of different racial, ethnic, or
cultural backgrounds.

vi

BENEFITS OF CULTURAL COMPETENCE

The literature review revealed that few studies make the link directly between cultural

competence and the elimination of racial/ethnic disparities in health care. Health care

experts in government, managed care, academia, and community health care, on the other

hand, make a clear connection between cultural competence, quality improvement, and

the elimination of racial/ethnic disparities.

MODEL PRACTICE SITE VISITS

The authors visited an academic, government, managed care, and community health care

program, each of which had been identified by experts interviewed in these fields as being

models of cultural competence. Models studied included:

Academic Site Visit: White Memorial Medical Center Family Practice

Residency Program, Los Angeles, CA

Support provided by the California Endowment to the White Memorial Medical Center

Family Practice Residency Program enabled several faculty members, including a director

of behavioral sciences, a manager of cross-cultural training, and a director of research and

evaluation, to devote time specifically to cultural competence training. A medical

fellowship position was also established with part-time clinical and supervisory

responsibilities to provide a practical, clinical emphasis to the curriculum.

The curriculum, which is required, begins with a month-long orientation to

introduce family medicine residents to the community. The doctors spend nearly 30 hours

on issues related to cultural competence, during which time they learn about traditional

healers and community-oriented primary care and hold small group discussions, readings,

and self-reflective exercises. Throughout the year, issues related to cultural competence are

integrated into the standard teaching curriculum and codified in a manual. Residents

present clinical cases to faculty regularly, with particular emphasis on the sociocultural

perspective. In addition, a yearly faculty development retreat helps to integrate cultural

competence into all of the teaching at White Memorial. The hospital is currently assessing

the outcomes of these interventions.

Government Site Visit: Language Interpreter Services and Translations,

Washington State

Washington’s Department of Social and Health Services launched its Language Interpreter

Services and Translations (LIST) program in 1991, at a time when the state’s immigrant

and migrant populations began to grow. LIST runs a training and certification program—

the only one of its kind in Washington—for interpreters and translators. It incorporates a

sophisticated system of qualification, including written and oral testing and extensive

vii

background checks. In addition, there is a quality control system, and the state provides

reimbursement for certified or qualified interpreter or translation services for all Medicaid

recipients and other department clients who need them. Requests for translation are

typically generated by providers or the social service program staff, with eight languages

readily available and all other languages accessible on-call. Interpreters bill costs directly to

LIST and the rest of the department programs for services. The program also provides

services for translation of documents.

Managed Care Site Visit: Kaiser Permanente, San Francisco, CA

Kaiser Permanente established a department of multicultural services that provides on-site

interpreters for patients in all languages, with internal staffing capability in 14 different

languages and dialects. A Chinese interpreter call center is also available to help Chinese-

speaking patients make appointments, obtain medical advice, and navigate the health care

system. A translation unit assures that written materials and signs are translated into the

necessary languages. A cultural diversity advisory board was also established for oversight

and consultation.

In addition, Kaiser has developed modules of culturally targeted health care

delivery at the San Francisco facility. The multilingual Chinese module and the bilingual

Spanish module provide care and services to all patients but have specific cultural and

linguistic capacity to care for Chinese and Latino patients. Both modules are multispecialty

and multidisciplinary. They include, for example, diabetes nurses, case managers, and

health educators, with the entire staff chosen for its cultural understanding and language

proficiencies.

On a national level, Kaiser Permanente has a director of linguistic and cultural

programs. The California Endowment recently awarded Kaiser a grant to assess the

outcomes of these programs and validate model programs for linguistic and cultural

services. Kaiser Permanente’s Institute for Culturally Competent Care now has six current

and future centers of excellence, each with a different mission and focus: African

American Populations (Los Angeles), Latino Populations (Colorado), Linguistic & Cultural

Services (San Francisco), Women’s Health, Members with Disabilities, and Eastern

European Populations. Each center can be used as a model and site of distribution for

materials, such as the culturally specific provider handbook, to other Kaiser Permanente

programs.

viii

Community Health Site Visit: Sunset Park Family Health Center Network of

Lutheran Medical Center, Brooklyn, NY

In the early1990s, the Sunset Park Family Health Center (SPFHC) began an effort to

expand access to care for the recent Chinese immigrants in its area. The Asian Initiative

would eventually become its first experience in creating culturally competent health care.

