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Cultural Cultural Competence in Competence in

Health Health AdministrationAdministrationPhilippa Strelitz, PhD, MPAffPhilippa Strelitz, PhD, MPAffDepartment of Health Administration Department of Health Administration

Alumni ConferenceAlumni ConferenceNovember 17, 2006November 17, 2006

Texas State University, San MarcosTexas State University, San Marcos

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OverviewOverview

Cultural competence drivers.Cultural competence drivers. What is cultural competence? What What is cultural competence? What

is it NOT?is it NOT? Some Best Practices for achieving Some Best Practices for achieving

cultural competence: data collection cultural competence: data collection and assessment. and assessment.

Cultural competence in the Health Cultural competence in the Health Administration curriculum.Administration curriculum.

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Cultural Cultural competence competence

driversdrivers

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What is driving the current What is driving the current focus on cultural focus on cultural

competence?competence?

Demographic changesDemographic changes

QualityQuality Patient safetyPatient safety Health disparitiesHealth disparities

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America’s Changing America’s Changing DemographicsDemographics

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Institute of Medicine (2001): Institute of Medicine (2001): Improve QualityImprove Quality

Health care Quality Dimensions:

•Safe

•Timely

•Patient-Centered

•Effective

•Efficient

•Equitable

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Two overarching domains Two overarching domains of Qualityof Quality

Clinical/Technical Clinical/Technical aspects aspects of patient careof patient care

ExperientialExperiential aspects of aspects of patient carepatient care

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Why is it important to link Why is it important to link culture and quality?culture and quality?

Cultural competence is Cultural competence is integrally integrally relatedrelated to the two core elements: to the two core elements: clinical/technicalclinical/technical aspect of patient care aspect of patient care and and experiential dimensionexperiential dimension of patient of patient care.care.

KnowledgeKnowledge of clinical and experiential of clinical and experiential factors that affect racially and ethnically factors that affect racially and ethnically diverse patients can significantly affect diverse patients can significantly affect quality.quality.

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Archives of Internal Medicine, 2006; 166:675-681Archives of Internal Medicine, 2006; 166:675-681

04/19/23 10 The American Journal of Medicine, 2005; 118:529-535The American Journal of Medicine, 2005; 118:529-535

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Consequences of not Consequences of not acknowledging the intersection of acknowledging the intersection of

culture and qualityculture and quality

Inability of the patient to understand Inability of the patient to understand English can lead to English can lead to medical errormedical error in in medications or in other treatment medications or in other treatment guidance.guidance.

Lack of organizational support—Lack of organizational support—signage, adequate interpreter services, signage, adequate interpreter services, effective community links—can effective community links—can compromise timelinesscompromise timeliness of care delivery of care delivery and and access to careaccess to care..

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Linking Cultural Competence Linking Cultural Competence to Qualityto Quality

Key IOM recommendations:Key IOM recommendations:

Support race/ethnicity Support race/ethnicity data collectiondata collection, , quality improvement, use of evidence-quality improvement, use of evidence-based guidelines.based guidelines.

FacilitateFacilitate interpretation interpretation services. services. Provider educationProvider education (mechanisms of (mechanisms of

decision making, cultural competence).decision making, cultural competence). Patient educationPatient education (health care system (health care system

navigation, activation in the medical navigation, activation in the medical encounter).encounter).

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Preliminary work show Preliminary work show cultural competence cultural competence

improves quality of careimproves quality of care

0

10

20

30

40

50

60

70

80

Exc. Good Fair Poor

Prevent medicationPrevent medicationunder use amongunder use amongchildren with children with

persistent persistent asthmaasthma

Cultural competence Cultural competence scorescore

Source: Lieu TA et al., Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003) 102-110.

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Institute of Medicine (1999):Institute of Medicine (1999):Ensure Patient SafetyEnsure Patient Safety

“First, do no harm…”

Mis-use

Over-use

Under-use

of medications and medical procedures:

44,000-98,000 deaths each year

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Institute of Medicine (2002):Institute of Medicine (2002):Reduce Health DisparitiesReduce Health Disparities

Disparities and Disparities and Quality:Quality:

There is a There is a critical gap in critical gap in the quality of the quality of treatment of treatment of patients from patients from racial and racial and ethnic minority ethnic minority groups.groups.

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Health and Healthcare Health and Healthcare Disparities: A National Disparities: A National

ProblemProblem

Health and Healthcare Health and Healthcare Disparities: A National Disparities: A National

ProblemProblem African Americans are:African Americans are:

Less likely to have a kidney transplant, Less likely to have a kidney transplant, surgery for lung cancer, bypass surgery.surgery for lung cancer, bypass surgery.

