Designing A Comprehensive Curriculum on Cultural Competence

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Designing A Comprehensive Curriculum on Cultural
Competence

• Presented by
• Brenda Battle
• Director, Barnes-Jewish Hospital
• Center for Diversity and Cultural Competence

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Objectives

• Define challenges in current health care system
  resulting in the need for cultural competency
  training
• Identify Federal, State, regulatory and
  accreditation calls for cultural competency
  training.
• Identify a necessary components of a cultural
  competency curriculum
• Recommend a model for training

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Challenges for Health Care Organizations and
Providers

• More culturally diverse society 33 of American
  population comprised of racial and ethnic
  minority groups, 40 by 2030, 50 by 2056
• Increased demand for patient-centered and
  equitable care to improve the quality of services
  and health care outcomes
• Minimal evidence of improved health care outcomes
  for ethnic minorities despite significant medical
  advances
• Evidence of lower quality of care for minorities
  and limited English proficient patients (LEP)
  when controlling for insurance, co-morbidity,
  education and SES IOM report Unequal
  Treatment
• About 90 million (47) US adults have limited
  capacity to obtain, process and understand basic
  health information and services needed to make
  appropriate health decisions (2003 National
  Assessment of Adult Literacy)

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Culturally Competent Defined

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

• A set pf academic and interpersonal skills that
  allow individuals to increase their understanding
  and appreciation of cultural differences and
  similarities, within, among, and between groups.
  This requires a willingness and ability to draw
  on community-based values, traditions, and
  customs and to work with knowledgeable persons of
  and from the community in developing focused
  interventions, communications and other supports.

Substance Abuse and Mental Health Services
Administration (1997). Cultural competence
guidelines in managed care mental health services
for Asian Pacific Islander populations.
Orlandi, M. A. (1992). The challenge of
evaluating community-based prevention programs A
cross-cultural perspective.
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Cultural Competence education to.

• Assist health care workers to understand and
  respond effectively to the cultural and
  linguistic needs brought by patients during the
  health care encounter.
• Develop health care workers and patient care
  teams competency levels resulting in improved
  interactions with patient/clients in the context
  of difference.

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Recommended training objectives

• Demonstrate the effects of cultural differences
  on clinical encounters and outcomes
• Offer strategies to resolve racial and ethnic
  disparities
• Offer elements of effective communication among
  diverse populations
• Demonstrate application of Title VI of the Civil
  Rights Act and CLAS Standards
• Identify and teach differences in clinical
  management of chronic illnesses as varied by
  different cultural groups.
• The educational content should emphasize the
  development of skills that allow
• health care professionals to effectively ask
  questions especially regarding
• medical care of individuals with Culturally
  diverse backgrounds.

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Federal Guidelines

• Title VI of 1964 Civil Rights Act
• No person in the United States shall, on the
  ground of race, color, or national origin, be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving Federal
  financial assistance.
• National Standards for Culturally and
  Linguistically Appropriate
• Services in Health Care (CLAS Standards)
• A collective set of mandates, guidelines, and
  recommendations intended to inform, guide, and
  facilitate required and recommended practices
  related to culturally and linguistically
  appropriate health services.

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CLAS StandardsCulturally and Linguistically
Appropriate Services

• Recommended activities include
• Developing core cultural competencies for health
  care professionals at all levels of education,
• Supporting efforts to diversify the professional
  workforce
• Developing curricula standards and evaluative
  tools for cultural competency training for health
  care professionals
• Raising awareness of and promoting adoption of
  the CLAS Standards

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CLAS Standards cont.

• Three main themes
• Culturally Competent Care (Standards 1-3)
• Language Access Services (Standards 4-7)
• Organizational Supports for Cultural Competence
  (Standards 8-14)
• Standards 1-7 have the most direct impact on
  clinical care
• Standards1 -3 standards are particularly relevant
  to supporting the
• incorporation of cultural competency curricula
  into health professionals
• education and training
• Standards 8-14 deal more directly with
  organizational activities

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Standard 1 Culturally Competent Health Care

• Health care organizations should ensure that
  patients/consumers receive from
• all staff members effective, understandable, and
  respectful care that is provided
• in a manner compatible with their cultural Health
  beliefs and practices in their
• preferred language.
• Effective care denotes care that results in
  positive outcomes for the patient.
• Understandable care means providing care in the
  patients preferred languages and ensuring that
  all information comprehensible.
• Respectful care means considering the values,
  beliefs, preferences and needs of each individual
  patient and incorporating them into each health
  care consumers care.

