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Workshop
C-6: Cultural competence training for health profesionals: How to reach
them and what difference it makes
Peer-topeer
practice advancement session
The goal of peer-to-peer practice advancement sessions is to allow professional
peers the opportunity to discuss, before an audience, issues of common
concern as a way of advancing the state of practice in their respective
fields. These two-hour sessions will have 5-7 featured experts who will
be led in a discussion of key issues related to the theme of the session.
Speakers will not make formal presentations, but instead provide critical
details of their programs to each other and to the audience in 2-page
handouts. During the session, each expert will concisely address specific
questions or topics developed and distributed in advance before engaging
in a moderated discussion with each other. The last half hour will be
reserved for audience Q&A.
This session will focus on mainstream and cutting edge approaches to
educating health professionals in practice about culturally and linguistically
appropriate health care, and the discussion will evolve from the following
stage-setting questions:
- What motivates health professionals to learn about culturally competent
health care?
- What are the barriers to teaching health professionals about culturally
competent health care? How can they be overcome?
- What are the essential elements of cultural competence training?
- How does one move beyond simply conveying facts to building skills
and changing attitudes?
- What elements of the workplace need to change to support the cultural
competence training, and the practice of culturally competent care by
health professionals?
- How do you measure the effectiveness of cultural competence training?
- How can some of these issues be addressed at the policy level—both
institutional and national?
The participants in this session are:
Joseph R. Betancourt, MD, MPH Senior Scientist,
Institute for Health Policy; Director of Multicultural Education, Massachusetts
General Hospital-Harvard Medical School (Boston, Massachusetts)
Diana Carr, MA Cultural and Linguistic Services,
Health Net of California (Pasadena, California)
Ann S. Kenny, MPH, RN Director, Center for
Healthcare Outreach and Management Support, Science Application International
Corporation (SAIC) (Falls Church, Virginia)
Robert C. Like, MD, MS Department of Family
Medicine, Robert W. Johnson Medical School (New Brunswick, New Jersey)
Guadalupe Pacheco, MSW Special Assistant.
to the Director, USDHHS Office of Minority Health (Rockville, Maryland)
Mary Walton, RN, MSN Nurse Manager, Department
of Nursing, The Children's Hospital of Philadelphia (Philadelphia, Pennsylvania)
Moderator: Ira SenGupta Executive Director,
Cross Cultural Health Care Program (Seattle, Washington)
Participant abstracts and bios can be found on the following pages.
Joseph R. Betancourt, MD, MPH, Senior Scientist,
Institute for Health Policy, Program Director for Multicultural Education,
Multicultural Affairs Office, Massachusetts General Hospital, Assistant
Professor of Medicine, Harvard Medical School, Boston, Massachusetts
Quality Interactions: A Patient-Based Approach to Cross-Cultural
Care© is an interactive, case-based e-learning program designed
to develop health care professional’s knowledge and skills to provide
quality care to culturally diverse patient populations. It was developed
by Joseph R. Betancourt, MD, MPH, Alexander R. Green, MD, and J. Emilio
Carrillo, MD, MPH, three physicians who founded Manhattan Cross-Cultural
Group and are nationally recognized experts in the field of cross-cultural
health care. The learning goals of the program are to:
- Understand how cultural competence is important to the delivery of
high quality patient care.
- Determine the social and cultural issues that are most relevant in
the care of diverse patient populations.
- Communicate effectively across cultures.
- Develop appropriate management strategies that take into account
patients’ cultural perspectives and preferences.
Quality Interactions allows users to move at their own pace,
at a time that is convenient for them. It presents three real-life patient
cases in an interactive format that allows users to develop skills as
they work through each case. This approach builds a framework to help
clinicians master how to integrate clinical information with cross-cultural
information from the individual patient to improve quality of care and
reduce disparities. Learners get the opportunity to interact with patients
by choosing questions and receiving responses along with learning points
about culturally competent care. They make hypotheses and decisions and
are able to link to evidence-based guidelines both for medical issues
such as hypertension management, as well as cross-cultural tools and skills.
Throughout this process the program presents cultural competence as an
integral part of high quality medical care rather than a separate or marginalized
issue. Evidence from the medical literature is used throughout to substantiate
the learning material, and abstracts are easily accessed for all references
cited. Personalized real-time feedback and a pre- and post-test verify
mastery of skills covered in the program. The program offers CME credit
for physicians and CEU credit for nurses and other health care professionals.
In sum, the key features of this approach are that it is:
- Rooted in the interface between social science and medicine: It practically
links medical anthropology, sociology, and evidence-based medicine into
a set of tools and skills that can practically be applied in the clinical
encounter.
- Framed in the medical inductive process: It presents real-life clinical
cases as “clinical challenges” for exploration, and speaks
the language of health care providers by asking them to consider differential
diagnoses, to apply a review of systems, and to use key tools and skills
to solve the case.
