Cultural Competency, Communication, and Implications for Quality Care

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Cultural Competency, Communication, and
Implications for Quality Care
Robert C. Like, MD, MS

Professor and Director

Center for Healthy Families and Cultural
Diversity
Department of Family Medicine

UMDNJ-Robert Wood Johnson Medical School
2
Faculty Disclosure Statement

• This session will not discuss any off-label or
  unapproved uses of drugs or medical devices.
• Consultant/Speaker/Other Cultural Competency
  Disparities in Health Health Care
• Network Omni Multilingual Communications
• MDNGLive.com, Medscape Outcomes, Inc

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Objectives

• Define the concept and rationale for culturally
  competent patient-centered care
• Identify key dimensions of patient-centered care
  and the important role played by
  communication in developing
  therapeutic relationships
• Describe best and promising cultural
  competency practices being implemented in health
  professions educational programs and healthcare
  organizations

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Perspective Matters
Maria A Poem by Rafael Campo


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What is Cultural Competence?

• The ability of systems to provide care to
  patients with diverse values, beliefs and
  behaviors including tailoring delivery of care to
  meet patients social, cultural, and linguistic
  needs. The ultimate goal is a health care system
  and workforce that can deliver the highest
  quality of care to every patient, regardless
  of race, ethnicity, cultural background,
  language proficiency, literacy, age, gender,
  sexual orientation, disability, or socioeconomic
  status.
  
  
• Adapted and expanded from the Commonwealth Fund.
  New York, NY, 2002

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Rationale for Culturally
Competent Health Care

• Responding to demographic changes
• Eliminating disparities in the health status of
  people of diverse racial, ethnic, cultural
  backgrounds
• Improving the quality of services outcomes
• Meeting legislative, regulatory, accreditation
  mandates
• Gaining a competitive edge in the marketplace
• Decreasing the likelihood of liability/malpractice
  claims

Cohen E, Goode T. Policy Brief 1 Rationale for
cultural competence in primary health care.
Georgetown University

Child
Development Center, The National Center for
Cultural Competence. Washington, D.C., 1999.
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Population Trends Increasing Diversity
Percent of population
Source Bureau of the Census
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http//www.dhhs.state.nh.us/DHHS/MHO/LIBRARY/Broch
ure/mho.htm
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• Gittell R, Lord T Profile of New Hampshires
  Foreign-born Population.
  Carsey Institute Issue
  Brief No. 8, Spring 2008
• http//www.carseyinstitute.unh.edu/publications/I
  B_NH_Foreign-Born_08.pdf

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Gittell R, Lord T Profile of New Hampshires
Foreign-born Population.
Carsey
Institute Issue Brief No. 8, Spring
2008http//www.carseyinstitute.unh.edu/publicatio
ns/IB_NH_Foreign-Born_08.pdf
UNH/Carsey Institute Report Highlights

• Percentage of the population that is foreign
  born in NH was above national average in first
  half of 20th C and is now significantly below
  national average
• In the early 2000s from a relatively lower
  base NHs percentage of foreign-born
  population has been increasing faster than
  all but six other states
• Immigrants to NH come from wider range of places
  than is true elsewhere

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Gittell R, Lord T Profile of New Hampshires
Foreign-born Population.
Carsey
Institute Issue Brief No. 8, Spring
2008http//www.carseyinstitute.unh.edu/publicatio
ns/IB_NH_Foreign-Born_08.pdf
UNH/Carsey Institute Report Highlights

• NHs foreign-born population has higher levels
  of educational attainment and income than the
  national average
• NHs foreign-born population is geographically
  concentrated in Hillsborough County and
  Manchester
• In the 1990s, NH had a lower foreign-born growth
  rate than the national average, but that is
  changing in the 21st century

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• http//www.accessproject.org/adobe/assessing_inter
  preter_capacity.pdf

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Institute of Medicine Reports

• To Err is Human Building a Safer Health
  System (1999)
• Crossing the Quality Chasm A New Health
  System for the 21st Century (2001)
• Unequal Treatment Confronting Racial and
  Ethnic Disparities in Health Care (2002)
• Health Literacy A Prescription to End
  Confusion (2004)

