Many different definitions of cultural competence are out there, but probably the most widely accepted is the following: “Cultural and linguistic competence is a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations. “Culture” refers to integrated patterns of human behavior that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups.
Competence” implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities. Cultural competence in health care combines the beliefs of patient centered care with an understanding of the social and cultural influences that affect the quality of medical services and treatment.
With the ever increasing diversity of the population of the United States and strong evidence of racial and ethnic disparities in health care, it is critically important that health care professionals are educated specifically to address issues of culture in an effective manner. Organizations such as the National Academies of Sciences’ Institute of Medicine and the American Medical Association have recognized this. ” (OMH – Ofiice of Minority Health) Cultural competence as a business imperative. Several researchers viewed cultural competence as being driven by both quality and business imperatives.
Ideally, they felt that cultural competence might improve outcomes and help control costs by making care more effective and efficient. Although unaware of any direct evidence that supported this hypothesis, they acknowledged important circumstantial evidence. They also felt that health insurers could market cultural competence initiatives to employers as a method of expanding their member market share, especially given an increasingly diverse workforce. Leadership, systems, and education.
The research done highlighted the “multilevel” nature of cultural competence, ncluding diversity in leadership and in the health care provider network; systemic capacities, such as multilingual services and literature, data collection, and quality measurement (including patient satisfaction); and training for health care providers and staff. Many acknowledged resistance to training, given providers’ perception of cultural competence as a “soft science. ” To incorporate cultural competence into training, they recommended that training be standardized and evidence based. Cultural competence links to quality and addressing disparities.
Throughout the research done, the researchers felt that managed care can advance cultural competence by embedding these strategies into quality improvement initiatives. There was also a sentiment that purchasers, with the appropriate information about how lack of culturally competent care contributes to disparities, can be instrumental in moving this issue forward. However, some have expressed disbelief given the multiple competing interests (including rising health care costs) purchasers face and their lack of knowledge about the issue.
All the researchers made a link between cultural competence and removing cultural disparities in health care. However, they were kept back in their expectations of its potential impact in achieving this goal, given the many causes for disparities. Recent trends in managed care. Recent trends in this industry bear out the researchers’ perspectives on cultural competence. For example, health insurers, such as Kaiser Permanente, Aetna, and BlueCross BlueShield of Florida, have developed initiatives in cultural competence.
Kaiser Permanente has had long-standing efforts that range from educational monographs in cultural competence to full-fledged “Centers of Excellence in Cultural Competence” targeting specific populations. In 2001, Aetna began to collect race and ethnicity data on its members, developed culturally competent disease management programs, and mandated cultural competence training for its internal medical directors, nurses, and case managers. BlueCross BlueShield of Florida has also embarked on initiatives that include internal diversity training and cultural competence education for providers.
In addition, health care purchasing coalitions such as the National Business Group on Health have been active in informing their memberships about cultural competence and Cultural disparities in health care. Accreditation agencies, including the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), are also exploring opportunities to include measures that track disparities and cultural competence.
At the end, major advancements have occurred in the area of cultural competence among managed care plans, health insurers, and health care purchasers. However, there still exists strong resistance to investing in cultural competence as these entities search for evidence that supports a potential for quality improvement and cost savings. Organizations that have invested in cultural competence see themselves as being committed to issues of diversity, equity, and quality, and they acknowledge the potential for increasing the market share through marketing of these efforts.
Educating the future health care workforce. All the researchers including those who were skeptical highlighted cultural competence as an educational strategy to prepare the future health care workforce to care for diverse patient populations. This group viewed cultural competence as the development of a skill set for more effective provider-patient communication. They stressed the importance of providers’ understanding the relationship between cultural beliefs and behavior and developing skills to improve quality of care to diverse populations.
A number of researchers expressed concern about the persistence of stereotypic teaching strategies (such as treating Hispanics one way and African Americans another). They mentioned additional components that were underemphasized such as empathy, exploring socioeconomic issues, and addressing bias in the clinical encounter. (Beamon, Devisetty and Forcina Hill) Cultural competence education gaining momentum.
In the research done in “A Guide to Incorporating Cultural Competency…” the researchers recognized the emerging regulatory pressures for undergraduate and graduate medical education; societal pressures; funding opportunities; and increasing diversity of patients, students, and faculty as key drivers of cultural competence. However, a few stated that there is still progress to be made. Others expressed concerns that the present climate is fragile and potentially transient, threatening the sustainability of the field. (Beamon, Devisetty and Forcina Hill) Standardization and quality of educational programs.
Although the researchers felt that cross-cultural training efforts were well intentioned and helpful, they noted the need for a unified teaching framework. Many cited great variability in the availability and quality of training programs and also mentioned the education of faculty members as crucial, given their impact as clinical role models. Need for more research. All the resources I’ve read have highlighted “greater attention to cultural disparities” as a reason for cultural competence education. However, they worried that outcomes research on cultural competence interventions has been sparse.
Nevertheless, most felt that cultural competence training could help reduce disparities. Recent trends in institutions of higher education. Since 2002 the regulatory pressures that the researchers highlighted have in fact become important drivers of curricular change. In response to the Liaison Committee on Medical Education’s cultural competence accreditation standard, which requires all medical schools to integrate cultural competence into their curricula, the Association of American Medical Colleges (AAMC) has developed a “tool for the assessment of cultural competence training” (TACCT) to assist medical schools in the process.