- Delivered using a problem-based, case-study method: Through the use
of clinical cases, the user interacts with patients and subsequently
“teachable moments” appear. The focus is on sentinel events
that activate the learner and link to evidence-based guidelines and
key facts that track to the findings and recommendations of the Institute
of Medicine’s Reports “Unequal Treatment” and “Crossing
the Quality Chasm.”
The e-learning format allows organizations to train large numbers of
clinicians without the costs and administrative challenges associated
with live trainings.
The inspiration for our approach stemmed from both the limitations of
current efforts in cross-cultural education, as well as the opportunities
that presented themselves using the e-learning format:
Current Limitations of Cross-Cultural Education:
- “Categorical” approach to cross-cultural training, in which
a set of unifying cultural beliefs and behaviors are taught about specific
groups, as opposed to a patient-centered approach focusing on tools
and skills
- Lecture-based teaching about key attitudes, knowledge and skills
as opposed to interactive, applied learning techniques for education
- Time and resource intensive nature of current modes of teaching, that
include expenditures on consultants and pulling health care providers
out of their practice to participate.
Benefits of E-Learning:
- Case-Based Approach: Teaches patient-based approach using real clinical
cases to highlight application of tools and skills in clinical practice
- Interactive: Activates the learner and uses “teachable moments”
to provide key facts and evidence-based guidelines, and provides individualized
feedback.
- Mindful of Time, Human, and Financial Resources: Allows users to
complete program 24/7, on their own terms, and at their own pace (can
come in and out of program over 2-hours). Research has shown that organizations
50-75% on training costs when using e-learning using this model.
Strengths and Innovative Characteristics of our Approach
- Teaches a patient-based, cross-cultural approach for providing high-quality
care to diverse populations. It is centered on the idea that patients
themselves are the best source of information about their cultural perspectives.
Utilizes the latest in problem-based learning educational theory, allowing
the user to actively engage in real clinical cases that are interactive
as well as instructive.
- Uses e-learning technology, which is time-flexible and allows the
user to move at their own pace—at a time that is convenient for
them—and provides personalized, real-time performance feedback.
- Was developed by clinicians for clinicians, focusing on the most
important aspects of the provider-patient interaction for use across
medical disciplines.
- Allows users to obtain continuing medical education (CME) credits
and continuing education units (CEU), and for organizations to track
the utilization and performance of their staff.
- Was created by nationally recognized experts with extensive experience
providing, researching, and teaching cross-cultural care. Together they
have accrued over forty years of combined experience in cross-cultural
care and education and have numerous peer-reviewed publications in the
field.
- Responds directly to the recommendations of the Institute of Medicine
Reports “Unequal Treatment” and “Crossing the Quality
Chasm” by focusing on quality of care, disparities, patient-centeredness,
equity, and the use of evidence-based practice guidelines (provided
as links in the program).
- Provides a framework to provide quality care to all patients in an
effective and time-efficient manner.
Limitations and Areas for Improvement
Cases currently designed for doctors and nurses and focus on issues
related to internal medicine, family practice, oncology, and surgery.
Plans underway to develop pediatric and obstetric cases, among others,
as well as cases for allied health professionals and administrators. Another
challenge was creating an internet-based course that was interactive but
easy to navigate. Through usability testing we were able to fine-tune
the functionality of the course so that it is accessible to even those
with little computer experience. We have also overcome the technical difficulties
of linking the program to the specifications of different organizations’
computer networks.
Lessons Learned
Feedback to date (of over 1500 users) has highlighted the following
issues:
- Organizations can train large numbers of individuals in a short
amount of time. One organization trained over 1000 people in less
than 3 months.
- Users learning from program. Average pre-test score has been
37%, while average post-test score has been 83%, indicating a 46-point
learning curve. Among those who have taken the course, 78% strongly
agree/agreed the program increased their understanding of cross-cultural
care and disparities; 77% strongly agree/agreed the program would improve
the patient care they delivered; and 77% would recommend the program
to others.
- Users feel cultural competence operationalized. Users state
they finally see the clinical applications of cultural competence, and
enjoy link between culturally competent care and evidence-based guidelines
as a vehicle to improve quality of care.
Dr. Betancourt’s primary interests include cross-cultural
medicine, minority recruitment into the health professions, and minority
health/health policy research. He has sat on the study committees of three
Institute of Medicine Reports over the last four years on issues related
to racial/ethnic disparities and healthcare workforce diversity. Dr. Betancourt
has written peer-reviewed articles on topics including racial/ethnic disparities
in health and health care; hypertension, diabetes, and cerebrovascular
disease in minority communities; cross-cultural care and education; ethics;
workforce diversity; clinical decisionmaking, and the impact of language
barriers on health care. He has served as Principal Investigator on grants
from the Center for Medicare and Medicaid Services and the Commonwealth
Fund, and is currently Principal Investigator on projects funded by the
California Endowment, the Commonwealth fund, in addition to being co-investigator
on a project funded by the National Cancer Institute and the Health Resources
and Services Administration.
