CULTURAL COMPETENCY: HEALTH CARE MEETING THE CHALLENGE OF DIVERSE SOCIETIES The New YorkJerusalem Di

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CULTURAL COMPETENCY HEALTH CARE MEETING THE
CHALLENGE OF DIVERSE SOCIETIESThe New
York/Jerusalem Dialog ProjectExperts
ExchangeWednesday, May 16, 2007
Opportunity and Promising Practices for Advancing
Cultural Competence in Health Care

• Dennis Andrulis
• Associate Dean for Research
• Director, Center for Health Equality
• School of Public Health
• Drexel University
• Philadelphia, PA

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• If you ask staff to describe patients or
  families they like and do not like, they usually
  like patients or families who are grateful or
  people from the same culture or who speak the
  same language, but beyond that the attributes of
  popular patients and families become pretty grim.
  The most popular patients never ring their call
  lights, never ask for help, never ask questions
  or challenge their nurses and doctors, and never,
  ever read medical books or use the Internet for
  help. Their families are not present, and they
  do not have friends. In fact, they are as close
  to dead as possible.
• Source Healthcare Quality Book, 2005

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• Growing importance of cultural competence,
  disparities reduction and language assistance in
  care management and improving quality of care.

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Defining Cultural Competence

• Cultural Competence is a set of attitudes,
  skills, behaviors, and policies that enable
  organizations and staff to work effectively in
  cross-cultural situations. It reflects the
  ability to acquire and use knowledge of the
  health-related beliefs, attitudes, practices and
  communication patterns of clients and their
  families to improve services, strengthen
  programs, increase community participation, and
  close the gaps in health status among diverse
  population groups.
• Cultural competence also focuses its attention on
  population-specific issues including
• Health-related beliefs and cultural values (the
  socioeconomic perspective),
• Disease prevalence (the epidemiological
  perspective),
• And treatment efficacy (the outcome
  perspective).
• Source Cross, et. al. 1989

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Elements from Cultural Competence Definitions

• Practitioner capability, awareness and related
  clinical standards/policies
• Improving outcomes, meeting goals for quality and
  efficiency
• Involving organizations
• Overcoming communication barriers
• Consumer focus/community participation
• Training and professional development

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RESEARCH
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POLICY AND PROGRAM RECOMENDATIONS
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POLICY AND PROGRAM RECOMENDATIONS
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USDHHS/OMH National Standards for Culturally and
Linguistically Appropriate Services in Health
Care (CLAS Standards)

• Fourteen Standards Issued in 2001 address
• Culturally Competent Care
• Language Access Service
• Organization Supports for Cultural Competence

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NIH PROGRAMS
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CONFERENCE LEADERSHIP
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• health care systems cannot effectively move
  their QI goals forward without specifically
  addressing the embedded problem of racial and
  ethnic disparities in treatment.
• Risa Lavizzo-Mourey
• Robert Wood Johnson Foundation

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Why is Cultural Competence Gaining Importance?

• Meeting the needs of an increasingly diverse
  society
• Reducing health disparities and improving health
  care quality
• Tailoring health care delivery to meet population
  and individual needs
• Meeting federal and state requirements
• Increasing treatment compliance, patient safety
  and reducing medical error
• Supporting organizational business strategies and
  objectives
• Growing accreditation interest JCAHO, NCQA

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The Consequences of Discrimination and Racism

• Tuskegee and health system mistrust in Black
  communities
• A national survey of Latinos found that almost
  one-third had experienced discrimination and that
  80 felt it was a problem.
• Black women with less than a college education
  who reported they have experienced discrimination
  in house or in other ways were more likely to
  have premature births, likely due to related
  stress they undergo.
• Blacks saying they experience discrimination were
  less likely to get kidney transplants.

