Cultural Competence in Health Administration

1. Cultural Competence in Health Administration Philippa Strelitz, PhD, MPAff Department of Health Administration Alumni Conference November 17, 2006 Texas State University, San Marcos

2. Overview • Cultural competence drivers. • What is cultural competence? What is it NOT? • Some Best Practices for achieving cultural competence: data collection and assessment. • Cultural competence in the Health Administration curriculum.

3. Cultural competence drivers

4. What is driving the current focus on cultural competence? • Demographic changes • Quality • Patient safety • Health disparities

5. America’s Changing Demographics

6. Institute of Medicine (2001): Improve Quality • Health care Quality Dimensions: • Safe • Timely • Patient-Centered • Effective • Efficient • Equitable

7. Two overarching domains of Quality • Clinical/Technical aspects of patient care • Experiential aspects of patient care

8. Why is it important to link culture and quality? • Cultural competence is integrally related to the two core elements: clinical/technical aspect of patient care and experiential dimension of patient care. • Knowledge of clinical and experiential factors that affect racially and ethnically diverse patients can significantly affect quality.

9. Archives of Internal Medicine, 2006; 166:675-681

10. The American Journal of Medicine, 2005; 118:529-535

11. Consequences of not acknowledging the intersection of culture and quality • Inability of the patient to understand English can lead to medical error in medications or in other treatment guidance. • Lack of organizational support—signage, adequate interpreter services, effective community links—can compromise timeliness of care delivery and access to care.

12. Linking Cultural Competence to Quality • Key IOM recommendations: • Support race/ethnicity data collection, quality improvement, use of evidence-based guidelines. • Facilitate interpretation services. • Provider education (mechanisms of decision making, cultural competence). • Patient education (health care system navigation, activation in the medical encounter).

13. Preliminary work show cultural competence improves quality of care Prevent medication under use among children with persistent asthma Cultural competence score Source: Lieu TA et al., Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003) 102-110.

14. Institute of Medicine (1999):Ensure Patient Safety “First, do no harm…” Mis-use Over-use Under-use of medications and medical procedures: 44,000-98,000 deaths each year

15. Disparities and Quality: There is a critical gap in the quality of treatment of patients from racial and ethnic minority groups. Institute of Medicine (2002):Reduce Health Disparities

16. Health and Healthcare Disparities: A National Problem • African Americans are: • Less likely to have a kidney transplant, surgery for lung cancer, bypass surgery. • More likely to have a foot amputation. • More likely to die prematurely. • Latinos/Hispanics are: • Less likely to receive pain medications. • Chinese? Pakistanis? Croatians? Iranians?

17. Linking cultural competence to disparities reduction: three domains • Patient activation • Language/communication assistance • Organizational supports (practices, policies, structures) for cultural competence/disparities reduction ↓

18. Take Home Message The “natural fit” of language and culture within the quality framework offers opportunity for practitioners and administrators to significantly improve quality for racially/ethnically diverse patients.

19. What is cultural competence? What is it NOT?

20. Defining Cultural Competence A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals, and enable that system, agency, or those professionals to work effectively in cross-cultural situations.

21. Dimensions of Cultural Competence

22. History of cultural competence • Early conceptions of cultural competence • Evolution of cultural competence • Expansion to consider racial/ethnic disparities

23. Expansion of cultural competence

24. Cultural competence and patient-centered care • Emphasize different aspects of quality – significant common ground • Patient-centered care: provide individualized care and restore emphasis on personal relationships • Cultural competence: increase health equity and reduce disparities

25. Cultural competence is NOT: • A “cultural cook book” approach to health care. • Culture is not simply a matter of race, ethnicity, or social status. • There is no “African American patient,” “Latino patient,” “Asian patient.”