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Standard 2 Staff Diversity

• Health care organizations should implement
  strategies to
• recruit, retain, and promote at all levels of the
  organization
• a diverse staff and leadership that are
  representative of the
• demographic characteristics of the service area.
• A diverse staff is defined as being
  demographically representative of the served
  community.
• Efforts to recruit and retain minority
  professionals are needed in order to reach
  demographic equity between patients and providers

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Standard 3 Staff Education and Training

• Health care organizations should ensure that
  staff
• at all levels and across all disciplines receive
• ongoing education and training in culturally and
• linguistically appropriate service delivery
• Ongoing education and training that is based on
  the needs of the organizational staff at all
  levels and relevant to the needs of the community
  are essential for ensuring CLAS delivery.

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State Initiatives

• New Jersey, California, and Washington have taken
  action at a policy level by enacting bills that
  set standards and expectations for providers,
  clinics, and other health related services
• Have also enacted legislative mandates to address
  issues of disparities
• Illinois, New York and Arizona are approaching
  the issue by funding programs and initiatives to
  provide cultural competency training in addition
  to considering policy level actions
• Are considering enacting legislative mandates to
  address issues of health disparities

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Suggestions for Physician Associations

• American Medical Association (AMA) Enhancing the
  Cultural Competency of
• Physicians (H-295.897), sets forth five
  objectives
• To continue efforts to inform medical schools
  residency programs about
• cultural competency resources and encourage
  them to include culturally effective health care
  in their curricula
• 2. To continue research into the need for and
  effectiveness of cultural competence training
• 3. To form an expert national advisory panel of
  consultants who will also
• develop a list of resources
• 4. To help physicians obtain information and/or
  training through an online resource database
• 5. To seek external funding for a 5-year program
  for promoting cultural competence in
  collaboration with a number of national
  health-related
• organizations the goal being to
  restructure medical education and staff /faculty
  development programs to deliberately emphasize
  cultural competence as part of professional
  practice.27

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Association of American Medical Colleges (AAMC)

• In 2000, the Liaison Committee on Medical
  Education
• (LCME) of the AAMC introduced standards for
  cultural
• competence
• The faculty and students must demonstrate an
  understanding of the manner in which people of
  diverse cultures and belief systems perceive
  health and illness and respond to various
  symptoms, diseases, and treatments.
• Medical students should learn to recognize and
  appropriately address gender and cultural biases
  in health care delivery, while considering first
  the health of the patient.

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AAMC requirements

• The AAMCs five institutional requirements for an
  effective cultural
• competence curriculum1) Support of the
  leadership, faculty, and students
• 2) Commitment of institutional and community
  resources
• 3) Involvement of community leaders in
  curriculum design and evaluation
• 4) Provision of integrated educational
  interventions appropriate to the level of the
  leaner
• 5) A clearly defined evaluation process
  including accountability and evaluation.
• AAMCs Tool for Assessing Cultural Competence
  Training (TAACT)

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American Academy of Pediatrics (AAP)

• The AAP (in conjunction with the AMA Committee on
  Minority
• Physicians) defines culturally effective
  pediatric health care as the
• delivery of care within the context of
  appropriate physician knowledge,
• understanding, and appreciation of cultural
  distinctions.
• Such understanding should take into account the
  beliefs, values,
• actions, customs, and unique health care needs of
  distinct population
• groups.
• Providers will thus enhance interpersonal and
  communication
• skills, thereby strengthening the physician
  patient relationship and
• maximizing the health status of patients.

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American Academy of Family Physicians (AAFP)

• Developed cultural proficiency guidelines based
  on
• a list of issues to consider in preparing
  informational
• or continuing medical education programs which
• include attention to
• the practice setting from both the patient and
  physician perspective,
• research-based information on cultural
  proficiency, cultural differences, and cultural
  expectations or beliefs.