However, the initiative was originally viewed by SPFHC leadership as an intervention in

community-oriented primary care, an approach that was well-established in the

organization’s philosophy, mission, and history. The initiative focused at first on reducing

barriers to care—offering flexible hours of service, establishing interpretation services and

translating signage, forming stronger links to community leadership and key resources, and

training Chinese-educated nurses in upgraded clinical skills so they could pass state

licensing exams in English. This last effort, one that addressed the shortage of linguistically

and culturally appropriate staff, reflects an institutional priority to recruit and hire from

within the community.

Building on these efforts, SPFHC has made cultural competence an important

goal, funding regular staff training programs, offering patient navigators, expanding its

relationships with community groups, and creating an environment that celebrates

diversity (e.g., by celebrating various cultural and religious holidays, displaying

multicultural artwork, offering an array of ethnic foods, and creating prayer rooms).

The Mexican Health Project is one of several recent primary care sites targeting a

rapidly growing immigrant community. When completed, the project will not only

provide an assessment of community health needs but will recommend various

interventions for communication in clinical settings and patient education.

RECOMMENDATIONS

To achieve organizational cultural competence within the health care leadership and

workforce, it is important to maximize diversity. This may be accomplished through:

• Establishing programs for minority health care leadership development and
strengthening existing programs. The desired result is a core of professionals who

may assume influential positions in academia, government, and private industry.

• Hiring and promoting minorities in the health care workforce.

• Involving community representatives in the health care organization’s planning
and quality improvement meetings.

ix

To achieve systemic cultural competence (e.g., in the structures of the health care

system) it is essential to address such initiatives as conducting community assessments,

developing mechanisms for community and patient feedback, implementing systems for

patient racial/ethnic and language preference data collection, developing quality measures

for diverse patient populations, and ensuring culturally and linguistically appropriate health

education materials and health promotion and disease prevention interventions. Programs

to achieve systemic cultural competence may include:

• Making on-site interpreter services available in health care settings with significant
populations of limited-English-proficiency (LEP) patients. Other kinds of

interpreter services should be used in settings with smaller LEP populations or

limited financial or human resources.a

• Developing health information for patients that is written at the appropriate
literacy level and is targeted to the language and cultural norms of specific

populations.

• Requiring large health care purchasers to include systemic cultural competence
interventions as part of their contracting language.

• Identifying and implementing federal and state reimbursement strategies for
interpreter services. Title VI legislation mandating the provision of interpreter

services in health care should be enforced and institutions held accountable for

substandard services.

• Using research tools to detect medical errors due to lack of systemic cultural
competence, including those due to language barriers.

• Incorporating standards for measuring systemic cultural competence into standards
used by the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) and by the National Committee for Quality Assurance (NCQA).

• Collecting race/ethnicity and language preference data for all beneficiaries,
members, and clinical encounters in programs sponsored by the federal

government and private organizations.b The data should be used to monitor racial

and ethnic disparities in health care delivery, for reporting to the public, and for

quality improvement initiatives.

a This report endorses the report by the U.S. Department of Health and Human Services report,

“Clarification of Title VI of the Civil Rights Act: Policies Regarding LEP Individuals.” It may be found at
www.thomas.loc.

b This paper endorses the detailed recommendations in Ruth T. Perot and Mara Youdelman, Racial,
Ethnic, and Primary Language Data Collection in the Health Care System: An Assessment of Federal Policies and
Practices (New York: The Commonwealth Fund, September 2001).

x

To attain clinical cultural competence, health care providers must: (1) be made aware

of the impact of social and cultural factors on health beliefs and behaviors; (2) be equipped

with the tools and skills to manage these factors appropriately through training and

education; and (3) empower their patients to be more of an active partner in the medical

encounter. Organizations can do this through:

• cross-cultural training as a required, integrated component of the training and
professional development of health care providers;

• quality improvement efforts that include culturally and linguistically appropriate
patient survey methods and the development of process and outcome measures

that reflect the needs of multicultural and minority populations; and

• programs to educate patients on how to navigate the health care system and
become an active participant in their care.