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Executive Summary New
Hampshire Racial Ethnic Data
Review A Final Report NH
Office of Minority Health October
2002 http//www.dhhs.state.nh.us/NR/rdonlyres/er
2xgcwsla7246p7qqhnk2lyhoprhgvikqgtlihkjm3n47gi3fuq
6f3i4axyhuacnefgo4fwbr6ydnhbl6z6cwnhtse/racial-eth
nic-data.pdf

• http//www.dhhs.state.nh.us/NR/rdonlyres/efaz2xwo
  argnslxjxewsva2v4btho3gzt6ylysxo7xygwv5zvvnolwhy7m
  75ydh23dql3dtd2z3mgqkl5cnjdbttyld/guide.pdf

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Diversity Plan Goals- Staff Development -
Community Partnering- Consumer Access -
Accountability - Performance Outcomes
- Data
http//www.dhhs.state.nh.us/NR/rdonlyres/en37hwbcg
znh5nxxgyrpdh77lzek7tnixjp7vibrqr6jrw2myultr2aivt7
ifmnebbecwoxwbpuck6wull6kvsl762g/diversity-plan.pd
f
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Emerging Accreditation Requirements and Guidelines

• Joint Commission on Accreditation of Health Care
  Organizations
• National Committee on Quality Assurance
• Liaison Committee on Medical Education
• Accreditation Council for Graduate
  Medical Education

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State Cultural Competency Legislation
New Jersey Legislation PassedCalifornia
Legislation Passed
Washington State Legislation
PassedNew Mexico Legislation Passed
Maryland
Legislation PassedNew York Legislation
PendingOhio Legislation PendingArizona
Legislation PendingKentucky Legislation Pending

Georgia Legislation
PendingIllinois Legislation DiedFlorida
Legislation DiedColorado Legislation Vetoed

• Dark Blue denotes legislation requiring (WA,
  CA, NJ, NM) or strongly recommending (MD)
• cultural competence training, which was
  signed into law.
• Purple denotes legislation which has been
  referred to committee and is currently under
• consideration.
• Royal Blue denotes legislation which died in
  committee or was vetoed.

http//www.thinkculturalhealth.com/cc_legislation.
asp
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The Business Case
Why Companies are Making Health Disparities
Their Business. The Business Case and Practical
Strategies. http//www.omhrc.gov/assets/pdf/check
ed/business_case.pdf National Business Group
Health Disparities Initiative Promoting Health
for a Culturally Diverse Workforce
http//www.wbgh.com/prevention/health_disparities.
cfm Reducing Disparities through Culturally
Competent Health Care An Analysis of the
Business Case. Brach C, Fraser I. Quality
Management in Health Care 200210(4)15-28.

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THE HEALTH CARE SYSTEM
Popular Sector
Individual-based




Family-based




Social nexus-based




Community-based
Professional Sector
Folk Sector
Adapted from Kleinman A Patients and Healers in
the Context of Culture An Exploration of the
Borderland between
Anthropology, Medicine, and Psychiatry, Berkeley,
University of California Press, 1980
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Community Voices Exploring
Cross-Cultural Care Through Cancer

Harvard
Center for Cancer Prevention, 2001
Fanlight Productions
(www.fanlight.com)

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The Growing Demand for Patient-
and Family-Centered Care
If you or a family member need medical care, what
do you want your experience to be like?
What
type of help do you want?

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What is Patient-Centered Care?
Providing care that is respectful of and
responsive to individual patient preferences,
needs and values, ensuring that patient values
guide all clinical decisions
IOM Report,
Crossing the Quality Chasm, 2001. Quality
healthcare achieved through a partnership between
informed and respected patients and their
families, and a coordinated healthcare
team National Health Council --
http//www.nationalhealthcouncil.org/initiatives/p
utting_patients.htm
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Patient- and Family-Centered
Care Initiatives

• Picker Institute Picker/Commonwealth Program
  for Patient-Centered Care
• http//www.pickerinstitute.org
• Planetree Health Alliance
• http//www.planetree.org
• Institute for Family-Centered Care
• http//www.familycenteredcare.org

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Information Communication
Based on The Picker Institutes Video, Through
the Patients Eyes. Volume II Ambulatory Care,
1998
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Patient-Centered Care in Hospitals

• Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL
  (eds.).Through the Patients Eyes Understanding
  and Promoting Patient-Centered Care. San
  Francisco, CA Jossey-Bass 1993
• American Medical Association. An Ethical Force
  Program Consensus Report. Improving Communication
  Improving Care How health care organizations
  can ensure effective, patient-centered
  communication with people from diverse
  populations, 2006.
• http//www.ama-assn.org/ama1/pub/upload/mm/369/ef_
  imp_comm.pdf
• Wynia M, Matiasek J. Promising Practices for
  Patient-Centered Communication with Vulnerable
  Populations Examples from Eight Hospitals.
  American Medical Association, Institute for
  Ethics, August 2006. http//www.cmwf.org/usr_doc/W
  ynia_promisingpracticespatientcentered_947.pdf

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• Patient-Centered Medical Home
  Key Principles
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and integrated
• Quality and safety
• Enhanced access
• Payment
• http//www.patientcenteredprimarycare.org/JOINT_PR
  INCIPLES.pdf
  

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Becoming a
Culturally Competent
Health Care Professional
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Mental Health
Nursing
Medicine

CULTURAL COMPETENCE EDUCATION
Oral Health
Pharmacy
Allied Health
Public Health
Social Work
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Professional
Medical Organizations

• The following are some of the specialty groups
  that have published guidelines and/or policies
  relating to the care of culturally diverse
  populations
  
  
  
• Society of Teachers of Family Medicine
• American Academy of Family Physicians
• American Osteopathic Association
• American Academy of Pediatrics
• American College of Physicians
• American Psychiatric Association
• American College of Obstetrics and Gynecology
• American College of Emergency Physicians
• American Academy of Orthopaedic Surgeons

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COMMUNICATION SKILLS
CULTURAL IDENTITY SYSTEMS OF PATIENT
CULTURAL IDENTITY SYSTEMS OF PROVIDER
CLINICAL ENCOUNTER


ISSUES IN THE COMMUNICATION BETWEEN
PATIENT PROVIDER EXPLANATORY MODELS




STEREOTYPING




RAPPORT





SATISFACTION




COMPLIANCE




RESPONSIBILITY
Hill RF, Fortenberry D, Stein HF Culture in
Clinical Medicine, Southern Medical Journal 83
(9) 1071-1080, 1990.
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Project Implicit
https//implicit.harvard.edu/implicit
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RESPECT MODEL
R Respect E Explanatory Model S
Sociocultural Context P Power E
Empathy C Concerns and Fears T
Therapeutic Alliance/Trust



Developed by the Boston
University Residency Training Program in Internal
Medicine, Diversity Curriculum Taskforce.
Published in Bigby J.A., ed. Cross-Cultural
Medicine, Philadelphia, PA, American College of
Physicians, 2003, p. 20.
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Cultural Competency
Distance Learning Programs
Office of Minority Health - A Physicians
Practical Guide to Culturally Competent
Care http//cccm.thinkculturalhealth.org Health
Resources and Services Administration Unified
Health Communication 101 Addressing Health
Literacy, Cultural Competency, and Limited
English Proficiency http//www.hrsa.gov/healthlite
racy/training.htm University Health System
Consortium/UHC Learning Exchange Cultural
Competence in Health Care http//uhclearningexchan
ge.uhc.edu/Presentations/pres-out67.html Manhatta
n Cross Cultural Group - Quality Interactions
A Patient-Based Approach
to Cross-Cultural Care http//www.qualityinteract
ions.org
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Key Points

• Need to create a learning environment that
  fosters safety, trust, and respect
• Within-group diversity is often greater than
  between-group diversity
• There is no cookbook approach to treating
  patients
• Avoid stereotyping and overgeneralization
• An assets and strengths-based perspective is
  important to maintain
• Every encounter is a cross-cultural encounter

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• Cultural competency training is necessary but
  NOT sufficient!
• Cultural competency needs to be integrated
  into ongoing quality improvement , patient
  safety, and organizational transformation
  efforts!