More likely to have a foot amputation. More likely to have a foot amputation. More likely to die prematurely.More likely to die prematurely.

Latinos/Hispanics are:Latinos/Hispanics are: Less likely to receive pain medications.Less likely to receive pain medications.

Chinese? Pakistanis? Croatians? Chinese? Pakistanis? Croatians? Iranians?Iranians?

African Americans are:African Americans are: Less likely to have a kidney transplant, Less likely to have a kidney transplant,

surgery for lung cancer, bypass surgery.surgery for lung cancer, bypass surgery. More likely to have a foot amputation. More likely to have a foot amputation. More likely to die prematurely.More likely to die prematurely.

Latinos/Hispanics are:Latinos/Hispanics are: Less likely to receive pain medications.Less likely to receive pain medications.

Chinese? Pakistanis? Croatians? Chinese? Pakistanis? Croatians? Iranians?Iranians?

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Linking cultural competence to Linking cultural competence to

disparities reduction: disparities reduction: three domainsthree domains

1.1. Patient activationPatient activation

2.2. Language/communication assistanceLanguage/communication assistance

3.3. Organizational supports (practices, Organizational supports (practices, policies, structures) for cultural policies, structures) for cultural competence/disparities reductioncompetence/disparities reduction

↓↓

Dimensions of Quality Dimensions of Quality Patient-centered care, safety, Patient-centered care, safety,

efficiency, effectivenessefficiency, effectiveness

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The “natural fit” of The “natural fit” of language language and cultureand culture within the within the quality quality frameworkframework offers opportunity for offers opportunity for practitioners and administrators practitioners and administrators to significantly to significantly improve qualityimprove quality for racially/ethnically diverse for racially/ethnically diverse patients.patients.

Take Home MessageTake Home Message

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What is cultural What is cultural competence? What competence? What

is it NOT?is it NOT?

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Defining Cultural Defining Cultural CompetenceCompetence

A set of congruent A set of congruent behaviorsbehaviors, , attitudesattitudes, and , and policiespolicies that come that come together in a system, agency, or together in a system, agency, or among professionals, and enable among professionals, and enable that system, agency, or those that system, agency, or those professionals professionals to work effectively to work effectively in cross-cultural situationsin cross-cultural situations..

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Dimensions of Cultural Dimensions of Cultural CompetenceCompetence

behaviors

attitudes structures

policies

practices

Cultural competence

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History of cultural History of cultural competencecompetence

Early conceptions of cultural Early conceptions of cultural competencecompetence

Evolution of cultural competenceEvolution of cultural competence

Expansion to consider racial/ethnic Expansion to consider racial/ethnic disparitiesdisparities

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Expansion of cultural Expansion of cultural competencecompetenceEarly Early ModelsModels

cross-cross-culturalcultural

Recent Recent ModelModel

cultural cultural competenccompetencee

Newer Newer ModelModel

CLAS/ CLAS/ qualityquality

PopulatioPopulationsns

immigrantimmigrants, s, refugees, refugees, LEP,LEP,

non-non-WesternWestern

+ All people of + All people of

color (those color (those affected affected

by disparities) by disparities)

+ + everyoneeveryone

ConceptsConcepts culture, culture, languagelanguage

+ prejudice, + prejudice, stereotyping, stereotyping, social social determinants determinants of health of health

+ safety, + safety, disparitiedisparitiess

ScopeScope interpersointerpersonal nal interactiointeractions ns

+ health + health care care organizationorganizationss

+ + systems, systems, communitcommunitiesies

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Cultural competence and Cultural competence and patient-centered carepatient-centered care

Emphasize different aspects of Emphasize different aspects of quality – significant common quality – significant common groundground

Patient-centered care: provide Patient-centered care: provide individualized care and restore individualized care and restore emphasis on personal relationshipsemphasis on personal relationships

Cultural competence: increase Cultural competence: increase health equity and reduce disparitieshealth equity and reduce disparities

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Cultural competence is Cultural competence is NOT:NOT:

A “cultural cook book” approach to A “cultural cook book” approach to health care.health care. Culture is not simply a matter of race, Culture is not simply a matter of race,

ethnicity, or social status.ethnicity, or social status. There is no “African American patient,” There is no “African American patient,”

“Latino patient,” “Asian patient.”“Latino patient,” “Asian patient.”

