October 1, 2006
Ellen Wu, Martin Martinez
E. Wu and M. Martinez, Taking Cultural Competency from Theory to Action, The Commonwealth Fund, October 2006
In the past 10 years, there has been a profusion of research in the field of cultural and linguistic competency, particularly on the capability of language services to improve the quality of patient care. However, while much work has focused on defining cultural competency, there has been considerably less on taking cultural competency from theory to action. This paper provides principles and recommendations for implementing cultural competency in the field. The following six key principles—discussed at length in this report—are key to a successful cultural competency effort:
- Community representation and feedback is essential at all stages of implementation.
- Cultural competency must be integrated into all existing systems of a health care organization, particularly quality improvement efforts.
- Changes made should be manageable, measurable, and sustainable.
- Making the business case for undertaking cultural competency initiatives is critical for long-term sustainability.
- Commitment from leadership is a key factor to success.
- Ongoing staff training is crucial.
The authors developed these principles based on their close ties with communities of color, their experience advocating for cultural and linguistic requirements, and an analysis of existing best-practice standards. Through interviews with key leaders in the field of cultural competency, they developed case studies based on specific practices and lessons learned from implementation of cultural competency initiatives.
Highlights from these case studies include:
- A project conducted by the National Initiative for Children's Healthcare Quality sought to integrate quality improvement and cultural competency in clinics. Participating providers found that providing trained interpreters—even by telephone—resulted in better communication, more appropriate diagnosis, and a deeper understanding of patient needs. Staff exposure to different cultures increased comfort in dealing with diversity and the use of more effective treatment plans. In addition, capturing data about race and ethnicity enabled programs to examine and address gaps in practice.
- At L.A. Care Health Plan, a non-profit, community health maintenance organization in Los Angeles, data from an employee survey—which found employees with more direct member contact were less satisfied and more pessimistic—was used to identify the need for cultural competency training and obtain commitment and resources for their implementation and evaluation.
- With the advent of new, committed leadership, Children's Hospitals and Clinics of Minnesota created a department for interpreter services. In addition to providing translation services, the hospital began using interpreters as cultural mediators, a change that addresses cultural competency in addition to language access. The new processes are well-integrated into the system—and well received by patients and the community—and therefore protected against potential changes in leadership.
- At Woodhull Medical and Mental Health Center, in Brooklyn, N.Y., the leadership sought to make large-scale, sweeping changes. Cultural competency is incorporated into the organization's mission, framed as a patient safety and customer service issue. Woodhull asks all patients what their language preferences are and whether they require an interpreter. The facility uses staff interpreters, with a telephone language line vendor as backup. In addition, cultural competency training is incorporated into the corporate-wide, five-day orientation for new hires.
- LEADing Organizational Change: Advancing Quality through Culturally Responsive Care (LEAD)—a three-year initiative to enhance the quality of care among California's public hospitals—illustrates the range of experiences of provider organizations in improving cultural competency. As the authors found, hospitals and other providers must carefully manage the size of changes they seek to implement; measure the effect of those changes; and frame cultural competency as a quality-of-care issue.
The authors believe that only by addressing the aforementioned principles can health care organizations—as well as the health care system as a whole—become more culturally competent and ensure the delivery of quality health care to diverse communities. In transforming theory into practice, they recommend that organizations:
- Seek out leaders of community groups to solicit their concerns and recommendations.
- Make cultural competency a component of disease management, quality improvement, patient safety, customer service, and patient–provider interaction.
- Consider how they will evaluate and quantify the positive impact of their cultural competency efforts.
- Explore the business case for implementing cultural competency initiatives, considering the social benefits of providing culturally competent care, improved market share, and decreased liability.
- Recruit a racially and ethnically diverse workforce and leadership that are committed to equality in health care.
- Support staff trainings by dedicating time and resources to implementation and ensuring that regular scheduling is part of formal policy.