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Cultural competency in health care organizations: why and how?

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Improving your organization's culture competence can help patient care in various ways, including reducing the risks for medical errors and malpractice claims.

As part of a quality mandate, you send a tactful deficiency notice about low rates of preventive mammography to a family physician in an outpatient clinic within your health system. In an irate return phone call, you learn that he cares for a population of women from Soviet Georgia who repeatedly decline the test.

"They come in complaining of pain in the liver and want an ultrasound. Or they say there's pain in their kidney and want a work up. But try to convince them to get a mammogram? They say that they have no pain, so they don't need a test. I've tried. It's impossible."

Given the nature of our complex and ever-changing health care system, it is not surprising that ineffectual communication occurs on a regular basis. Cultural misunderstandings can hinder effective patient-provider communication, heighten the friction of already explosive situations, and increase the likelihood of adverse consequences.

To provide safer, higher quality, more efficient health care, physician leaders need to understand the relevance of cultural competence and shore up the cultural competency of their organizations.

Cultural competence has been defined in many ways. Initially, experts in the field viewed cultural competence--or cross-cultural communication--as the knowledge and interpersonal communications skills necessary for an individual provider to function effectively with individuals from other cultural and ethnic groups. Educational efforts focused on teaching providers about the attitudes, behaviors, and beliefs of specific cultural groups.

Subsequently, in an effort to avoid potential stereotyping and inappropriate assumptions about patient groups, educational efforts shifted to a focus on the development of skills and a framework that would allow providers to communicate and work with patients across cultural differences.

Several decades ago, experts broadened their focus to include the structures and capacity of health care organizations to respond and effectively deliver care to patients from different cultural groups.

The National Center for Cultural Competence at Georgetown University in Washington, DC, views cultural competence as a developmental process and defines it as the capacity of an organization to: (1)

* Have a defined, congruent set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them and their personnel to work effectively cross-culturally.

* Have the capacity to value diversity, conduct self-assessment, manage the dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to diversity and the cultural contexts of the communities they serve.

* Incorporate the above in all aspects of policymaking, administration, practice, and service delivery, and systematically involve patients, families, and their communities.

For several reasons, cultural competence is a highly relevant topic for leaders of health care organizations today.

Why now?

The need for health care leaders to understand and support cultural competence has never been greater. Because of shifting demographics in the United States, physicians across the country care for more patients of diverse racial and ethnic backgrounds than in past decades. These trends are expected to continue. Forecasters believe that by 2050, 50 percent of the population will, by self-identification, belong to a racial or ethnic group other than white, non-Hispanic. (2)

Although evidence linking cultural competency to improvement in specific health outcomes is not yet available, research has shown that several elements related to cultural competence, such as interpreter services or culturally appropriate teaching tools, are associated with improved intermediate clinical outcomes.

For example, a 2007 meta-analysis found that use of professional medical interpreters for patients with limited English proficiency had a positive impact on intermediate clinical outcomes (e.g., such as C-section rates and HbAIc levels), as well as on communication, utilization, and patient satisfaction. (3)

Similarly, a 2006 case-control study found that the use of a diabetes self-management program adapted to the culture of the patient population was associated with significant decreases in HbAIc. (4)

According to Carol Mostow, LICSW, associate director of psychosocial training in the department of family medicine at Boston Medical Center, cultural competency represents a cost-effective means for improving patient-provider communication. "An enormous amount of money is spent on technological development to improve quality of care, yet there are low-cost, low-tech solutions to improve communication, which can help improve health care outcomes."

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Supporters of cultural competence also point to the moral and legal obligation to ensure equity in health care. As Mostow puts it, "Part of the mission of physicians and health care is to provide quality care. If major portions of the population are lingering behind with persistent disparities in care and outcome, they are not receiving the quality of care that providers want to provide."

Susan L. Freeman, MD, MS, CPE, FACPE, chief medical officer of Temple University Hospital in Philadelphia, highlights the moral duty to provide high-quality, safe care, "Cultural competence should be an integral part of any quality and safety program and is part of our obligation to delivering efficient, high-quality care."

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Federal legislation prohibiting discrimination based on nation of origin specifically requires providing translation services for patients. Leaders of academic institutions must address cultural competence in order to ensure compliance with accreditation mandates, which now include a requirement for training on the topic during medical school.

Improved cultural competence may increase workforce retention and provider satisfaction. According to Tawara D. Goode, MA, assistant professor at Georgetown University Medical Center and director of the National Center for Cultural Competence, health care organizations should have in place policies, structures, and resources to support physicians in obtaining the knowledge and skills they need to communicate effectively with patients from culturally and linguistically diverse groups. Goode posits that such support can enhance staff recruitment and retention efforts.

Freeman views building this foundation as part of her job as a health care executive. "As physician leaders, it is our obligation and responsibility to make sure that we provide tools, training, and support to individuals who are dealing with a culturally diverse patient population on a daily basis."

