“cultural competency”: healthcare meeting the challenges of diverse societies “tools for...

““Cultural Competency”: Healthcare Cultural Competency”: Healthcare Meeting the Challenges of Meeting the Challenges of

Diverse SocietiesDiverse Societies“Tools for Change”“Tools for Change”

Young LeeDirector, HR/Training & Development

Coney Island HospitalNew York City Health & Hospitals Corporation

Brooklyn, NYEmail: [email protected]

““Best Wishes!”Best Wishes!”

Webinar Presentation GoalsWebinar Presentation Goals

1.1. Define cultural competence in context of healthcareDefine cultural competence in context of healthcare

2.2. Examine critical issues for developing cultural Examine critical issues for developing cultural competence in healthcare competence in healthcare

3.3. Provide Tools for Change: Developing “cultural Provide Tools for Change: Developing “cultural excellence”excellence”

4.4. Continuing cultural excellence: Moving forwardContinuing cultural excellence: Moving forward

““Cultural Competency”: Healthcare Meeting the Cultural Competency”: Healthcare Meeting the Challenges of Diverse SocietiesChallenges of Diverse Societies

1. Challenge Defined1. Challenge Defined

Cultural Diversity is a FactCultural Diversity is a Fact

The World has some 6,000 communities and as many The World has some 6,000 communities and as many

distinct languages.distinct languages.

Difference leads to diversity of vision, values, beliefs, Difference leads to diversity of vision, values, beliefs, practice and expression.practice and expression.

Each culture deserves equal respect and dignity.Each culture deserves equal respect and dignity.

-- Source: United Nations, 2007

Cultural Diversity is an Cultural Diversity is an Everyday RealityEveryday Reality

The international migration rate is growing faster The international migration rate is growing faster every yearevery year

We live in an increasingly heterogeneous societyWe live in an increasingly heterogeneous society


Reflecting the Respect of Reflecting the Respect of Fundamental RightsFundamental Rights

Culture is a set of distinctive spiritual, material, Culture is a set of distinctive spiritual, material, intellectual and emotional features of society or a social intellectual and emotional features of society or a social groupgroup

Respecting and safeguarding culture is a matter of Respecting and safeguarding culture is a matter of human rightshuman rights

Cultural diversity presupposes respect of all persons to Cultural diversity presupposes respect of all persons to participate in the cultural life of one's choiceparticipate in the cultural life of one's choice


Cultural Diversity is our Cultural Diversity is our Collective StrengthCollective Strength

Rich diversity Rich diversity ++ collective strength collective strength == Quality Quality Healthcare Healthcare

Cultural diversity is a natural fact that we need simply Cultural diversity is a natural fact that we need simply recognize and respectrecognize and respect

It is about plurality of knowledge, wisdom and energy It is about plurality of knowledge, wisdom and energy which all contribute to improving and moving the which all contribute to improving and moving the World forwardWorld forward


Best Patients Best Patients

“(If you) ask staff to describe patients or families they like and do not like, they usually like patients or families who are grateful or people from the same culture or who speak the same language, but beyond that the attributes of popular patients (and) families become pretty grim. The most popular patients never ring their call lights, never ask for help, never ask questions or challenge their nurses and doctors, and never, ever read medical books or use the internet for help. Their families are not present, and they do not have any friends. In fact, they are close to dead as possible.”

-- Source: Healthcare Quality Book, 2005


2. Critical Issues in 2. Critical Issues in

Cultural CompetencyCultural Competency

Why is Cultural Competence Gaining Importance?Why is Cultural Competence Gaining Importance?

Meeting the needs on an increasingly diverse societyMeeting the needs on an increasingly diverse society Reducing health disparities and improving health care qualityReducing health disparities and improving health care quality Tailoring health care delivery to meet population and individual Tailoring health care delivery to meet population and individual

needsneeds Meeting federal requirementsMeeting federal requirements Increasing treatment compliance, patient safety; and reducing Increasing treatment compliance, patient safety; and reducing

medical errormedical error Supporting organizational business strategies and objectivesSupporting organizational business strategies and objectives Growing accreditation interestGrowing accreditation interest

-- Dennis Andrulis, Drexel University, May, 2007

““Hospitals, Language and Culture: Hospitals, Language and Culture: A Snapshot of the Nation”A Snapshot of the Nation”

Exploring Cultural and Linguistic Services in the Nation’s Exploring Cultural and Linguistic Services in the Nation’s Hospitals - A Report of Findings: A Report of findings Hospitals - A Report of Findings: A Report of findings

from the Joint Commissionfrom the Joint CommissionMarch 29, 2007 March 29, 2007

http://www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf

– – The Joint Commission, 2007


Providing Culturally and Linguistically Appropriate Providing Culturally and Linguistically Appropriate Care is ChallengingCare is Challenging

Six research areas studiedSix research areas studied LeadershipLeadership Quality Improvement and Data useQuality Improvement and Data use WorkforceWorkforce Patient Safety and Provision of CarePatient Safety and Provision of Care Language ServicesLanguage Services Community EngagementCommunity Engagement


Coordinate services relating to language and culture as Coordinate services relating to language and culture as part of part of organization to quality.”part of part of organization to quality.”

Create uniform data collection mechanism related to Create uniform data collection mechanism related to providing quality care … Ethnic, linguistic, cultural …providing quality care … Ethnic, linguistic, cultural …



““Linguistically and culturally appropriate care has Linguistically and culturally appropriate care has direct impact on quality and safety, and is a growing direct impact on quality and safety, and is a growing issue that is not going away.”issue that is not going away.”

-- Paul M. Schyve, M.D.,

Senior Vice President, The Joint Commission

Linguistic CompetenceLinguistic Competence

Language/Interpretation services: an Language/Interpretation services: an important part of total important part of total communication;communication;

Medically Trained InterpretersMedically Trained Interpreters Clinical skills vs. Interpretation skillsClinical skills vs. Interpretation skills Telephonic translations, interpreter Telephonic translations, interpreter

services, literacy assistanceservices, literacy assistance ““Cultural LiaisonsCultural Liaisons” – M. Schlesinger” – M. Schlesinger Importance of varied approaches to Importance of varied approaches to

meet diverse needs.meet diverse needs.

Model for Developing Cultural CompetenceModel for Developing Cultural Competence

Change agents: public/privateChange agents: public/private Organizational culture, structural/systemic realities, Organizational culture, structural/systemic realities,

everyday interaction with diversityeveryday interaction with diversity Education, Modeling, