Cultural Competence in Health Administration

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Cultural Competence in Health Administration

• Philippa Strelitz, PhD, MPAff
• Department of Health Administration
• Alumni Conference
• November 17, 2006
• Texas State University, San Marcos

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Overview

• Cultural competence drivers.
• What is cultural competence? What is it NOT?
• Some Best Practices for achieving cultural
  competence data collection and assessment.
• Cultural competence in the Health Administration
  curriculum.

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Cultural competence drivers
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What is driving the current focus on cultural
competence?

• Demographic changes
• Quality
• Patient safety
• Health disparities

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Americas Changing Demographics
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Institute of Medicine (2001) Improve Quality

• Health care Quality Dimensions
• Safe
• Timely
• Patient-Centered
• Effective
• Efficient
• Equitable

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Two overarching domains of Quality

• Clinical/Technical aspects of patient care
• Experiential aspects of patient care

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Why is it important to link culture and quality?

• Cultural competence is integrally related to the
  two core elements clinical/technical aspect of
  patient care and experiential dimension of
  patient care.
• Knowledge of clinical and experiential factors
  that affect racially and ethnically diverse
  patients can significantly affect quality.

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Archives of Internal Medicine, 2006 166675-681
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The American Journal of Medicine, 2005
118529-535
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Consequences of not acknowledging the
intersection of culture and quality

• Inability of the patient to understand English
  can lead to medical error in medications or in
  other treatment guidance.
• Lack of organizational supportsignage, adequate
  interpreter services, effective community
  linkscan compromise timeliness of care delivery
  and access to care.

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Linking Cultural Competence to Quality

• Key IOM recommendations
• Support race/ethnicity data collection, quality
  improvement, use of evidence-based guidelines.
• Facilitate interpretation services.
• Provider education (mechanisms of decision
  making, cultural competence).
• Patient education (health care system navigation,
  activation in the medical encounter).

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Preliminary work show cultural competence
improves quality of care

• Prevent medication
• under use among
• children with persistent
• asthma
• Cultural competence
• score

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)Ensure 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)Reduce Health
Disparities

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

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Health and Healthcare Disparities A National
Problem

• African Americans are
• Less likely to have a kidney transplant, surgery
  for lung cancer, bypass surgery.
• More likely to have a foot amputation.
• More likely to die prematurely.
• Latinos/Hispanics are
• Less likely to receive pain medications.
• Chinese? Pakistanis? Croatians? Iranians?

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Linking cultural competence to disparities
reduction three domains

• Patient activation
• Language/communication assistance
• Organizational supports (practices, policies,
  structures) for cultural competence/disparities
  reduction
• ?

Dimensions of Quality Patient-centered care, safety, efficiency, effectiveness
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Take Home Message
The natural fit of language and culture within
the quality framework offers opportunity for
practitioners and administrators to significantly
improve quality for racially/ethnically diverse
patients.
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What is cultural competence? What is it NOT?
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Defining Cultural Competence

• A set of congruent behaviors, attitudes, and
  policies that come together in a system, agency,
  or among professionals, and enable that system,
  agency, or those professionals to work
  effectively in cross-cultural situations.

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Dimensions of Cultural Competence

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History of cultural competence

• Early conceptions of cultural competence
• Evolution of cultural competence
• Expansion to consider racial/ethnic disparities

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Expansion of cultural competence
Early Models cross-cultural Recent Model cultural competence Newer Model CLAS/ quality
Populations immigrants, refugees, LEP, non-Western All people of color (those affected by disparities) everyone
Concepts culture, language prejudice, stereotyping, social determinants of health safety, disparities
Scope interpersonal interactions health care organizations systems, communities
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Cultural competence and patient-centered care

• Emphasize different aspects of quality
  significant common ground
• Patient-centered care provide individualized
  care and restore emphasis on personal
  relationships
• Cultural competence increase health equity and
  reduce disparities

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Cultural competence is NOT

• A cultural cook book approach to health care.
• Culture is not simply a matter of race,
  ethnicity, or social status.
• There is no African American patient, Latino
  patient, Asian patient.

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OMH Culturally and Linguistically Appropriate
Services (CLAS)

• Culturally Competent Care
• Promote and support staff skills
• Management strategy
• Community and consumer involvement
• Language Access Services
• Strategies to diversify staff
• Ongoing education for staff
• Provide interpretation services
• Provide notices of free interpreter services

• Organizational Supports for Cultural Competence
• Translate materials for predominant language
  groups
• Train interpreters
• primary language and race/ethnicity in patient
  records
• Collect accurate data
• Organizational self-assessments
• Ability to address cross-cultural ethical and
  legal conflicts
• Annual progress report on adopting CLAS standards

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Cultural Competence What Are You Doing About It?

• Public Service Announcement.
• http//www.hret.org/hret/programs/cclpsa.html
• Raises critical questions for health care
  organizations to consider in addressing the
  challenges of serving patients from diverse
  communities.
• Provides a provocative visual presentation of the
  experience.

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Best Practices for achieving cultural
competence
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Cultural competence and diversity management
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Why support cultural competence/diversity
initiatives?

• Mission, Values.
• Its a community responsibility.
• Its a moral issue.
• Its a legal issue.

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There is a strong business case

• Source of patients/market share
• To address workforce shortages
• Strategic advantage
• Enriches our organizations
• Improve capabilitiesmore input/perspectives into
  what works
• Technical competency/quality
• Community expectations/relations
• Avoid regulatory/legal problems

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The Cultural Competence Agenda

• Increase awareness
• Collect/monitor data on health disparities
• Change systems
• Improve communication/trust
• Engage communities

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Diversity/Cultural CompetenceBest Practices

• 1. C-Suite leadership commitment
• Dedicated Diversity Officer
• Dedicated resources for Diversity Initiatives
• Clear metrics, vision and mission
• 2. Continuous benchmarking and improvement
• 3. Outstanding communication strategy

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Race, ethnicity, language data collection

• IOM Report, Unequal Treatment Confronting
  Racial and Ethnic Disparities in Healthcare
• Disparities are more likely to result from
  unconscious
• stereotyping than from overt racism.
• 2003 Report on The Right to Equal Treatment
• Data collection is more critical in health
  care
• because discrimination is rarely apparent.

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

• Monitor quality of care.
• Design innovative programs to eliminate
  disparities and rigorously test them.
• Know our patients so we can better meet their
  needs and show communities that we deliver the
  best care possible to them.
• Satisfy legal, regulatory and accreditation
  requirements (i.e. JCAHO, CMS, etc.).
• Take a national leadership position and show
  other health care organizations what is possible.

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Cultural competence in the Health Administration
curriculum
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Cultural Competence in the Health Administration
Curriculum

• Assess cultural competence education in health
  administration curriculum.
• Determine training characteristics that predict
  preparedness to manage care for diverse patients.
• Provide evidence directly linking cultural
  competence training in health administration to
  improvements in health care quality.

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Overview of proposed research activities

• Survey cultural competence training in leading
  programs in health administration through review
  of syllabi for cultural competence content.
• Interview core faculty of leading programs in
  health administration regarding the nature and
  extent of cultural competence training in their
  course, and their constructions of centrality of
  cultural competence.

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Overview of proposed research activities

• Interview/assess graduate students in their first
  year of training pre-exposure to cultural
  competence and in their final year of training
  post-exposure to cultural competence.
• Interview alumni currently in the field re
  relationship of cultural competence training to
  performance.
• Interview internship and residency preceptors
  before and after cultural competence training.

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

• Managing cross-cultural conflict (Among staff,
  between patients and providers)
• Responding to regulatory environment
• Community outreach
• Managing data collection
• Dealing with language barriers
•  

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

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In Conclusion

• There is a link between quality, disparities and
  cultural competence.
• There are practical, evidence-based strategies to
  advance this agenda.
• Health administrators play a critical role in
  advancing this agenda.