Finally, improving cultural competence can help reduce the risk of adverse events and malpractice claims. A study of a regional pediatric hospital found that patients whose families faced language barriers were more likely to experience a serious medical error than patients of families without these barriers. (5)

Indeed, risk management research has identified poor communication as a root cause in many malpractice cases. (6) Linguistic or cultural barriers may hinder a patient's ability to provide consent that is truly informed, potentially increasing a provider's liability risk. Addressing these barriers can improve communication and may reduce risk.

How?

Given the strong rationale for fostering cultural competency in health care organizations, what can a physician leader do to promote this capacity in his or her organization?

According to Mostow, the first step is effective communication of respect and empathy for others' perspectives. Inspired by the needs of a demoralized and frustrated intern, Mostow, along with a racially and culturally diverse group of providers at Boston Medical Center, created a framework for more effective cross-cultural communication with patients. The model uses the mnemonic RESPECT to remind providers of specific behaviors they can use during interactions with patients. (See Figure 1)
Figure 1 The RESPECT Model

Respect               Show respect by maintaining appropriate eye
                      contact, following cues about personal
                      space and greetings. Welcome the patient
                      and introduce yourself. Inquire how he or
                      she prefers to be addressed. Recognize and
                      affirm the patient's strengths and efforts.

Explanatory model     Ask the patient what he or she thinks is
                      causing the illness and what will alleviate
                      symptoms. Listen without judgment.

Social context        Gather information about the impact of the
                      patient's life on his or her illness and
                      the impact of the illness on his or her
                      life.

Power                 Reduce inherent power discrepancy by
                      reducing physical barriers, sitting during
                      conversations, listening attentively, and
                      limiting interruptions. Elicit the
                      patient's preferences and active
                      participation in discussion, decision
                      making, and treatment planning.

Empathy               Show empathy by listening attentively and
                      responding accordingly. Name and validate
                      the patient's emotions by conveying
                      specific understanding of what the
                      experience means to the patient.

Concerns              Ask the patient about worries regarding
                      symptoms, diagnosis, treatment, or other
                      issues. Use open-ended questions supported
                      by receptive nonverbal cues.

Trust/Team            Trust: Notice and respond to any signs of
building/Therapeutic  distrust. Ask about expectations. Reassure,
alliance              clarify next steps, and follow through on
                      promised actions. Team-building:
                      Collaborate with other members of health
                      care team. Therapeutic alliance: Search for
                      specific common goals, identify
                      differences, and collaboratively negotiate
                      mutually agreeable alternatives when needed.

Source: Mostow C, Crosson J, Gordon S, Chapman S, Gonzalez P,
Hardt E, et al. Treating and precepting with RESPECT: a relational
model addressing race, ethnicity, and culture in medical training.
J Gen Intern Med. 25(Suppl 2):146-152, May 2010.


Mostow suggests that leaders extend the empathy component of the RESPECT model to providers as well. "We need to remember that all practitioners entered their field to do the best they could for patients. We need to empathize with practitioners to support their efforts to face challenges and improve outcomes; we need to support strengths, build on skills, and make it safe to try new approaches and improve care for all patients."

To support these priorities, Mostow recommends that leaders review and adapt their organization's systems, including electronic medical records, the configuration of office staff and clinical teams, provision of ancillary services, and staff rewards or incentives, further protecting and promoting relationship- and patient-centered care.

Richard Davis, MD, MSc, regional chief medical officer for Christus Spohn Health Care System in Corpus Christi, Texas, uses an empathic approach when speaking with providers about cultural misunderstandings.

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For example, when addressing a less-than-ideal interaction between a female nurse and a male physician with a patriarchal mindset, possibly related to his cultural background, Davis provides the physician with feedback about how his communication was perceived by the nurse.

"Often the reaction is, 'That's not what I meant. How did she get that idea?'" He then frames the issue as a time difference. "In the past, we may have interacted with staff that way. Today, we work as a team."

If the physician becomes resistant or insists on "blaming the hearer," Davis uses the analogy of a motor boat in a harbor. "Legally, the driver is responsible not only for avoiding collisions but also for the impact of the boat's wake on others. In the same way, we are responsible for the impact of our words and behavior on others."

He points out that 7 percent of communication relates to the words used and 93 percent to the nonverbal actions and gestures--and that people often react to the nonverbal portion. Davis is careful to focus on the common goal: achieving better patient care. Rather than dissecting a specific incident with the physician, he asks, "What can we learn from the experience to handle it better the next time?"

Physician executives can take several steps to improve cultural competence throughout their organizations. According to Goode, one step is gathering data.

"Leaders should know the current and emergent demographic trends in the patient populations that access care at their organizations. They should identify which populations are experiencing disparities in health care--related to the delivery of care--and in health status. Leaders must be able to use these data to make changes in the delivery of care, inform quality improvement, broaden health education, and foster community engagement."

Mostow agrees. Once they have gathered these data, she believes that leaders should share the knowledge to build awareness within their organization. Based on her participation with the multi-cultural group that created the RESPECT model, Mostow suggests that leaders encourage mutual problem-solving with insights from practitioners of diverse backgrounds.

At Temple University Hospital, Freeman and other leaders support cultural competence across the organization in several ways. Through onsite medical interpreters, a dual-role medical interpreter program, and telephonic interpretation, translation of 196 different languages is available around the clock.