Joseph R. Betancourt, MD, MPH
Senior Scientist, Institute for Health PolicyProgram
Director for Multicultural Education, Multicultural Affairs Office,
Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
50 Staniford Street, Suite 942 Boston, MA 02114
Phone: 617.724.9713 Fax: 617.724.4738
jbetancourt@pol.net
Diana M. Carr, MA Anthropology, Cultural and Linguistic
Specialist, Health Net of California, Inc., Pasadena, California
Under California’s managed health care program for Medicaid, health
plans have the responsibility of supplying their contracted providers
with culturally appropriate information about the health care practices
and beliefs of very diverse Medicaid beneficiaries. However, it has been
challenging for health plans to develop a format that attracts physicians.
When surveyed, physicians indicate that they would like more information
from the health plans that assists them in meeting the health care needs
of their patients. Traditional methods of delivering cultural information
to providers have included newsletter articles, speakers at CME events
and conferences. Monitoring surveys from members and physicians indicated
that traditional methods have not been successful and physicians do not
find them particularly useful. Health Net wanted to develop an innovative
approach to delivering cultural information that took into consideration
the needs of physicians and the desire of members. Health Net implemented
a pilot project in 2003 to build communication bridges with contracting
providers in the Los Angeles area. The goal of the pilot project was to
discover and test innovative ways of delivering cultural information in
an appealing format that would attract large groups of providers. The
presentation will outline the steps that were taken to develop and implement
the pilot project as well as some of the successes and drawbacks.
The pilot project was innovative in two ways. One, the health plan involved
the provider group in the entire creation of the project. The Provider
group was challenged to create a project that could deliver culturally
relevant information to its contracted physicians. Health Net offered
to fund it through a grant process. Two, Health Net selected proposals
from provider groups that encouraged the collaboration of the health plan,
provider group, local hospitals and local academic institutions. Grants
were funded through Health Net based on the provider group’s ability
to demonstrate the feasibility of their proposed project with in the proposal
budget. Health Net selected Global Care, Los Angeles provider group and
awarded a year long grant. Together, the provider group and the health
plan arranged educational luncheons for physicians. Each luncheon had
a dedicated clinical topic area and a corresponding cultural information
section. Local area hospitals hosted the luncheon which offered continuing
medical education credit and helped increase attendance. The local hospital
benefited by adding a cultural presentation to its schedule of clinical
presentations. The local academic institutions, health plans and health
agencies were asked to supply expert speakers for the luncheons. Each
presentation was centralized around a clinical topic. There was an authoritative
speaker for the clinical topic, followed by an expert on the cultural
aspects of the clinical topic. The provider group selected the clinical
topics for the presentation based on the needs of their patients in the
areas they operate. The topics selected included: at risk pregnancy, health
literacy, diabetes, HIV and STDs, Complementary and Alternative medicine,
cardiovascular disease, Civil Rights and interpreter services and end
of life decisions.
There were seven luncheons throughout the year. Each luncheon had an
average of 45 attendants with a total of 315 attendants by year’s
end. Outcomes were measured using a pre and post-presentation evaluation
for the clinical and cultural information. The evaluations indicated that
ninety percent found the information very useful. However, a couple of
interesting observations also indicate that the project was successfully
delivering cultural information to physicians. Even though the luncheons
took place in several different hospitals throughout the community there
was a set of physicians that attended each presentation. As the presentations
progressed throughout the year there was an increase in dialogue between
physicians and presenters. Additional requests from physician office’s
for information have continued in the following year.
Lessons learned include the importance of time management for the event.
Many physicians were able to attend the luncheon as the meeting location
was consistent with either morning or afternoon responsibilities at the
hospital. However, it was crucial that the food be served on time, that
the speakers kept to their schedules and the program began and ended on
time. One obstacle in particular remains: how to entice those physicians
that do not perceive the need for information on culturally responsive
care to attend as well? While the grant program has ended, there may be
other opportunities to continue this type of program. Attendants would
be invited to discuss modifications to the pilot project or alternative
suggestions to reach a wider spectrum of the physicians.
Diana Carr, MA, Health Net of California, Cultural and Linguistic
Services. Ms. Carr holds a Master of Art’s degree in anthropology
and is a candidate in the doctoral program at University of California,
Riverside. Ms. Carr is a medical anthropologist whose areas of specialization
are non-western health care, cognition and ethnopharmacology. Ms. Carr
has worked with under-served populations in Los Angeles focusing on migrant
populations and their health care needs. She has seven years of experience
teaching anthropology and culture at local universities. Ms. Carr also
has extensive background in anthropological linguistics, which includes
the cultural transmission of information through language and exploring
the processes involved in learning by various cultures. Ms. Carr has been
employed by Health Net of California as a Cultural and Linguistic Specialist
for four years. Her areas of responsibility include developing and delivering
cultural competency training programs that are used to educate internal
staff and health care providers, formulating programs or services to assure
compliance with regulatory requirements for cultural competency and assessing
the cultural aspects of health care needs for Health Net’s patient
populations.