26. Culturally Competent Care Promote and support staff skills Management strategy Community and consumer involvement Language Access Services Strategies to diversify staff Ongoing education for staff Provide interpretation services Provide notices of free interpreter services Organizational Supports for Cultural Competence Translate materials for predominant language groups Train interpreters primary language and race/ethnicity in patient records Collect accurate data Organizational self-assessments Ability to address cross-cultural ethical and legal conflicts Annual progress report on adopting CLAS standards OMH Culturally and Linguistically Appropriate Services (CLAS)

27. Cultural Competence What Are You Doing About It?” • Public Service Announcement. • http://www.hret.org/hret/programs/cclpsa.html • Raises critical questions for health care organizations to consider in addressing the challenges of serving patients from diverse communities. • Provides a provocative visual presentation of the experience.

28. Best Practices for achieving cultural competence

29. Representation Attempt to racially/culturally reflect the communities we serve • Inclusiveness • How we create an environment that is welcoming to patients and staff Cultural Competence Care delivery that is sensitive to and respectful of the patient’s background and health beliefs Metrics: Numbers; Retention Metric: Employee, Provider Satisfaction Metrics: Patient Satisfaction, Safety, Disparities Cultural competence and diversity management

30. Why support cultural competence/diversity initiatives? • Mission, Values. • It’s a community responsibility. • It’s a moral issue. • It’s a legal issue.

31. There is a strong business case: • Source of patients/market share • To address workforce shortages • Strategic advantage • Enriches our organizations • Improve capabilities—more input/perspectives into what works • Technical competency/quality • Community expectations/relations • Avoid regulatory/legal problems

32. The Cultural Competence Agenda • Increase awareness • Collect/monitor data on health disparities • Change systems • Improve communication/trust • Engage communities

33. Diversity/Cultural CompetenceBest Practices 1. C-Suite leadership commitment • Dedicated Diversity Officer • Dedicated resources for Diversity Initiatives • Clear metrics, vision and mission 2. Continuous benchmarking and improvement 3. Outstanding communication strategy

34. Race, ethnicity, language data collection • IOM Report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare: Disparities are more likely to result from unconscious stereotyping than from overt racism. • 2003 Report on The Right to Equal Treatment: “Data collection is more critical in health care because discrimination is rarely apparent.”

35. Why Should We Collect Patient Race/Ethnicity, and Primary Language Data? Monitor quality of care. • Design innovative programs to eliminate disparities and rigorously test them. • Know our patients so we can better meet their needs and show communities that we deliver the best care possible to them. • Satisfy legal, regulatory and accreditation requirements (i.e.: JCAHO, CMS, etc.). • Take a national leadership position and show other health care organizations what is possible.

36. Cultural competence in the Health Administration curriculum

37. Cultural Competence in the Health Administration Curriculum • Assess cultural competence education in health administration curriculum. • Determine training characteristics that predict preparedness to manage care for diverse patients. • Provide evidence directly linking cultural competence training in health administration to improvements in health care quality.

38. Overview of proposed research activities • Survey cultural competence training in leading programs in health administration through review of syllabi for cultural competence content. • Interview core faculty of leading programs in health administration regarding the nature and extent of cultural competence training in their course, and their constructions of centrality of cultural competence.

39. Overview of proposed research activities • Interview/assess graduate students in their first year of training pre-exposure to cultural competence and in their final year of training post-exposure to cultural competence. • Interview alumni currently in the field re: relationship of cultural competence training to performance. • Interview internship and residency preceptors before and after cultural competence training.

40. Managing cross-cultural conflict (Among staff, between patients and providers) Responding to regulatory environment Community outreach Managing data collection Dealing with language barriers Dealing with new immigrants Dealing with patients whose religion affects treatment, whose health beliefs at odds with Western medicine, who distrust US health care, who use complementary and/or alternative medicine Assessment of managers’ cultural competence includes effectiveness and facility in the following areas

41. In Conclusion… • There is a link between quality, disparities and cultural competence. • There are practical, evidence-based strategies to advance this agenda. • Health administrators play a critical role in advancing this agenda.