Consent forms and educational materials have been translated into many languages. In addition, the hospital offers a variety of educational experiences to improve the cultural competence of physicians and staff, including formal training programs, case study review, and mentoring and coaching opportunities.

"Just like in clinical medicine, we train, mentor, and coach staff. Our staff gains experience, then they mentor and coach others." She points out that an important component of training is awareness of one's own biases and the ability to keep those biases in check.

Mostow recommends that health care leaders recruit, hire, and strive to retain a culturally and ethnically diverse workforce. According to Mostow, leaders should elicit and value the input of these staff members.

"Leaders should promote practitioners from all backgrounds who excel at connecting effectively with the patients they serve and help these practitioners share best practices and mentor others."

By bringing varied perspectives into the organization, a diverse workforce helps the organization become more responsive to the needs of a diverse patient population. Diversity of the workforce also may signal to the community that the organization embraces cultural and ethnic diversity.

However, proponents acknowledge that while cultural competence is a necessary condition for equitable care, it is not sufficient for addressing racial disparities in health care. (7) As one researcher stated, "Cultural competence is not a panacea that will single-handedly improve health outcomes and eliminate disparities, but a necessary set of skills for physicians who wish to deliver high-quality care to all patients." (8)

Goode cautions, "Race and ethnicity concordance alone do not make for cultural competence. Providers need specific knowledge and skill sets to provide culturally competent care." By prioritizing the development of this knowledge and these important skills, physician leaders can promote improved health care quality and safety within their organizations.

Relating to the mammograms, you find a private moment and speak with the physician one-on-one. After asking about his experience and listening to his frustration, you suggest a team approach to making better connections with his patients.

After collecting demographic information on the patients currently served at the site, you schedule an in-service for all staff. You hire a trainer to help with communication skills and a member of a community organization to explain the health beliefs and values of the larger population groups served by the center.

Afterward you meet with the physician to brainstorm on ways to more effectively communicate with these patients. He decides to try reframing his suggestions for preventive services: he'll recommend the screening test as a way to avoid pain in the breast, which might occur if the patient ultimately develops cancer.

The next month, he reports with enthusiasm that five of the 10 eligible women of this cultural group whom he saw agreed to mammography. He tells you with obvious pride that other providers have begun asking him for help in communicating with their patients.

References:

(1.) Goode TD, Dunne MC, Bronhcim SM. The evidence base for cultural and linguistic competency in health care. National Center for Cultural Competence, Center for Child and Human Development, Georgetown University. October 2006. Available at: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf. Accessed April 30, 2010.

(2.) U.S. Census Bureau. United States population projections: 2000 to 2050. Available at: http://www.census.gov/population/www/projections/analyticaldocumento9.pdf. Accessed May 6, 2010.

(3.) Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. (2):727-54, Apr. 2007.

(4.) Gilmer TP, Philis-Tsimikas A, Walker C. Outcomes of Project Dulce: a culturally specific diabetes management program. Ann Pharmacother. 39(5):817-22, May 2005.

(5.) Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics. 116(3):575-79, Sept 2005.

(6.) Joint Commission. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. Available at: http://www.jointcommission.org/NR/rdonlyres/658A9BB9-3485-4ACB91BF-FCDCA73E4F30/0/2007_Annual_Report.pdf. Accessed May 6, 2010.

(7.) Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008; 100(11):1275-1285, Nov. 2008.

(8.) Betancourt JR. "Cultural competence-marginal or mainstream movement?" N Engl J Med. 2004 351(10):953-55, Sept. 2, 2004.

Diane Shannon, MD, is a freelance health care writer.

dshannon@mdwriter.com

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By Diane Shannon, MD

Show empathy by listening attentively and responding accordingly.

RELATED ARTICLE: Cultural Competence at the Frontlines

Andrew Gotlin, MD, primary care provider and medical director at Ryan/ Chelsea-Clinton Community Health Center in midtown Manhattan, likens effective communication across cultural differences to effective management.

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"I can't proclaim an edict. If I understand what inspires the people I supervise, then I can motivate them and tailor my requests to improve the likelihood of success. It's the same with patients. If I understand a belief they hold about disease or symptoms, it makes communication and treatment easier."

Gotlin believes that ongoing staff training in cultural competence is essential. As part of both state and national associations of community health centers, Gotlin's center has access to onsite cultural competency training for staff and management. Center administrators monitor the shifting demographics of the facility to ensure they can provide for the needs of patients who access care at the site.

Several years ago the administrators noticed an uptick in female Arabic patients, apparently drawn to the center because of a newly hired female pediatrician who appeared to be of Middle East descent. She was not of this cultural/ethnic background and had no specific insight into the patients' health beliefs and values.

However, because a monitoring system was in place, administrators quickly identified the shift in demographics and accessed additional training and resources to provide language services and culturally sensitive care for this new patient population.
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Title Annotation:Culture
Author:Shannon, Diane
Publication:Physician Executive
Geographic Code:1USA
Date:Sep 1, 2010
Words:2968
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