At the 2004 AAMC annual meeting, several sessions highlighting TACCT were held to guide medical schools on how to meet their accreditation requirement in cultural competence. Likewise, residency programs have responded to the Accreditation Council of Graduate Medical Education’s cultural competence standards. A 2004 study in the Journal of the American Medical Association found that among close to 8,000 graduate medical educational programs surveyed in the United States, 50. 7 percent offered cultural competence training in 2003–2004, up from 35. 7 percent in 2000–2001.
This was felt to be attributable to the recognition of the increasing diversity of the patient population, in response to pressure from ACGME and the IOM, which recommended that cross-cultural curricula be part of the training of clinicians from undergraduate to continuing medical education. The New York State Department of Health also made its mark in this area, as it modified its $33 million per year Graduate Medical Education Reform Incentive Pool to reward residency programs that provide eight hours of cultural competence training to at least 80 percent of residents.
In the first year, 66 of the 104 residency programs in New York State proposed new cultural competence curricula (Hogan). Regarding CME, New Jersey has legislation pending that would require cultural competence education as a requirement for the licensure of health care professionals. Professional societies, such as the American Medical Association and the American Nurses Association, have statements in support of, and are pursuing active agendas in, cultural competence education.
In sum, institutions of higher education have seen strong advances in cultural competence and many incentives have been used to move the field forward. Beamon, Devisetty and Forcina Hill) Increasing access to high quality care for the most vulnerable. Given the role of federal, state, and local governments in managing and financing health care delivery for vulnerable populations, cultural competence was seen as a method of increasing access to quality care for all patient populations. The researchers felt that minorities could have difficulty getting appropriate, timely, high quality care because of linguistic and cultural barriers.
As such, cultural competence targets to change a “one size fits all” health care system to one that is more responsive to the needs of an increasingly diverse patient population. Key dimensions of cultural competence. The OMH has highlighted essential components of culturally competent care, including diversity among staff and providers; system capacities, including data collection (to assess the needs of the patient population and track progress in improving health outcomes) and effective interpreter services; and cultural competence education for management, providers, and staff. OMH – Ofiice of Minority Health) Purchasing power as leverage to advance cultural competence.
Experts agreed that health care purchasers, both public and private, can help stimulate change if they understood the impact of disparities on cost and quality of health care and how cultural competence might address this problem. The roles of the Centers for Medicare and Medicaid Services (CMS), JCAHO, and state health care provider licensing boards were also mentioned, as was the need to clarify the “business model” for these interventions. Cultural competence as one step toward eliminating disparities.
Experts saw a clear link between cultural competence and eliminating racial/ethnic disparities in health care. However, there was agreement that disparities are the result of many factors and that cultural competence alone could not address the problem. The Culturally and Linguistically Appropriate Services (CLAS) standards project was often referred to as an effective blueprint for improving the cultural competence of our health care system. Recent trends in government. The federal government has been advancing the cultural competence agenda in various ways.
For instance, the Health Resources and Services Administration (HRSA), in partnership with the Institute for Healthcare Improvement (IHI), has developed Health Disparity Collaborates focused on addressing racial/ethnic disparities at community health centers. Through the use of quality improvement models, several strategies are being implemented to improve health care delivery to diverse populations, including developing culturally competent systems of care and techniques for more effective cross-cultural communication.
The National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ) have funded research and education in cultural competence over the past few years. On the federal legislative side, there has been less progress. In 2004 several bills were developed in the House and Senate targeting the elimination of racial/ethnic disparities in health care. Within this proposed legislation have been activities related to cultural competence education. Although none of these were brought forward for a vote, they may still move forward in the upcoming years.
Most notably, it appears that cultural competence has caught the attention of federal policymakers as part of the effort to eliminate racial/ethnic disparities. (OMH – Ofiice of Minority Health) Questionnaire: A total of 20 questionnaires’ were filled out, these are the results.
* Sex/Gender: Male – 10 (50%), Female – 10 (50%) * Sexual orientation: Straight – 17 (85%), Gay/Lesbian – 1 (5%), Open/Bisexual – 2 (10%) * Race/Ethnicity: African American/Black – 4 (20%) American Indian/Alaska Native – 2 (10%) Latino/Hispanic – 4 (20%) Caucasian – 7 (35%) Other – 3 (15%) * Experienced Cultural Insensitivity: No – 15 (75%), Yes – 5 (25%) Conclusion and personal opinion. As you probably know, we live in an extremely diverse world that is composed of thousands of different cultures and nowhere is it more diverse than right here in the United States. Just looking at the results of the questionnaire, you can see how different we actually are. Considering that we have one of the most advanced medical systems in the world, in my opinion, it is sad that we are so far behind when it comes to cultural competence.
As I stated in my presentation, the cost of implicating this issue into our medical system is estimated to be 2. 7 billion dollars but the estimated cost of not implicating it is almost triple (due to lack of patient knowledge, willingness to follow doctors instructions, doctors giving instructions that are culturally insensitive, etc… ). Just looking at the results of the questionnaire, we can see that 25% of the class have suffered some kind of cultural insensitivity.
That being said, the numbers in nationwide surveys are much, much, higher. The main question that remains is “why don’t we do it? ” Well, I seriously don’t know!! Throughout all the reading and research I’ve done and the different people I’ve asked, the main reason that came up is, as usual, MONEY. But even that doesn’t make any sense, all the numbers say that we’d be saving and not spending more. What is left is ignorance and even though the trends are heading the right direction, there is a lot more work that needs to be done.