1

CULTURAL COMPETENCE IN HEALTH CARE:

EMERGING FRAMEWORKS AND PRACTICAL APPROACHES

INTRODUCTION

Culture has been defined as an integrated pattern of learned beliefs and behaviors

that can be shared among groups. It includes thoughts, styles of communicating, ways of

interacting, views on roles and relationships, values, practices, and customs.1,2 Culture is

shaped by multiple influences, including race, ethnicity, nationality, language, and gender, but

it also extends to socioeconomic status, physical and mental ability, sexual orientation, and

occupation, among other factors. These influences can collectively be described as “sociocultural

factors,” which shape our values, form our belief systems, and motivate our behaviors.

The 2000 United States Census confirmed that our nation’s population has

become more diverse than ever before, and this trend is expected to continue over the

next century (Figure 1).3 As we become a more ethnically and racially diverse nation,

health care systems and providers need to reflect on and respond to patients’ varied

perspectives, values, beliefs, and behaviors about health and well-being. Failure to

understand and manage sociocultural differences may have significant health consequences

for minority groups in particular.c

Figure 1. Demographic Projections:
Growing Diversity

White
Black
Hispanic
Asian/PI
N Am/Ak N

70% 60%

12%

13%

13%
19%

4% 7%

2000 2030

Racial/Ethnic Composition
of the U.S. Population

Source: U.S. Census Bureau, 2000.

1% 1%

c The definition of “minority group” used in this paper is consistent with that of the U.S. Office of

Management and Budget (OMB-15 Directive) and includes African Americans, Hispanics, Asian/Pacific
Islanders, and Native Americans/Alaska Natives.

2

A number of factors lead to disparities in health and health care among racial and

ethnic groups, including social determinants (e.g., low socioeconomic status or poor

education) and lack of health insurance. Sociocultural differences among patients, health

care providers, and the health care system, in particular, are seen by health care experts as

potential causes for disparities. These differences, which may influence providers’

decision-making and interactions between patients and the health care delivery system,

may include: variations in patients’ ability to recognize clinical symptoms of disease and

illness, thresholds for seeking care (including the impact of racism and mistrust),

expectations of care (including preferences for or against diagnostic and therapeutic

procedures), and the ability to understand the prescribed treatment.4–13

The field of “cultural competence” in health care has emerged in part to address

the factors that may contribute to racial/ethnic disparities in health care. Cultural

competence in health care describes the ability of systems to provide care to patients with

diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social,

cultural, and linguistic needs. The ultimate goal is a health care system and workforce that

can deliver the highest quality of care to every patient, regardless of race, ethnicity,

cultural background, or English proficiency.

While cultural competence is widely recognized as integral to the elimination of

disparities in health care, efforts are still ongoing to define and implement this broad

construct.14–17 Legislators ask, for example, what policies can foster the cultural

competence of our health care system. Administrators want to know what we can do to

make managed care organizations or hospitals more culturally competent. Academicians

ask what we should teach our health care professional students about cultural competence.

Finally, providers ask how we can deliver more culturally competent care at the

community level.

To address these questions, this report set out to:

• Review current definitions of cultural competence and identify benefits to health
care, based on the medical literature and interviews with health care experts in

government, managed care, academia, and community health care delivery.

• Identify models for achieving culturally competent care.

• Identify key components of cultural competence and develop recommendations
for appropriate interventions.

3

FINDINGS

The literature review and interviews with experts yielded a practical definition of

cultural competence in health care, highlighted sociocultural barriers that impair culturally

competent care, and identified the benefits of culturally competent care.