Diana M. Carr,
MA Anthropology
Health Net of California
Cultural and Linguistic Services
1055 E. Colorado Blvd
Pasadena, CA 91106
Ph: 626 683 6307
Fax: 626 683 6324
Diana.m.carr@health.net
Ann S. Kenny, MPH, RN Director, Center for Healthcare
Outreach and Management Support, Science Application International Corporation
(SAIC), Falls Church, Virginia
Guadalupe Pacheco, B.A., M.S.W., Special Assistant to the Director
and Public Health Advisor, Office of Minority Health, U.S. Department
of Health and Human Services, Rockville, Maryland
In order to help achieve its mission of “improving the health of
racial and ethnic minority populations through the development of effective
health policies and programs that help to eliminate disparities in health”,
the Office of Minority Health (OMH), the Department of Health and Human
Services (DHHS), developed the Cultural Competency Curriculum Modules
(CCCMs). These modules, anchored in the principles and concepts of the
National Standards for Culturally and Linguistically Appropriate Services
(CLAS), were designed to effectively equip family physicians with cultural
and linguistic competencies. The CCCMs represent a comprehensive effort
to educate and train primary health providers in cultural competency using
the CLAS standards as a guiding framework.
The rigorous development process of the CCCMs included production of
an extensive environmental scan, oversight and review by a National Project
Advisory Committee comprised of experts in the field of medical education,
cultural competency, linguistics, and family medicine; comprehensive pilot
and field testing of the modules by diverse groups of family physicians
across the country; and accreditation of the CCCMs for 9 Continuing Medical
Education credits by both the American Academy of Family Physicians and
the American Medical Association.
During the development and testing of the modules we found that physicians
preferred to have the modules delivered in a variety of formats to accommodate
their technological capabilities and to allow flexibility with their work
schedules. They felt that their time would be more manageable if they
were able to have the modules accredited by theme, i.e., Culturally Competent
Care, Language Access Services, and Organization Supports, offering three
CME credits per theme. The physicians wanted links to resources and access
to valuable tools that would be available to them on an ongoing basis.
They also stressed the importance of having a mechanism to be able to
provide feedback to OMH about the CCCMs. They expressed a desire to be
able to interact with other physicians regarding the case studies and
to discuss their perceptions with other peers confidentially as part of
the self-awareness exercises via an online “chat room”. They
wanted access to a “Frequently Asked Questions” section of the
website where they could pose questions, view other questions asked, and
receive responsive answers to questions they may have. Physicians and
members of the advisory committee also felt that it would be essential
to develop a mechanism that would allow both the full-scale implementation
of the CCCM program and an outcomes assessment effort to determine what
knowledge and skills learned through the program are incorporated into
daily physician practice behaviors.
Based on the feedback received and lessons learned from the physician
focus groups, the CCCMs were redesigned to offer all of the capabilities
desired by physicians. The entire CCCM program exists in several versions
to easily meet the demands of busy practitioners. They have been produced
in a case study format, integrated with “Fast Facts” and a wealth
of information on key cultural and linguistic topics in a meaningful and
practical way. Current versions of the CCCMs include a PDF version, hard-copy
paper version, and as an interactive website with a digital versatile
disc (DVD) application. Together with the CME accreditation, providing
the CCCMs in these easy to use formats will increase their use by physicians
nationwide. With these goals and strategies in mind, the Office of Minority
Health plans to launch the CCCM CME program in 2004.
Ms. Kenny has over 26 years experience developing and conducting
innovative healthcare education and training programs for public, professional,
minority, high-risk and military populations. This includes over 17 years
of management and leadership experience, primarily in planning, developing,
implementing, resourcing, and evaluating population health, prevention,
and health promotion programs. Ms. Kenny currently serves as the Director,
Center for Outreach and Management Support, Civilian Health Services Division
with the Science Applications International Corporation. In previous positions
she managed three cultural competency research projects for the Office
of Minority Health, to include development of the Cultural Competency
Curriculum Modules for Physicians and Nurses and as Project Director for
the National Heart, Lung, and Blood Institute’s Health Information
Network project. Throughout her 21 years in the Department of Defense,
Ms. Kenny served in key positions in both the domestic and international
arenas, to include serving as Director of Strategic Planning, Office of
the Assistant Secretary of Defense, Health Affairs and as Senior Advisor
and manager for the Military Health System 2025 project. Ms. Kenny has
extensive experience in conducting public health seminars and presentations,
consensus-building sessions, and focus groups – particularly with
respect to culturally sensitive issues.
Mr. Pacheco serves as the Public Health Advisor and Special Assistant
to the Deputy Assistant Secretary for the Office of Minority Health, Department
of Health and Human Services. He has occupied numerous key positions in
State and Federal government agencies, as well as in numerous nonprofit
organizations. His work includes designing and implementing service delivery
programs for diverse populations, developing and executing annual budgets
exceeding $20 million, managing annual procurement activities ranging
from $25K to $11 million. In his current position, Mr. Pacheco is responsible
for managing multiple projects that address health disparities of racial
and ethnic minority communities. He coordinates cultural competency activities
through the Office of Minority Health’s Center for Linguistic and
Cultural Competence in Health Care. Additionally, he staffs and coordinates
Hispanic initiatives that serve to enhance service delivery to Hispanic
Americans. Mr. Pacheco serves in leadership roles on several Boards of
Directors and is heavily involved in minority initiatives and grants programs.