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IOMs Unequal Treatment

• Recommendations
• Increase awareness of existence of disparities
• Address systems of care
• Support race/ethnicity data collection, quality
  improvement, evidence-based guidelines,
  multidisciplinary teams, community outreach
• Improve workforce diversity
• Facilitate interpretation services
• Provider education
• Health Disparities, Cultural Competence,
  Clinical Decision making
• Patient education (navigation, activation)
• Research
• Promising strategies, Barriers to eliminating
  disparities

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• Quality Health Care
• Health care should be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Health Disparities
The Institute of Medicine, in its publication,
Unequal Treatment Confronting Racial and Ethnic
Disparities in Health Care, determined that the
development and implementation of training
programs for health care providers around topics
of cultural competence offers promise as a key
intervention strategy in reducing healthcare
disparities.
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Training in Medical and Dental Schools

• Cultural immersion programs students take part
  in an international elective or serve part of a
  clinical rotation in a more localized native
  community
• Integration of cultural competency curriculum
  into existing school courses often through
  case-based, small-group sessions touching on
  subjects, such as core cultural beliefs of
  various ethnic groups, complementary and
  alternative medicine, language barriers,
  substance abuse, racism, and cross-cultural
  interviewing skills
• Service learning to address cultural competence
  training, looking to teach students about various
  localized cultures through projects that seek to
  improve the health of the surrounding community.

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Components of a Training Toolkit

• The rationale and the guiding principles
  underlying cross-cultural practice.
• Health disparities, and the link between quality
  and the clinical encounter.
• Cultural dynamics influencing the cross-cultural
  encounter.
• Methods to enhance clinical assessment processes.
• Methods to enhance treatment planning and
  adherence.
• Methods to enhance patient communication.
• Information on factors that can affect
  decision-making during the cross-cultural
  encounter.
• Information for improving organizational supports
  and system tools in practice settings.

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Include Root Causes of Racial/Ethnic Disparities
in Health

• Social Determinants
• Access to Care
• Health Care systems and clinical
• decision making

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Include Cross-Cultural Clinical Guidelines to

• Improve skills for gathering information related
  to those factors that influence a patients
  health values, beliefs, behaviors and
  expectations for care.
• Develop clinically effective treatment plans that
  are compatible with a patients values,
  preferences and needs.
• Increase awareness of individual and
  institutional factors influencing clinical
  decision-making processes that affect outcomes of
  care.
• Improve communication that promotes a
  doctor-patient relationship based on mutual
  respect and trust.

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A cultural assessment

• What is the patients ethnic affiliation?
• Who are the patients major support persons and
  where do they live?
• With whom should we speak about the patients
  health or illness?
• What are the patients primary and secondary
  languages, and speaking and reading abilities?
• What is the patients economic situation? Is
  income adequate to meet the patients and
  familys need?
• If patient is an immigrantWhere did they grew
  up?
• What decade did they arrive in the U.S.? time
  has an impact on acculturation, communication,
  health beliefs and practices. May be tricky is
  patient is an illegal alien and may result in
  patient not returning for care.
• Why did you leave your homeland and what brought
  you to the U.S.?

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The Explanatory ModelArthur Kleinman, Ph.D.

• A culturally sensitive approach to asking
  about a health problem
• What do you call your problem?
• What do you think caused your problem?
• Why do you think it started when it did?
• What does your sickness do to you? How does it
  work?
• How severe is it? How long do you think you will
  have it?
• What do you fear most about your illness?
• What are the chief problems your sickness has
  caused you?
• Anyone else with the same problem?
• What have you done so far to treat your illness
  What treatments do you think you should receive?
  What important results do you hope to receive
  from the treatment?
• Who else can help you?

