The five papers released at the Fifth National Conference on Quality Health Care for Culturally Diverse Populations summarize the current body of evidence about three important and interrelated topics in contemporary health care: patient-centered care, cultural competence, and linguistic competence. As we read them, we confront three questions:
- What does it all mean?
- What should we do?
- What more do we need to know?
What we need is a model that incorporates the answers to all three questions—that, in effect, tells a story that can be easily remembered and acted upon.
There are two useful models that encompass patient-centered care, cultural competence, and linguistic competence. For clinicians, whose direct focus is the patient, the most easily remembered and actionable model is that of patient-centered care, which nests within it both cultural competence and linguistic competence (broadly defined to include health literacy). Patient-centered care is the overarching conceptual principle, while cultural and linguistic competence are methods for ensuring "patient-centeredness."
For the health care organization, health plan, community, and health care system as a whole, cultural and linguistic competence begin to take on more independent significance. Cultural and linguistic competence not only help create a supportive environment in which the treatment team can provide patient-centered care to each patient, but they also suggest appropriate applications to populations of patients—ranging from a hospital's inpatients and outpatients, to the community served by a health plan. At these broader levels, a model in which patient-centered care, cultural competence, and linguistic competence are overlapping yet still distinct concepts may be more actionable.
Both models begin with the same four goals for health care:
- Improved health outcomes for individuals and communities—effectiveness
- Improved safety for patients—safety
- Fewer unnecessary costs—efficiency
- Reduced racial and ethnic disparities in patient care, health outcomes, and satisfaction—equity.
These goals are not evidence-based. Rather, they express the values of individuals and society. The papers' authors describe the search to date for effective policies, practices, and behaviors that are intended to achieve these value-based goals.
So what are the challenges we face in developing these two models?
First, when we try to achieve multiple value-based goals simultaneously, it is often the case that actions taken to maximally achieve one goal may be different than—and sometimes conflict with—those actions that would maximally achieve another goal.
Second, the policies, practices, and behaviors suggested by the models are applicable at different levels in the health care system, from the societal level to the individual practitioner. The implemented policies, practices, and behaviors at one level can either facilitate or inhibit the desired policies, practices, and behaviors at another level.
Third, health care is composed of multiple complex, interacting, open systems. Actions in one system that achieve a desired goal in the context of certain behaviors of surrounding systems may no longer achieve that goal if those surrounding systems change. Because surrounding systems change over time, the effectiveness of a policy, practice, or behavior may also change over time. Further, changing one system can result in unanticipated effects not only on that system, but also on interacting systems.
Therefore, as we build and utilize these two models of patient-centered care, cultural competence, and linguistic competence, we should heed three cautions:
- Because various stakeholder groups may each place different priorities on shared values when those values conflict with each other, all stakeholders need to be included in designing the model. Evidence-based policies, practices, and behaviors will not be successfully implemented if they are designed to achieve value-based goals that are not owned by the stakeholders.
- Because the effectiveness of specific policies, practices, and behaviors may change over time, research funding needs to be available not only for seeking answers to new questions, but also for checking the continued validity of existing "answers."
- Because the institution of a new policy, practice, or behavior in a system can produce unpredicted, unintended, or undesirable outcomes either within that system or in surrounding systems, we must be vigilant for unpleasant surprises.
This set of papers is an excellent starting point for the development of memorable, actionable models for patient-centered, culturally competent, linguistically competent care. We have much more to do, and likely the work will never be done. But that's what it will take to build and maintain a health care system that achieves the goals we value.
Paul Schyve, M.D., is senior vice president of the Joint Commission on Accreditation of Healthcare Organizations.
The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.