He has been a key leader in the field of cultural competency and diversity
and has championed the implementation of the National Standards for Culturally
and Linguistically Appropriate Services.
Guadalupe Pacheco, B.A., M.S.W.
Special Assistant to the Director and Public Health Advisor
Office of Minority Health
U.S. Department of Health and Human Services
1101 Wootten Parkway, Suite 600
Rockville, MD 20852
Phone: (301) 443-3379
Fax: (301) 594-0767
gpacheco@osophs.dhhs.gov
Ann Kenny, RN, B.S.N., M.P.H.
Director, Center for Outreach and Management Support
Civilian Health Services Division, SAIC
5107 Leesburg Pike, Suite 2200
Falls Church, VA 22041
Phone: (703) 575-4153
Fax: (703) 824-5879
kennya@saic.com
Robert C. Like, MD, MS, Department of Family Medicine,
Robert W. Johnson Medical School, New Brunswick, New Jersey
The Center for Healthy Families and Cultural Diversity (CHFCD) in the
Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School
(http://www2.umdnj.edu/fmedweb/chfdc/index.htm)
was established in 1997, and is dedicated to leadership, advocacy, and
excellence in promoting culturally-responsive, quality health care for
diverse populations. The CHFCD recognizes that persisting racial and ethnic
disparities in health and health care are major clinical, public health,
and societal problems. Our approach to developing cultural competency
involves a systems/ecological perspective, a focus on life-long professional
and personal learning, and collaboration with key stakeholders and constituency
groups.
CHFCD faculty and staff have provided multicultural education and training
to residents and medical and public health students at UMDNJ-Robert Wood
Johnson Medical School, as well as to numerous health care professionals
in the United States and abroad. Technical assistance/consultation has
also been provided to academic medical centers, hospitals, ambulatory
care facilities, managed care plans, community organizations, governmental
agencies, and medical communications and pharmaceutical companies. Topic
areas addressed include: clinical and organizational cultural competence;
participatory quality improvement; and cross-cultural health promotion
and disease prevention.
Selected examples of major cross-cultural training and research initiatives
the CHFCD has actively participated in include:
- Society of Teachers of Family Medicine's "Recommended Core Curriculum
Guidelines for Culturally Sensitive and Competent Health Care"
(http://www.stfm.org/corep.html)
- American Academy of Family Physicians/HRSA "Quality Care for
Diverse Populations" educational program
- American Institutes for Research/OMH "Cultural Competency Curriculum
Modules for Family Physicians" project (http://www.air.org/cccm/)
- Management Sciences for Health/HRSA "Provider’s Guide to
Quality and Culture" website (http://erc.msh.org/quality&culture)
- Institute for Healthcare Improvement/HRSA National Health Disparities
Collaboratives "Cultural Competence in the Clinical Care of Patients
with Diabetes and Cardiovascular Disease Curriculum"
- HRSA Centers of Excellence "Cultural Competence Assessment and
Curriculum Development project
- HRSA and OMH "Cross-Cultural Communication in Health Care: Building
Organizational Capacity” National Satellite Educational Broadcast
(www.hrsa.gov/financeMC/broadcast)
- California Endowment "Setting Standards in Cultural Skills Training
for Healthcare Professionals" project
- Georgetown University National Center for Cultural Competence, "Cultural
Competence Health Practitioner Assessment Instrument"
- UMDNJ/Robert Wood Johnson Medical School (RWJMS) Four National Conferences
on Culturally Competent Care (http://www2.umdnj.edu/fmedweb/chfcd/chfcd_conferences.htm)
- UMDNJ Continuing Medical Education Multicultural Education Programs
- "REACH: Realizing Equity Across Cultures in Healthcare"
and "Building Cultural Competency in Clinical Practice" (Eden
Communications/Pfizer)
- Bildner Family Foundation New Jersey Campus Diversity Initiative
- "Developing Cultural Competency at UMDNJ"
- Northeast Consortium on Cross Cultural Medical Cultural Medical Education
and Practice
- American Journal of Multicultural Medicine Series (Liberty Communications
Network/Cardinal Health)
- Aetna Foundation-funded research project, "Assessing the Impact
of Cultural Competency Training Using Participatory Quality Improvement
Methods"
- European Union’s Migrant–Friendly Hospitals Initiative
to Promote the Health and Health Literacy of Migrants and Ethnic Minorities
(www.mfh-eu.net).
