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Cultural Competency: A Comprehensive Framework

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Title: Cultural Competency: A Comprehensive Framework


1
Cultural Competency A Comprehensive Framework
  • J. Emilio Carrillo, M.D., M.P.H.
  • VP Community Health, NewYork-Presbyterian
    Hospital
  • Associate Professor Clinical Public Health and
    Medicine, WCMC
  • El Centro
  • May 21, 2010

2
El Centro 1971
  • Generated by a desire for Social Justice,
    Knowledge, Diversity and Cultural Competency
  • Frank Bonilla, Josie Nieves, Judge Caro, Nick
    Sanchez, Maria Canino, Pedro Pedraza de las
    Piedras and many others
  • PRSU and Lewisohn Hall Occupation, Columbia
    College. 1971
  • A Study of the Misuse of Methylphenidate
    (Ritalin) on Puerto Rican Schoolchildren in East
    Harlem, Aguirre-Molina, Carrillo. 1973

3
What is Cultural Competency?
  • Cultural competency is the ongoing capacity of
    healthcare systems, organizations and
    professionals to provide for diverse patient
    populations high quality care that is safe,
    family- and patient- centered, evidence-based,
    and equitable.
  • National Quality Forum, National Voluntary
    Consensus Standard, 2009

4
What is Cultural Competence?
  • Applies to Systems, Organizations and
    Professionals educators, social workers, urban
    planners, health providers.
  • Ongoing capacity to provide to diverse
    populations services and care that are
  • Highest Quality
  • Individual and Family Centered
  • Equitable
  • Applies to race, ethnicity, gender, sexual
    orientation, disabilities.

5
Principles of Cultural Competency
  • Equal access to quality services and care and
    non-discriminatory, person-centered practices by
    educators and providers.
  • Necessary, but not sufficient, to achieving an
    equitable healthcare or educational system.
  • An ongoing process and a multi-level approach
    targeting the system, organizational, group,
    community, and individual levels. Not an
    endpoint, rather a continuous improvement.
  • Requires an organizational commitment with a
    systems approach towards cultural competency.

6
Domains
  1. Leadership
  2. Integration into Management Systems and
    Operations
  3. Care Delivery and Supporting Mechanisms
  4. Workforce Diversity and Training
  5. Community Engagement
  6. Data Collection, Public Accountability, and
    Quality Improvement (QI)
  7. Patient-Provider Communication

7
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication
  • Quality Improvement for cultural competency
    directly stems from the leadership.
  • Commitment to diversity, awareness,
    organizational culture, dedicated staff and
    resources, policies, training and development

8
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication
  • Integrate culturally competent care into
    management systems
  • Strategic Planning
  • Service Planning
  • Marketing
  • Staff evaluation reward

9
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication

Care Delivery and Supporting Mechanisms Providing
culturally competent care means properly
addressing the manner in which care is delivered,
the physical environment where that care is
delivered, and linkages with supportive services
and providers.
10
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication
  • A diverse workforce can
  • Improve access, concordance
  • Expand pool of professionals
  • Advance culturally competent care
  • Reflect the community served

11
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication
  • Engage the community
  • Understand the community
  • Outreach, involve and invest
  • CBPR

12
  • Leadership
  • Integrate Throughout
  • Care delivery
  • Diversity
  • Community
  • Data Collection
  • Communication
  • Data Collection, Public Accountability and
    Quality Improvements
  • Health Research Educational Trust (HRET)
  • Performance measures (QI)
  • Transparency

13
Communication Satisfaction Adherence Health
Outcomes
(IOM., 2003)
  • Leadership
  • Integrate
  • Throughout
  • Care delivery
  • Diversity
  • Community
  • Data
  • Communication
  • Clear patient-provider communication is
    essential for effective care and impacts quality
    and adherence
  • Language access
  • Interpreter services
  • Translation
  • Health literacy strategies
  • Cross-Cultural Communication skills

14
What is Patient (Individual) Based
Cross-Cultural Care?
  • Patient Based Cross-Cultural Care is a dynamic
    process of care which focuses on the unique
    social and cultural characteristics of the
    patient and provides skills to facilitate
    communication across social and cultural
    boundaries.

(Carrillo, 04)
15
How do we provide Patient Based Cross-Cultural
Care ?
  • Language interpretation
  • Understand local population
  • Avoid cultural categorization
  • Identify and address areas of
  • cross-cultural sensitivity
  • Serve the individual
  • Be aware of you own personal perspective and
    pre-conceptions
  • Explore the patients perspective
  • Explore the patients expectations
  • Engage the patient, Earn the trust

(Carrillo, 04)
16
Language Interpretation
  • ? Opportunities for Cultural Brokering
  • ? Concerns
  • - Dual role interpreters (Episodic)
  • - Ad-hoc interpreters (Family)
  • - Errors of omission
  • - False fluency
  • - Substitutions
  • - Editorializations

(www.hablamosjuntos.org)
17
How do we provide Patient Based Cross-Cultural
Care ?
  • Language interpretation
  • Understand local population
  • Avoid cultural categorization
  • Identify and address areas of
  • cross-cultural sensitivity
  • Serve the individual
  • Be aware of you own personal perspective and
    pre-conceptions
  • Explore the patients perspective
  • Explore the patients expectations
  • Engage the patient, Earn the trust

(Carrillo, 04)
18
Local Population is Defined By
  • Socio-economic profile
  • Migration patterns
  • Regional co-migration
  • Religion
  • Cultural Traits

19
How do we provide Patient Based Cross-Cultural
Care ?
  • Language interpretation
  • Understand local population
  • Avoid cultural categorization
  • Identify and address areas of
  • cross-cultural sensitivity
  • Serve the individual
  • Be aware of you own personal perspective and
    pre-conceptions
  • Explore the patients perspective
  • Explore the patients expectations
  • Engage the patient, Earn the trust

(Carrillo, 04)
20
What is Culture?
  • Shared system of values, beliefs, and learned
    patterns of behavior
  • Not equivalent to ethnicity or race
  • Dynamic, not static

21
(No Transcript)
22
  • The Three Cultures in the Room
  • Culture Goes Both Ways in Clinical Encounters

23
How do we provide Patient Based Cross-Cultural
Care ?
  • Language interpretation
  • Understand local population
  • Avoid cultural categorization
  • Identify and address areas of
  • cross-cultural sensitivity
  • Serve the individual
  • Be aware of you own personal perspective and
    pre-conceptions
  • Explore the patients perspective
  • Explore the patients expectations
  • Engage the patient, Earn the trust

(Carrillo, 04)
24
Identify and address areas of cross-cultural
sensitivity
  • Every culture has areas of sensitivity
  • Sometimes sensitivities clash in the
    cross-cultural encounter
  • Patients
  • Staff
  • Be alert to these sensitive areas

(Carrillo, Green, Betancourt 99)
25
What are some of these sensitive areas?
  • Styles of communication
  • Informality may be seen as disrespect
  • Eye contact
  • Touch
  • Whos in charge?
  • Gender of professional
  • Mistrust and Prejudice
  • Food preferences

(Carrillo, Green, Betancourt 99
26
How do you know? SIMPLY ASK!
Respect
Curiosity
Empathy
(Carrillo, Green, Betancourt 99)
27
How do we provide Patient Based Cross-Cultural
Care ?
  • Language interpretation
  • Understand local population
  • Avoid cultural categorization
  • Identify and address areas of
  • cross-cultural sensitivity
  • Serve the individual
  • Be aware of you own personal perspective and
    pre-conceptions
  • Explore the patients perspective
  • Explore the patients expectations
  • Engage the patient, Earn the trust

(Carrillo, 04)
28
  • Explore the patients perspective
  • What does the illness or the symptoms mean to the
    patient?

(Kleinman, Eisenberg, Good, 1978)
29
Picture.
30
Why is it important to explore the meaning of the
illness?
  • To facilitate diagnosis
  • To enhance patient satisfaction
  • address patients expectations, fears
  • earn patients trust
  • strengthen doctor-patient relationship
  • To promote adherence to therapeutic plan

31
  • Explore the patients expectations
  • What does the patient expect?
  • Patients social context

32
(No Transcript)
33
  • Explore the patients expectations
  • What is at stake for the patient?

34
  • 45 year old Puerto Rican woman lives in East
    Harlem, El Barrio, depressed, adhering poorly
    to DM and BP medications. Major concern is
    obtaining Public Housing.

35
  • What do you think
  • is going on?
  • What do you expect?
  • Whats at stake?
  • Whats wrong?
  • What will happen?
  • What can I do?

Patient
Provider
Acknowledge
Present Bio-Med Model (Syntonic)
Negotiate
Mutual Accord
M. A. P. S.
Adherence
? Satisfaction
(Carrillo, 04)
36
  • Engage the Patient, Earn the Trust
  • Acknowledge
  • Explain
  • Negotiate

37
How do we provide Patient Based Cross-Cultural
Care?
  • Recognize Our Personal Perspective and
    Preconceptions
  • Patients Perspectives
  • What does it mean?
  • What is expected?
  • What is at stake?
  • Engage the patient, Earn the trust
  • Acknowledge
  • Explain
  • Negotiate
  • Patients Sensitivities
  • Identify Sensitive
  • Areas
  • Simply Ask

Language Interpretation
(Carrillo, 04)
38
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    Closing the Divide How Medical Homes Promote
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