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by: Kari Heistad, CEO Culture Coach International

Cultural Competency in Healthcare

​Assessment of Issues and Strategies in Developing a Culturally Competent Healthcare Organization

The Healthcare Urgency for Cultural Competency

The Push for Culturally Competent Healthcare
Healthcare is currently facing pressure from many sources to provide culturally competent care to patient populations. The pressures are coming from a variety of factors including changes in regulations, changes in patient demographics and a shortage of physicians.

Changes in Patient Demographics
The U.S. population is becoming increasingly diverse and as this occurs the growing numbers of ethnic and cultural populations within the U.S. are seeking healthcare services from providers who both “speak their language” and who are able to provide care that is culturally appropriate.

The majority of children born in the U.S. today are a racial or ethnic minority. A million new immigrants a year still move to the U.S. and increasingly the U.S. population is marrying across race and ethnicity. Currently, approximately 30% of the population of the United States is a minority and 13% of the population is foreign born.  The growth in minority and foreign populations in the United States are trends that show no sign of receding. These changing demographics have an impact upon the patients seeking medical care as well as the changing local marketplace for hospitals that are seeking to attract patients from their local service area. By developing cultural competency skills within the hospital, patients are more likely to choose the hospital as their primary healthcare provider.

In addition to local populations becoming more diverse, patients are increasingly crossing national borders for healthcare. These international patients also contribute to the need to provide culturally competent care.

Shortage of Physicians and Using Foreign Born Providers
There is a nationwide problem facing the United States: that of a shortage of physicians.  While medical schools are reacting to this growing problem by expanding the size of their classes and opening up new institutions to educate medical students, these efforts will not be sufficient and the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

Meanwhile, by 2030, nearly 1 in 5 Americans will be 65 or older, and the 85-and-older population will more than triple by 2050, according to the U.S. Census Bureau. As the U.S. population ages, the demand for healthcare services will also increase.

Increasingly, hospitals are turning to foreign born physicians and nurses to help fill the need for providers.  With the employment of international physicians and nurses comes both the addition of their native skill and cultural expertise, as well as the added challenges of helping them to adjust to the American culture and provide quality care to American patients.

Affordable Care Act
Due to the surge of new people (some estimate up to 30 million) eligible for health insurance under the Affordable Care Act, the U.S. will need more physicians. Experts believe that a large majority of this new group of people enrolling in the healthcare system is racially and ethnically diverse. This diverse patient population influx into the healthcare system provides an additional need for cultural competency.

Healthcare Disparities
It is well documented that minority racial, ethnic, and cultural populations often receive care that is not the best that it could be[1].  As a result of this evidence, there is an increasingly moral and ethical reason to provide culturally competent care, in addition to regulators who are seeking to reduce the disparities in care provided.

The Joint Commission
The Joint Commission has accreditation requirements to help hospitals better address effective communication, cultural competence, and patient-centered care. Although many aspects of these issues were supported by existing requirements, the new requirements further improve the safety and quality of care for all patients.

The standards development initiative builds upon The Joint Commission’s study on Hospital Language and Culture: A Snapshot of the Nation. That study examined how hospitals in the United States respond to the diverse cultural and language needs of their patients. It found that practices used to promote effective communication and cultural competence vary widely from hospital to hospital.  It is hoped that the new requirements will provide improved consistency in the delivery of culturally competent care.

HCAHPS Surveys
With the Affordable Care Act came changes in how Medicare reimburses hospitals for services with its Value Based Purchasing.  Payment rates are now based in part upon patient satisfaction surveys (HCAHPS) that look at measurements including nurse and doctor communication, responsiveness of the staff, and communication about medication. With a more diverse patient population will come the need to provide training to staff so that the ratings a hospital receives on the HCAHPS continue to remain high.

Office of Minority Health and US Dept of Health and Human Services
The office of Minority Health has recently updated its 15 standards for providing Culturally and Linguistically Appropriate Care (CLAS).  The guidelines are increasingly being adopted by organizations to help in delivering culturally competent care. The Department of Health and Human Services is also pushing improved care that helps them to achieve their stated goal: “to eliminate healthcare disparities.”

Compliance with State Regulations
Increasingly, states are passing legislation about cultural competency in healthcare. While the regulations vary by state, there is a focus by legislators on this topic.

Guiding Principles for Health Care and Cultural Competency

All Patients Are Treated Equally
An important component to the provision of culturally competent healthcare is the practice of treating all patients equally no matter their background, race, or ethnicity. All patients should receive high quality care that is nondiscriminatory and patient-centered.

Cultural Competency Has No Endpoint
The cultural competency journey for a hospital is one without a distinct endpoint but rather one that is continuously evolving. As an institution becomes culturally competent, it will need to use an approach that addresses changes in systems, assessments, and interventions at all levels of the institution from individuals through groups, departments, and to the hospital overall. This focus on continuous improvement helps the institution to respond to changes in the marketplace, health care, and demographics that will impact the services to be delivered and the way to deliver them.

Organizational Development Approach
Successful cultural competency initiatives that achieve high quality, culturally competent, patient-centered care require an organization-wide commitment with a systems approach toward cultural competency. The initiative needs to address both organizational and clinical aspects of cultural competency while taking into consideration the needs of a diverse workforce, the surrounding community, and the patient population.

Challenges for Healthcare Institutions
From its work in healthcare, CCI has ascertained that there are nine key issues facing healthcare institutions that are seeking to develop a culturally competent organization.