Consistent with the principles of adult learning theory and critical
pedagogy, the CHFCD believes that it is important for learners to: 1)
be active participants in their education; 2) engage in iterative reflection,
questioning, and praxis (i.e., "critical consciousness raising");
and 3) become life-long, self-directed learners, advocates, and social
change agents. We make use of a variety of educational strategies/methods
during cultural competency and diversity-related seminars, workshops,
and courses. These include didactic lectures, videos, case-based learning,
experiential exercises, role plays, simulations, and interactive question
and answer sessions. We particularly value interdisciplinary team teaching
using participatory learning approaches. The CHFCD has disseminated information
through publications, websites, videos, CDs, and e-learning, and more
than 300 presentations have been given on the subject of culturally and
linguistically appropriate health care.
There is a great deal of important "factual information"
that health professionals need to learn about racial and ethnic disparities
in health and health care, the historical and contemporary experiences
of minority and multicultural populations with the health care system,
the legacy of racism and other forms of discrimination in medicine and
public health, the human genome project and diversity issues in population
genetics, ethnopharmacology, evidence-based multicultural medicine, the
Office of Minority Health's National Standards for Culturally and Linguistically
Appropriate Service (CLAS) in Health Care, etc. On the other hand, presenting
"lists of facts" about health beliefs and behaviors in
different ethnic and sociocultural groups unfortunately can generate inappropriate
(and potentially dangerous) stereotypes and overgeneralizations that result
in a lack of individualization and tailoring of services provided in clinical
settings.
We have found instead that the use of narratives, stories, case examples,
simulations, and other experiential exercises can be very helpful in "building
skills and changing attitudes." Facilitated self- and group-reflection,
authentic communication, and the development of trust in a safe and respectful
environment are of critical importance. We need to avoid "essentializing"
and "pathologizing" culture, recognize that "every encounter
is a cross-cultural encounter," understand that "diversity within
groups is often greater than between groups," and value the "strengths,
assets, and resources" that exist in all populations. Interviewing
mnemonics that we have developed including ETHNIC, BATHE, ADHERE, and
TRANSLATE can help clinicians provide more patient-centered, family-focused,
and community-oriented care. The archetypal and universal aspects of health,
illness, suffering, transformation, and the human experience are extremely
important to emphasize during training.
In our recently completed Aetna Foundation-funded research project,
"Assessing the Impact of Cultural Competency Training Using Participatory
Quality Improvement Methods," we addressed the following questions:
1) What are the views and perspectives of physicians, staff, and patients
on addressing the Office of Minority Health's National Standards for Culturally
and Linguistically Appropriate Services (CLAS) in Health Care in a family
practice setting? 2) Does a cultural competency training program result
in improved physician knowledge, skills, attitudes, and comfort levels
relating to the care of patients from diverse backgrounds?; 3)What impact
does patient request fulfillment have on patient satisfaction with cross-cultural
clinical encounters?; and 4) How were participatory quality improvement
activities and methods utilized to address the care of patients from diverse
backgrounds? Qualitative and quantitative methods were utilized in four
corresponding substudies to develop a richer and deeper understanding
of how cultural competence can be effectively incorporated into organizational
and clinical practice. We made use of a newly developed Clinical Cultural
Competency Questionnaire (CCCQ) and found statistically significant
pre- and post-test improvements in faculty physicians' (N = 15) self-assessments
for 7 of the 16 knowledge items, 8 of the 15 skills items, and 4 of the
12 comfort items. Although these results are interesting, it is unclear,
if the positive changes can be directly attributed to the training intervention
given the lack of a control group and the influence of other organizational
and environmental factors. Data analysis and further interpretation is
ongoing. The CCCQ has been translated into six languages and a modified
version is currently being used by eight participating pilot hospitals
in the European Union's Migrant Friendly Hospitals Initiative.
Our experience has been that practicing clinicians become interested
in learning more about cultural competence if it helps them to communicate
more effectively with patients, provide better care, reduce errors, and
increase satisfaction. When a business and legal case can be made, so
much the better. For public health practitioners, their interests tend
to be more population-oriented, and the role of cultural competence in
helping to close the gap in disparities in health and health care, increasing
access and service utilization, and improving quality, patient safety,
and outcomes needs to be emphasized. It is also important to “respect
and work with resistance,” and understand its root causes and functions.
Sometimes "resisters" can become future "champions."
As our work continues, the following meditations may be helpful to revisit
periodically:
- “Statistics are people with the tears wiped off” (Kerr
White)
- “We need to comfort the afflicted and afflict the comfortable”
(Eleanor Roosevelt)
- “Sometimes it’s easier to change the world than to change
oneself" (Rabbi Yakov Hilsenrath)
Robert C. Like (M.D., '79, Harvard; M.S., '84, Case Western Reserve)
is a practicing family physician with a background in medical anthropology
who is nationally known for his work in the area of cultural competence
and health professions education. Dr. Like has served as co-chair of the
Society of Teachers of Family Medicine's Group on Multicultural Health
Care and Education, and as a member of the DHHS Office of Minority Health's
CLAS Standards National Project Advisory Committee. He was principal investigator
on an Aetna Foundation-funded study entitled, "Assessing the Impact
of Cultural Competency Training Using Participatory Quality Improvement
Methods," and is consulting to the European Union’s Migrant
Friendly Hospitals initiative. Dr. Like is a 2004 Pfizer/American Academy
of Family Physicians Foundation Visiting Professor in Family Medicine,
and is actively involved in providing training and technical assistance
relating to the delivery of culturally responsive, patient-centered care
to diverse populations.