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OMH Culturally and Linguistically OMH Culturally and Linguistically Appropriate Services (CLAS)Appropriate Services (CLAS)

Culturally Competent Culturally Competent CareCare

Promote and support staff Promote and support staff skillsskillsManagement strategyManagement strategyCommunity and consumer Community and consumer

involvementinvolvementLanguage Access ServicesLanguage Access ServicesStrategies to diversify staffStrategies to diversify staffOngoing education for staffOngoing education for staffProvide interpretation Provide interpretation servicesservicesProvide notices of free Provide notices of free interpreter services interpreter services

Organizational Supports for Organizational Supports for Cultural CompetenceCultural Competence

Translate materials for Translate materials for predominant language groupspredominant language groups

Train interpretersTrain interpreters primary language and primary language and

race/ethnicity in patient race/ethnicity in patient recordsrecords

Collect accurate dataCollect accurate data Organizational self-Organizational self-

assessmentsassessments Ability to address cross-Ability to address cross-

cultural ethical and legal cultural ethical and legal conflictsconflicts

Annual progress report on Annual progress report on adopting CLAS standardsadopting CLAS standards

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Cultural Competence What Cultural Competence What Are You Doing About It?”Are You Doing About It?”

Public Service Announcement.Public Service Announcement. http://www.hret.org/hret/programs/http://www.hret.org/hret/programs/

cclpsa.htmlcclpsa.html

Raises critical questions for health Raises critical questions for health care organizations to consider in care organizations to consider in addressing the challenges of serving addressing the challenges of serving patients from diverse communities.patients from diverse communities.

Provides a provocative visual Provides a provocative visual presentation of the experience. presentation of the experience.

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Best Practices Best Practices for achieving for achieving

cultural cultural competencecompetence

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Cultural competence and Cultural competence and diversity managementdiversity management

Cultural Competence

Care delivery that is sensitive to and respectful of the

patient’s background and health beliefs

Representation

Attempt to racially/culturally

reflect the communities we

serve

Inclusiveness

How we create an environment that is

welcoming to patients and staff

Metrics: Numbers; Retention

Metric: Employee, Provider Satisfaction

Metrics: Patient Satisfaction, Safety, Disparities

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Why support cultural Why support cultural competence/diversity competence/diversity

initiatives?initiatives?

Mission, Values.Mission, Values. It’s a community responsibility.It’s a community responsibility. It’s a moral issue.It’s a moral issue. It’s a legal issue.It’s a legal issue.

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There is a strong business case:There is a strong business case:

Source of patients/market shareSource of patients/market share To address workforce shortagesTo address workforce shortages Strategic advantageStrategic advantage Enriches our organizationsEnriches our organizations Improve capabilities—more input/perspectives Improve capabilities—more input/perspectives

into what worksinto what works Technical competency/qualityTechnical competency/quality Community expectations/relationsCommunity expectations/relations Avoid regulatory/legal problemsAvoid regulatory/legal problems

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The Cultural Competence The Cultural Competence AgendaAgenda

Increase awareness Collect/monitor data on health

disparities Change systems Improve communication/trust Engage communities

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Diversity/Cultural CompetenceDiversity/Cultural Competence

Best PracticesBest Practices

1.1. C-Suite leadership commitmentC-Suite leadership commitment

Dedicated Diversity OfficerDedicated Diversity Officer

Dedicated resources for Diversity InitiativesDedicated resources for Diversity Initiatives

Clear metrics, vision and missionClear metrics, vision and mission

2. 2. Continuous benchmarking and improvementContinuous benchmarking and improvement

3.3. Outstanding communication strategyOutstanding communication strategy

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Race, ethnicity, Race, ethnicity, language data language data

collectioncollection

Race, ethnicity, Race, ethnicity, language data language data

collectioncollection IOM Report, IOM Report, Unequal Treatment: Confronting Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare:Racial and Ethnic Disparities in Healthcare:

Disparities are more likely to result from Disparities are more likely to result from unconscious unconscious stereotyping than from overt racism.stereotyping than from overt racism.

2003 Report on The Right to Equal Treatment:2003 Report on The Right to Equal Treatment:

““Data collection is more critical in health Data collection is more critical in health care care because discrimination is rarely apparent.”because discrimination is rarely apparent.”

IOM Report, IOM Report, Unequal Treatment: Confronting Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare:Racial and Ethnic Disparities in Healthcare:

Disparities are more likely to result from Disparities are more likely to result from unconscious unconscious stereotyping than from overt racism.stereotyping than from overt racism.

2003 Report on The Right to Equal Treatment:2003 Report on The Right to Equal Treatment:

““Data collection is more critical in health Data collection is more critical in health care care because discrimination is rarely apparent.”because discrimination is rarely apparent.”