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Becoming a
Culturally Competent
Healthcare Organization
and Service Delivery System
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Beach MC, Saha S, Cooper LA. The role and
relationship of cultural competence and
patient-centeredness
in health care
quality. The Commonwealth Fund, October 2006.


http//www.cmwf.org/usr_doc/Beach_rolerelationship
cultcomptpatient-cent_960.pdf
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National Standards on Culturally and
Linguistically Appropriate Services (CLAS)
in Health Care
Final Report
DHHS Office of Minority Health
Federal Register December 22, 2000, Volume
65, Number 247, pages 80865-80879
www.omhrc.gov/CLAS
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Medicare Quality Improvement
Community (MedQIC) Practice
Cultural Quality
CLAS Standards
Pre-Assessment Tool Physician Office Quality
Improvement Resources Cultural Competency
Website http//www.medqic.org/dcs/ContentServer?ci
d1157485168058pagenameMedqic2FMQTools2FToolTe
mplatecMQTools Developed by the Oklahoma
Foundation for Medical Quality
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Joint Commission
Hospitals, Language, and Culture A Snapshot of
the Nation, March 2007 http//www.jointcommissi
on.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4
BF8BD3/0/hlc_paper.pdf One Size Does Not Fit
All Meeting the Health Care Needs of Diverse
Populations, April 2008 http//www.jointcommission
.org/NewsRoom/NewsReleases/nr_04_21_08.htm What
Did the Doctor Say? Improving Health Literacy
to Protect Patient Safety, February 2007
http//www.jointcommission.org/NR/rd
onlyres/D5248B2E-E7E6-4121-8874-99C7B4888301/0/imp
roving_health_literacy.pdf Crosswalk Between OMH
CLAS Standards and Joint Commission 2007
Standards for Hospitals, Ambulatory, Behavioral
Health, Long Term Care and Home
Care http//www.jointcommission.org/NR/rdonlyres/5
EABBEC8-F5E2-4810-A16F-E2F148AB5170/0/hlc_omh_xwal
k.pdf
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National Committee for
Quality Assurance (NCQA)

Innovative Practices in Multicultural Health
Care 2006 -2007

http//web.ncqa.org/Portals/0/HEDISQM/CLAS/CLAS_I
nnovativePrac06.pdf http//www.ncqa.org/Portals
/0/HEDISQM/CLAS/CLAS_InnovativePrac07.pdf Funded
by the California Endowment/Support from
CMS Multicultural Health Care

A Quality Improvement Guide, 2008

http//www.ncqa.org/tabid/676/Default.aspx

Funded by Eli Lilly
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Improving Cultural Competency in Childrens
Health Care

• National Initiative for Childrens Healthcare
  Quality (NICHQ)
• Project Funding The California Endowment
• http//www.nichq.org/NR/rdonlyres/5B534B7B-0C38-4A
  CD-8996-EBB0C4CB2245/0/NICHQ_CulturalCompetencyFIN
  AL.pdf

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Straight Talk Model Hospital Policies and
Procedures on Language Access Authors Melinda
Paras, Paras Associates
California Health Care Safety Net Institute,
2005 Funded by the California Endowment http//
www.safetynetinstitute.org/publications/documents/
StraightTalkFinal.pdf
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Ongoing Challenges

• How can we
• Identify the leadership and resources needed for
  championing and supporting these initiatives?
• transform ourselves as individuals,
  organizations, and health and social care
  delivery systems?
• generate interest, deal with resistance and
  inertia, and support the desire to
  become more culturally competent?
• address historical and contemporary isms
  and fears?

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Ongoing Challenges

• How can we
• partner and work more effectively with
  communities and with key stakeholders/constituenci
  es in the public and private sectors?
• Calculate the return on investment and education
  (ROI and ROE)?
• align the social, economic, and business cases
  for cultural competence?
• support a more culturally competent and
  participatory health policy environment?

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Cultural Humility

• A lifelong commitment to self-evaluation and
  self-critique
• Redressing power imbalances
• Developing mutually beneficial partnerships
  with communities on behalf of individuals
  and defined populations

Tervalon M, Murray-Garcia J Cultural humility
versus cultural competence a critical
distinction in defining physician training
outcomes in multicultural education, Journal of
Health Care for the Poor and Underserved 1998
9(2)117-124.
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Diversity in America
Kaleidoscope
Rainbow
Mosaic
What is your preferred image?
Salad
Cauldron
Melting Pot
Other?
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Adding wings to caterpillars does not create
butterflies -- it creates awkward and
dysfunctional caterpillars. Butterflies are
created through transformation.
Stephanie Pace Marshall