Robert C. Like, M.D., M.S.
Associate Professor and Director
Center for Healthy Families and Cultural Diversity
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
1 Robert Wood Johnson Place
New Brunswick, N.J. 08904
phone: 732-235-7662
fax: 732-246-8084
like@umdnj.edu
http://www2.umdnj.edu/fmedweb/chfcd/index.htm
Mary K. Walton, MSN, RN, Nurse Manager, Department
of Nursing, The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
The Children’s Hospital of Philadelphia is a comprehensive pediatric
healthcare network with facilities throughout the tri-state region of
Pennsylvania, New Jersey and Delaware. Our resources are committed to
providing exceptional patient care, training new generations of pediatric
healthcare providers and pioneering major research initiatives. The Children's
Hospital of Philadelphia, the oldest hospital in the United States dedicated
exclusively to pediatrics, strives to be the world leader in the advancement
of healthcare for children by integrating excellent patient care, innovative
research and quality professional education into all of its programs.
In 2001 a Cultural Competency initiative was launched as an outgrowth
of our commitment to Family-Centered Care under the auspices of the hospital
Diversity Council. The first element of this initiative was a presentation
given to ninety administrative and clinical leaders titled “Cultural
Competency in Caring for Patients and Families” by noted expert Josepha
Campinha-Bacote PhD, RN. This experience prompted administrators to form
a Cultural Competency Task Force with four objectives:
- Conduct an inventory of educational offerings related to cultural
competence for caregivers & support staff.
- Summarize National Models in academic healthcare settings for systematically
educating caregivers & support staff in the area of culturally competence
and cultural effectiveness.
- Recommend a comprehensive approach to education of caregivers and
support staff.
- Recommend a measurement methodology to document and track effectiveness.
The Strategic Objectives recommended as a result of the Task Force work
included:
- Every family seeking or receiving services will be able to receive
information about their child’s condition in their preferred language
and participate in decision-making about the plan of care.
- Every employee will be knowledgeable about cultural differences among
the patients and families and have the knowledge and skills to meet
patient and family needs depending on their area of responsibility.
- Systems and structures will be in place to facilitate an institutional
framework for cultural competency – including job descriptions,
performance expectations, and outcomes measurement.
- The organization will be positioned and known as a culturally proficient
institution with programs and services that meet the needs of a multicultural
U.S. and international population of patients.
The Cultural Competence Task Force Report recommended an educational
approach based on the Center for the Health Professions, University of
California, San Francisco curriculum, Toward Culturally Competent Care:
A Toolbox for Teaching Communication Strategies.
In 2002 an interdisciplinary in-house planning team developed the operational
plan providing a detailed breakdown of tasks and activities recommended
to Senior Leadership to be addressed in a formalized project. A sample
of the areas of focus in driving the project to completion include:
- Enhancing interpreter and translation services - e.g., working
with Social Work, Patient-Family Education, and Family Faculty to improve
use of interpreters and translated materials. Working with Facilities
to improve signage and Patient Access to enhance Registration.
- Providing culturally competent care – e.g., working with
Nutrition Services and the Chaplaincy to address improvements to provision
of dietary and religious services. Working with all parties who provide
education to drive access to and education of clinical and non-clinical
personnel.
- Organizational supports – e.g., working with Diversity
Council, Senior Leadership and others to determine assessment indicators
and a methodology to monitor progress in this area over time. Involvement
in tasks related to enhancing diversity of the workforce in collaboration
with the Human Resource department.
A Director position for the now named Cultural Effectiveness Initiative
was created in 2003. A physician leader was appointed with a 70% time
commitment over a two-year period. Key initiatives in progress for 2004-2005
include:
- Communication Campaign
- Expansion of Language Access Services
- Implementation of new signage and improved way finding
- Definition and implementation of new processes to secure dietary
requests for any culture
- Assessment and implementation of new resources to accommodate a broader
representation of spiritual preferences
- Provision of Cultural Effectiveness training to all clinical and
non-clinical staff: establish education work group; secure UCSF resources
to provide on-site training; roll out training to prioritized staff
groups.
- Expansion of numbers of diverse employees and physicians in workforce
- Refine data collection processes
- Assessment, maintenance and strengthening of current community partnerships,
perform demographic profile, implement family focus groups to assess
needs re future partnerships.
Department of Nursing Cultural Competence Program 2002-2004
As an outgrowth of the 2001 organizational task force, the Department
of Nursing launched a Cultural Competence program including assessment
and education. Led by a workgroup of advanced practice nurses , key elements
include:
- Baseline assessment of nursing leadership: Campinha-Bacote’s
Inventory for Assessing the Process of Cultural Competence Among Healthcare
Providers (IAPCC).