1. Program-by-Program Approach as Opposed to a Systematic Approach
Most institutions that are seeking to address the issue of providing culturally competent care are doing so in an ad hoc format of individual programs. While the institutions are to be applauded for tackling how to make their organizations more culturally competent, an ad hoc approach means that:

There is no systemic approach that allows the organization to understand long term strategies and solutions
As there is no strategic approach, resources are not leveraged as effectively as they could be in terms of time, money, and staff engagement

2. Lack of Senior Level Support
Programs that lack senior level support are rarely successful in the long-term. Engagement from the senior level is critical to a systematic implementation. Senior level support is also vital to attaining funding for programs.

3. Cultural Competency Programs Driven by Solo Champions
One champion who is deeply committed to the program or idea of cultural competency often drives cultural competency initiatives. This means that if the champion leaves or becomes burned out that the initiative typically stops. Programs driven by one passionate champion are also harder to duplicate in other parts of the organization unless an equally passionate champion can be found.

4. Programs Driven by Interpreter Services
Interpreters are often called upon to translate both what is being said or written, as well as the cultural context in which the information is being provided. Thus, many cultural competency programs come from the desire of the interpreter services department to push the organization towards cultural competency.  While it is critical to involve interpreters who are at the front line of helping to provide culturally competent care, typically programs that are initiated solely from this department lack the senior level engagement and support necessary to become highly effective.  They are also often driven by a program-to-program approach instead of systemic approach.

5. Lack of a Cultural Competency “System”
There appears to be no model in the marketplace that provides an overall “road map” that hospitals can follow in order to understand the overall strategic and programmatic changes that are necessary in order to create a culturally competent organization.  Thus, hospitals often lack a systemic approach to developing and maintaining cultural competency amongst their staff.

6. Cultural Competency Programs Have Historically Been Under Resourced
Historically, cultural competency programs have not been allocated sufficient funding necessary to implement said programs on a hospital-wide basis, thus leading to a more reactive rather than proactive approach to obtaining cultural competency.

7. Lack of an Integrated Approach to Training and Development
The training and development of staff is critical to developing a culturally competent organization. In order to shift an institutions’ culture from what it currently is to one of cultural competency will require a multipronged approach over many years. Cultural competency cannot be achieved through any single training program or initiative. Given this reality, it is vital to the achievement of cultural competency that institutions use an integrated approach to training and communication. Any training programs provided must be done within the context of institutional communications, patient and community engagement, and with the firm commitment from senior management.

8. Not Engaging and Supporting Managers
To create long-term organizational cultural change, managers must be engaged in the process. Supervisors, Team Leaders, and Managers at all levels are integral to the daily interactions of an institution.  Yet, supervisors and managers are rarely given any training on how to implement training content into the daily work environment. Nor are they given any team meeting tools that will help them have conversations with their teams about the desired changes in organizational culture and the affects that this will have on the daily interactions amongst employees and with patients.  With little or no guidance, managers frequently do not become involved in promoting the organizational culture change as they see little benefit to themselves or to their teams.

9. Lack of Standards for Measurement
With few, if any, standards available for measuring behaviors, attitudes, and competencies, staff at all levels are not held accountable for attaining, maintaining, and using culturally competent skills and procedures when interacting with each other or with patients.

Benefits of Developing a Strategic Approach to a Culturally Competent Organization
1. Alignment with Joint Commission Requirements
The Joint Commission is increasing its focus on helping institutions provide culturally competent care. By developing a strategic approach to culturally competent care, institutions are able to comply with Joint Commission standards instead of facing problems during the recertification process.

2. Responsive to Demographic Changes
By better understanding and then responding appropriately to demographic changes, institutions are able to respond in a proactive manner to changes in their patient populations instead of being caught in a reactive stance when changes happen and they are not prepared. Providing culturally competent care that is responsive to local communities helps the institution to appropriately allocate resources, responding more effectively to community needs.

3.  Assistance with HCHAPS and Reimbursement Rates
Increasing the cultural competency skills within a hospital will in turn help to improve the patient satisfaction score that impact the Medicare reimbursement rates.

 4. Competitive Marketplace Advantage
Healthcare is an increasingly competitive market.  Providing culturally competent care that respects patients’ cultural beliefs and values becomes a competitive advantage over other healthcare providers who are providing the same services. 

5. Community Engagement
Reaching out to the local community as part of a comprehensive strategy to develop culturally competent care is a way to further deepen ties to the local community, thus engaging local community leaders and positioning the institution as a partner to the local community.

6. Cost Savings
Healthcare disparities are a well-documented issue in healthcare today. These disparities result in worse healthcare outcomes for the patients and additional healthcare costs for minority patients. By creating a culturally competent organization, a healthcare institution will:

  1. Reduce the disparities in the healthcare provided to its patients
  2. By providing better quality care, the hospital will reduce the unnecessary escalation of healthcare incidences that result from the disparity in care
  3. By reducing future avoidable healthcare issues, the hospital is able to save money and resources by
    • Not spending time (and money) treating healthcare incidences that could have been avoided
    • Avoiding higher workloads on staff which results in less job satisfaction and higher burnout rates
    • Increasing satisfaction of staff by being able to focus on providing quality not quantity care
    • Reduce staff turnover and thus save money in recruitment and training
    • Not treating complicated free healthcare cases that result from a disparity in care

Healthcare is riding the wave of tremendous changes coming from a shift in regulations, changing demographics and cultural changes. Providing quality culturally competent care to patients has become an increasing priority and necessity in today’s competitive healthcare environment.  Focusing on the further development of cultural competency skills allows healthcare institutions to provide patient centered care in a way that patients appreciate and value.

[1] See for example: HHS’s “Healthy People 2020,” CDC’s “Health Disparities and Inequalities Report 2011.”