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Pre-publication draft - not for reproduction
Establishing the Importance of
Cultural Competence in Health Care Quality Improvement:
A report for the Agency for Healthcare
Research and Quality
on the significance of current activity, the development of a
conceptual framework, and an agenda for future work
Julia Puebla Fortier
Resources for Cross Cultural Health Care &
SUNY Downstate Medical Center
TABLE OF CONTENTS
Acknowledgements
Executive
Summary
Glossary
I. Introduction
II. Defining quality and cultural competence, and conceptualising
a link between the two
III. Bringing together quality and cultural competence: Elaborating
the conceptual framework and trends in current activities
- Patient centeredness
- Safety
- Timeliness
- Effectiveness
- Cross Cutting
IV. Analysis of current trends and challenges
V. Next steps
Appendices
- Quality and Cultural Competence Matrix
- Abstracts of quality and cultural competence activities by stakeholders
- Project and meeting materials
EXECUTIVE SUMMARY
In the past decade, health care providers, policymakers, and consumer
groups have paid increasing attention to raising the overall quality of
health care in the United States, and improving the care and health status
of racially and ethnically diverse communities. Yet these efforts have
not always been well connected. Observers have commented that the “cultural
competence movement and that quality movement have both much to learn
from each other and much to offer each other in terms of power and support.”
In this context, a group of key stakeholders have begun to look more closely
at the connections between specific cultural and linguistic competence
interventions and broader efforts to improve health care quality.
The Agency for Healthcare Quality and Research (AHRQ) commissioned Resources
for Cross Cultural Health and SUNY Downstate Medical Center to convene
a meeting of key stakeholders—providers, policymakers, funders, and
experts on quality and cultural competence. The objective was to discuss
issues related to the link between quality and cultural competence and,
from this discussion, to develop:
- A framework that defines the link between cultural competence and
the key elements of health care quality improvement
- Documentation and analysis of recent and ongoing efforts in this area
- A preliminary agenda for future work in this area
Framework
To visualize the relationship between quality and cultural competence,
and bring structure to the analysis of the activities reported by stakeholders
in this nexus, we developed a matrix of the specific and operational aspects
of quality and cultural competence. Based on seminal work by the Institutes
of Medicine and the US Department of Health and Human Services, the key
domains discussed in the paper include the following dimensions of quality
and cultural competence:
Quality:
- Patient centeredness
- Safety
- Timeliness
- Effectiveness
Cross-cutting:
- Cultural Competence:
- Culturally Sensitive Interventions
- Language Assistance
- Organizational Supports for Cultural Competence
Current Activity
Stakeholders reported a surprising quantity and variety of activities
that combine elements of quality and cultural competence. These activities
are analyzed and incorporated into the framework. Looking at quality through
the lens of cultural competence yielded some important insights on how
pursuing cultural competence might enhance quality improvement for diverse
populations:
Patient centeredness:
- Address communication barriers caused by limited English proficiency
and low literacy
- Increase the diversity of the health workforce
- Develop survey tools that address cultural and linguistic concerns
- Implement programs that involve patients and communities in the service
delivery and evaluation of health care organizations
Safety:
- Adapt institutional initiatives on informed consent, medication compliance,
adverse events and other safety concerns to address cultural, linguistic,
and low literacy issues.
Timeliness:
- Investigate and address access barriers for specific ethnic communities
- Implement patient navigator/cultural case manager and other support
systems for ethnic populations
- Improve the efficiency and responsiveness of interpreter programs
in health care institutions
Effectiveness:
- Support and disseminate the results of research on effective strategies
to improve health outcomes for ethnic populations
- Use institutional data to target health interventions for specific
populations
Cross Cutting:
- Race/ethnicity/language data collection, language assistance programs,
cultural competence training, and the use of cultural intermediaries
all have relevance across several domains of quality
- National health organizations and Federal agencies such as JCAHO,
NCQA, NQF, AMA, and CMS should widely disseminate the findings of current
initiatives to address cultural and linguistic issues in their quality
improvement programs
From the analysis of the stakeholder issues and discussion at the meeting,
we proceed to investigate the challenges facing the nexus of cultural
competence and quality. The report identifies conceptual challenges (including
cultural competence, and quality, outcomes, disparity reduction) and practical
challenges that include clinical setting, organizational, and system,
policy, research characteristics. These challenges are, in turn, cast
as opportunities to make all stakeholders aware of and comfortable with
seeing cultural competence as an integral part of quality.
Agenda for Future Work
The report concludes with recommendations for action. These include:
- Actions that should undertaken by key stakeholder organizations, both
those who participated in the meeting and other organizations focused
on health care
- Continuing and broadening participation in the dialogue about the
link between quality and cultural competence
- Strengthening the cultural competence field through research, measurement,
evaluation, implementation, and dissemination
- Strengthening and articulating the case for integrating quality and
cultural competence
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