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Optional Training formats

• Small group discussions with trained facilitator
• - utilize training vignettes
• - during divisional meetings or retreat
• Large group presentations/conferences presented
  by guest speaker with expertise in cultural
  competence
• Dedicated conferences, Grand Rounds
• Online, web-based training with vignettes and
  quizzes
• Cross-cultural simulation and experiential
  training

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Training Recommendations

• Train trainers
• Annually or bi-annual training minimally
• Oversight organization to track participation
• Evaluation of the impact of training on staff,
  faculty and patient

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Expected Training Competencies

• Demonstrate an understanding of the impact of
  culture on health care delivery and the health
  care decision-making of providers, patients and
  families
• Describe world view from a theoretical and
  practical standpoint and predict potential areas
  of conflict with patients and families.
• Identify national and regional demographic trends
  and discuss their impact on health care providers
  on the medical center campus.
• Apply an understanding of the regulatory, patient
  safety and quality excellence aspects of
  culturally competent care delivery to their
  particular practice setting.
• Articulate strategies to bridge language and
  cultural differences and to build powerful
  healing relationships for patients and their
  families.
• Identify and access internal and external
  resources to promote culturally and
  linguistically competent care delivery.

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Core training should comprise

• Foundational sessions which include the business
  case for cultural competence, emphasis on Title
  VI, CLAS standards and accreditation and
  licensing requirements and specifics about St.
  Louis community
• Communication sessions focusing on
• Direct vs. indirect, high context vs. low
  context, saving face, public behaviors, time
  conceptualizations, power, prejudice and
  stereotyping nonverbal communication (gestures,
  voice, space, facial expressions, other body
  language)
• Communicating through interpreters (face-to-face)
  and using telephonic interpreting when no
  face-to-face interpreting available
• Be able to define four dimensions of world view
  (locus of control, concept of self, communication
  style and power distance) and operationalize
  dichotomous variations.
• Identify ones own personal world view around
  these four dimensions.
• Predict resulting behaviors and attitudes when
  experiencing specific (defined) cultural
  disconnects within each of these dimensions.

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Locus of Control

• External - Realist/fatalist
• Fate is my path
• Many things must be accepted as they are
• My destiny is set

• Internal - Optimist/activist
• Fate little importance
• Few things CANT be changed
• I am master of my destiny

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Concept of Self

• Individualist
• Self is smallest unit of survival
• Protecting self protects others
• Independence leadership is prized taught

• Collectivist
• Primary group smallest unit of survival
• Protecting others protects self
• Dependence blending is prized taught

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Communication Style

• Direct (Low Context)
• People say what they mean mean what they say
• Words convey information
• Words are primary carrier of
  information
• Goal is getting/receiving information

• Indirect (High Context)
• Read between the lines for meaning
• Words convey power
• What not said ( implied by omission) as
  meaningful as what is said
• Goal is to create/preserve/ strengthen
  relationship

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Power Distance

• High
• Power centralized
• Followers are managed
• Open disagreement with authority carries
  consequences

• Low
• Power to be shared
• Potential leadership nurtured
• Discourse disagreement with authority may be
  healthy

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ExampleIf that is what awaits me then I would
hope to face it with Gods help.
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ExampleNo, please you must ask my
husband. He will tell you what we must do.
Please you must wait and talk to him.
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ExampleThe doctorsaid it was Rok.
All this treatment is useless and just makes her
ill. We will care for her now.
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ExampleI realize that you think this is
impossible. But, if you make her hear this
thingif you tell her that it is cancer she will
just die. Flat out. She will put her energy into
preparation for deathand she will die. It is not
a matter of patho-physiologywell, once she stops
eating, perhaps it is.
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Another Way of Looking at Culture
Source Lewis, R. D. (1999). When cultures
collide. London Nicholas Brealey Publishing.
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Socrates Education is the kindling of the
flame, not the filling of a vessel.

• ______________________________________
• It is extremely challenging to shape a new
  generation of healers with an eye to excellence
  in care for all patients and the elimination of
  health care disparities. Especially since
  oppression and racism continue to challenge the
  field of health and medicine.

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References

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• U.S. Department of Health and Human Services,
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• Institute of Medicine, Unequal Treatment, Chapter
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  disparities (pp. 29-80) Chapter 3, Assessing
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  disparities in care Patient- and system-level
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• http//www.aetna.com/foundation/health/disparity.h
  tm.

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• Thank you,
• Brenda Battle
• bbattle_at_bjc.org
• 314-362-7939