DEFINING CULTURAL COMPETENCE

The literature review yielded various working definitions for cultural competence, with

nearly all touching upon the need for health systems and providers to be aware of and

responsive to patients’ cultural perspectives.18–20 All experts interviewed tended to see

cultural competence as a way to increase access to quality care for all patient populations

and as a business imperative to respond to diverse patient populations and attract new

patients and market share.

These working definitions generally held that minorities have difficulty getting

appropriate, timely, high-quality care because of language barriers and that they may have

different perspectives on health, medical care, and expectations about diagnosis and

treatment. Achieving cultural competence in health care would help remove these

barriers, supplanting the current one-size-fits-all approach with a system more responsive

to the needs of an increasingly diverse population.

BARRIERS TO CULTURALLY COMPETENT CARE

The literature review and interviews identified sociocultural barriers among patients,

providers, and the health care system that might affect quality and contribute to racial and

ethnic disparities in care.

Lack of Diversity in Health Care Leadership and Workforce

Many journal articles and several key informants cited the lack of diversity in health care

leadership as a potential barrier to care. Minorities make up 28 percent of the U.S.

population but only 3 percent of medical school faculty, 16 percent of public health

school faculty, and 17 percent of all city and county health officers (Figure 2).21

Furthermore, fully 98 percent of senior leaders in health care management are white.22

This is a major concern because minority health care professionals in general may be more

“Cultural competence is a set of behaviors and attitudes and a culture within the business or
operation of a system that respects and takes into account the person’s cultural background, cultural
beliefs, and their values and incorporates it into the way health care is delivered to that individual.”

— Administrator, Managed Care Organization

4

likely to take into account sociocultural factors when organizing health care delivery

systems to meet the needs of minority populations.23

Figure 2. Minorities Are Underrepresented
Within Health Care Leadership

3

16 17

28

0

10

20

30

Medical School
Faculty

Public Health School
Faculty

City/County Health
Officials

Total Minority
Population

Percent minority

Sources: Bureau of Health Professions, 1999; Yax, 1999; and Collins et al., 1999.

Figure 3. Minorities Are Underrepresented
Within the Health Care Workforce

7
5

3 4 3

28

0

10

20

30

Physicians Dentists Pharmacists Optometrists Nurses Total Minority
Population

Percent minority

Sources: Bureau of Health Professions, 1999; Yax, 1999; and Collins et al., 1999.

5

Minorities are also underrepresented in the health care workforce (Figure 3).

Several studies pointed to links between the racial and ethnic diversity of the health care

workforce and health care quality. For example, studies have found that when there is

racial concordance between doctor and patient—that is, when they share the same racial

or ethnic background—patient satisfaction and self-rated quality of care are higher.24–26

Higher satisfaction and self-rated care are, in turn, closely linked to certain health outcomes,

including more effective blood pressure control.27–29 Other work has established that

minority physicians disproportionately serve minority and underserved communities.30–32

Systems of Care Poorly Designed for Diverse Patient Populations

Various systemic issues were raised in the literature and by the health care experts

interviewed, including poorly constructed and complicated systems that are not responsive

to the needs of diverse patient populations.33 The issue of language discordance between

provider and patient was foremost.34 Systems lacking interpreter services or culturally and

linguistically appropriate health education materials lead to patient dissatisfaction, poor

comprehension and adherence, and lower-quality care, according to various studies.35–43

Poor Cross-Cultural Communication Between Providers and Patients

Experts and articles noted that other communication barriers, apart from language barriers,

lead to disparities in care.44 When health care providers fail to understand sociocultural

differences between themselves and their patients, the communication and trust between

them may suffer. This in turn may lead to patient dissatisfaction, poor adherence to

medications and health promotion strategies, and poorer health outcomes.45–56 Moreover,

when providers fail to take sociocultural factors into account, they may resort to

stereotyping, which can affect their behavior and clinical decision-making.57

“If we don’t have at the table people of color and the diverse populations we serve, you can be sure …