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Why Should We Collect Patient Why Should We Collect Patient Race/Ethnicity, and Primary Language Race/Ethnicity, and Primary Language

Data?Data?

Why Should We Collect Patient Why Should We Collect Patient Race/Ethnicity, and Primary Language Race/Ethnicity, and Primary Language

Data?Data?Monitor quality of care.Monitor quality of care.1.1. Design innovative programs to eliminate Design innovative programs to eliminate

disparities and rigorously test them.disparities and rigorously test them.2.2. Know our patients so we can better meet Know our patients so we can better meet

their needs and show communities that their needs and show communities that we deliver the best care possible to them.we deliver the best care possible to them.

3.3. Satisfy legal, regulatory and accreditation Satisfy legal, regulatory and accreditation requirements (i.e.: JCAHO, CMS, etc.).requirements (i.e.: JCAHO, CMS, etc.).

4.4. Take a national leadership position and Take a national leadership position and show other health care organizations show other health care organizations what is possible.what is possible.

Monitor quality of care.Monitor quality of care.1.1. Design innovative programs to eliminate Design innovative programs to eliminate

disparities and rigorously test them.disparities and rigorously test them.2.2. Know our patients so we can better meet Know our patients so we can better meet

their needs and show communities that their needs and show communities that we deliver the best care possible to them.we deliver the best care possible to them.

3.3. Satisfy legal, regulatory and accreditation Satisfy legal, regulatory and accreditation requirements (i.e.: JCAHO, CMS, etc.).requirements (i.e.: JCAHO, CMS, etc.).

4.4. Take a national leadership position and Take a national leadership position and show other health care organizations show other health care organizations what is possible.what is possible.

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Cultural Cultural competence in the competence in the

Health Health Administration Administration

curriculumcurriculum

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Cultural Competence in the Cultural Competence in the Health Administration Health Administration

CurriculumCurriculum

Assess cultural competence educationAssess cultural competence education in health administration curriculum. in health administration curriculum.

Determine training characteristicsDetermine training characteristics that that predict preparedness to manage care predict preparedness to manage care for diverse patients.for diverse patients.

Provide evidenceProvide evidence directly linking directly linking cultural competence training in health cultural competence training in health administration to improvements in administration to improvements in health care quality.health care quality.

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Overview of proposed Overview of proposed research activitiesresearch activities

SurveySurvey cultural competence training in cultural competence training in leading programs in health leading programs in health administration through review of syllabi administration through review of syllabi for cultural competence content. for cultural competence content.

InterviewInterview core faculty of leading core faculty of leading programs in health administration programs in health administration regarding the nature and extent of regarding the nature and extent of cultural competence training in their cultural competence training in their course, and their constructions of course, and their constructions of centrality of cultural competence. centrality of cultural competence.

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Overview of proposed Overview of proposed research activitiesresearch activities

Interview/assess graduate studentsInterview/assess graduate students in in their first year of training pre-exposure to their first year of training pre-exposure to cultural competence and in their final cultural competence and in their final year of training post-exposure to cultural year of training post-exposure to cultural competence. competence.

Interview alumniInterview alumni currently in the field re: currently in the field re: relationship of cultural competence relationship of cultural competence training to performance.training to performance.

Interview internship and residency Interview internship and residency preceptorspreceptors before and after cultural before and after cultural competence training.competence training.

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Assessment of managers’ cultural Assessment of managers’ cultural competence includes effectiveness competence includes effectiveness and facility in the following areasand facility in the following areas

Managing cross-Managing cross-cultural conflict cultural conflict (Among staff, between (Among staff, between patients and providers)patients and providers)

Responding to Responding to regulatory regulatory environment environment

Community outreachCommunity outreach Managing data Managing data

collectioncollection Dealing with language Dealing with language

barriersbarriers  

Dealing with new Dealing with new immigrants immigrants

Dealing with patients Dealing with patients whose religion whose religion affects treatment, affects treatment, whose health beliefs whose health beliefs at odds with Western at odds with Western medicine, who medicine, who distrust US health distrust US health care, who use care, who use complementary complementary and/or alternative and/or alternative medicine medicine

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In Conclusion…In Conclusion…

There is a link between quality, There is a link between quality, disparities and cultural competence.disparities and cultural competence.

There are practical, evidence-based There are practical, evidence-based strategies to advance this agenda.strategies to advance this agenda.

Health administrators play a critical Health administrators play a critical role in advancing this agenda.role in advancing this agenda.