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Hospitalized Minority Patients Report More
Problems with Respect for Their Preferences
Percent of hospital patients reporting more
problems in dimensions of patient experiences
More problems defined as highest quintile of
problem scores in each dimension. SOURCE L. S.
Hicks et al., Is Hospital Service Associated
with Racial and Ethnic Disparitiesin Experiences
with Hospital Care? American Journal of
Medicine, May 2005 118(5)52935.
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A physician who apparently knew some Spanish and
liked to deal directly with the patientends up
eliciting from her that shes having some trouble
sleeping and so he said Well, I can give you
some sleeping pills. At which point the patient
immediately breaks into tears and the
doctorturns to the interpreter and says Whats
going on here? Well, the patient had just told
you that she is very depressed and had been
saving up her sleeping medication to kill herself
and so you told her youd give her some sleeping
medication. Source Paul Schyve, JCAHO,
2002
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Language Proficiency and Adverse Events in U.S.
Hospitals A Pilot Study

• Patients with Limited English Experience More
  Serious Errors
• LEP patients were more likely than
  English-speaking patients to experience an
  adverse event that caused some physical harma
  greater proportion of adverse events among LEP
  patients resulted in moderate or severe harm.

Source Divi C, Koss RK, Schmaltz SP, Loeb JM.
International Journal for Quality in Health
Care. ( April, 2007)
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Recommended actions for reducing racial and
ethnic disparities.
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Points of intervention

• Education About the Patient
• Language
• Service Setting
• Information System
• Workforce and Community
• State Initiatives

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A. Education About the Patient

• Identify beliefs regarding health and illness
  (e.g., fatalism)
• Determine how family members fit contribute to
  medical decisions.
• Recognize and understand other factors that can
  affect treatment adherence such as gender issues
  in care, treatment conflicts.

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• Language

• For interpretation, acknowledge the value of
  language concordance and its association with
  higher ratings of physical and emotional well
  being (Perez-stable et. al.), and possibly better
  outcomes (Tocher et. al.)
• Acknowledge the value of professional
  interpretation in the health care encounter

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Examples of best practices undertaken by US
hospitals focused on language needs

• Conducting a system wide assessment of language
  access needs and offering a set of programs that
  include on site interpreter staff, advocacy for
  interpreter needs, translation of written
  materials, formation of diversity and language
  access committees, partnerships with community
  based programs for language services
• Developing family and patient education
  committees to promote understanding among LEP
  patient regarding general consent to treatment,
  anesthesia consent, use of educational materials
  for specific care and discharge instructions

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Service Setting

• Developing service initiatives including
  diversity training modules on cultural competence
  and group-specific health care handbooks
• Instituting policies to promote diversity in
  hiring, retention, promotion, mentoring
• Diversifying board memberships and developing
  program wide diversity initiatives
• Developing market strategies for diverse patients
  through targeted strategies that match culturally
  competent care, data and growth in diverse
  markets.
• Linking actions to outcomes measurement
• Creating a diversity curriculum task force it
  identify and address factors affecting successful
  medical encounters

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Practice-site policies to promote cultural
competence, the use of reports to clinicians, and
access and continuity predicted higher quality of
care for children with asthma in managed
Medicaid.
Source Lieu, et. al. Pediatrics. 114 102
(2004).
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Conducting Cultural Competence Organizational
Assessments
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The 4 cornerstones of cultural competence for
providers and health care settings

• The organizations relationship with its
  community
• The administration and management relationship
  with stafforganization policies
• Interstaff relationships at all levels of the
  organizationtraining, education, communication
• The patient/enrollee-practitioner encounter

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• Information System

• Identifying specific issues for diverse
  populations Health literacy, interpreter needs,
  preferred language family role.
• Linking racial/ethnic information to patient
  satisfaction, grievances and complaints filed.
• Developing bilingual staff availability and test
  consistency bilingual staff
• Offering information guidance to clinicians
  regarding predisposition to certain conditions
  and drug dosage sensitivity association with
  racial/ethnic heritage (e.g., high sickle cell
  anemia rates)

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• Workforce and Community

• Use community health workers as a way to increase
  racial/ethnic access to health care and to serve
  as a liaison between health care providers and
  communities
• Lay workers can help with care coordination and
  continuity and help assure adherence to medical
  regimens, and can increase awareness of screening
  for conditions (Bird et. al. and others)
• Consider using multidisciplinary teams for
  addressing risk reduction and for related health
  priorities such as smoking and obesity.

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State Initiatives

• 43 states have language access laws
• Comprehensive
• Targeted (e.g. emergency room, hospital)
• NJ, CA and WA have laws requiring cultural
  competency continuing education for health
  professionals
• Some states moving towards health care
  interpreters certification
• 13 states provide Medicaid reimbursement

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