- Chart Audit of patients identified as having challenging cultural
needs.
- Administrative and clinical staff submission of clinical scenarios
identifying both effective and needed resources to meet patient/family
needs.
- Cultural Competence education
- Leadership program: Directors, Nurse Managers, and Staff Leaders.
- Orientation program for all newly hired nurses.
- Annual educational requirements for all nursing staff including communicating
effectively through medical interpreters.
- Ongoing staff development programs using literature, movies, training
simulations; focus on staff-identified cultural competency needs.
- Nursing Grand Rounds presentations with national leaders.
- Establishment of standard to integrate “culture” into all
department educational efforts.
What inspired your approach to cultural competence training?
- Ethics Committee clinical consultation work. Experience working with
families and staff during difficult decision points along the continuum
of care. Conflicts with treatment options and end of life care illustrated
the culture clash that occurs between well meaning caregivers and loving
families.
- UCSF Center for Health Professions program: Health and Illness:
Communicating Across Cultural Differences. (August 2001). I found
the faculty and program truly inspirational.
- Presentations by experts at national meetings. Participation in conferences
and programs. Opportunities to discuss and shape ideas and approaches
with colleagues.
- Anne Fadiman book: The Spirit Catches You and You Fall Down
- Review of the literature on health disparities.
- Staff recognition of cultural needs and desire to meet those needs
when organizational resources were not available.
What are the strengths and innovative characteristics of your approach?
- Identification of champions to plan creative educational programs
with goal of changing attitudes, building communication skills and learning
organizational resources and systems to meet family needs.
- Incorporation of CLAS Standards, IOM Reports, pediatric literature,
staff/family identified needs into educational programs.
- Adaptation of UCSF curriculum.
- Collaboration with other departments in developing and expanding
resources.
What are the limitations? What would you improve?
- Department of Nursing approach was in advance of some organization
change. Thus nurses were requesting services that were not completely
in place. Interdisciplinary work is now ongoing with organization wide
efforts.
Lessons learned
- Connect work to quality of patient care/patient outcomes and satisfaction
of the health care provider.
“Understanding a patient’s cultures and beliefs not
only helps physicians resolve purely medical complaints; cultural
competence brings solace and sustenance-for the provider as well
as the patient. …By leaving behind preconceived notions and
opening our minds to other sets of values and beliefs, we embark
on a voyage of spiritual discovery of our fellow human beings. It
is a voyage that can mature us and strengthens for the rest of our
lives.” Miguel Angel Corzo
Ms. Walton received a Bachelor of Science in Nursing and a Master
of Science in Nursing of Children from the University of Pennsylvania.
During her career at the Children’s Hospital of Philadelphia, she
has held a variety of clinical and leadership positions. Her Clinical
Nurse Specialist years working with children with chronic lung disease
offered the opportunity to learn about a variety of family health belief
systems. Clinical ethics consultation work as a hospital Ethics Committee
member, highlighted the critical importance of meeting the cultural and
spiritual needs of families with acutely ill children. Participation in
The University of California, Center for Health Professionals, cultural
competency programs provided the foundation for her approach to Cultural
Competence education. She co-chaired the organizational cultural competence
task force and led the Department of Nursing efforts. Currently she leads
the education planning for the organization-wide Cultural Effectiveness
Initiative and co-chairs the hospital Ethics Committee. Her research interest
in the history of pediatric nursing also informs her knowledge in the
area of cultural care.
Mary Walton, MSN, RN, Nurse Manager,
Department of Nursing,
The Children’s Hospital of Philadelphia
3535 Market Street, Room 1427,
Philadelphia, PA. 19104,
Phone: 215-590-2505
waltonm@email.chop.edu
www.chop.edu
Facilitator:
Ira SenGupta Executive Director, Cross Cultural Health Care Program,
Seattle, Washington
Ira SenGupta, Cross Cultural Health Care Program’s Executive
Director and past Director of Cultural Competency Programs, has developed
and conducted over 2,600 hours of trainings nationally and eight train
the trainer courses in cross cultural issues for health and social service
providers in the past year alone. She conducts major cultural competency
institutional assessments and serves as a consultant for the HRSA Managed
Care Technical Assistance Center. She has led community-based research
projects and is the principal investigator for a national study of best
practices for the CLAS (Culturally and Linguistically Appropriate Services)
standards for the Department of Health and Human Services (HHS) Office
of Minority Health. She has also served on the National Committee for
Cultural Competence and the Committee for the Development of Cultural
Competence Curriculum and Training Modules for Primary Care Physicians.
She is currently serving on the NIH/NCI Cultural Competency in Cancer
Centers National Advisory Council.
Ira SenGupta,
Executive Director
Cross Cultural Health Care Program
270 South Hanford St., Suite 100
Seattle, WA 98134
Phone: 206-860-0329
Fax: 206-860-0334
iras@xculture.org
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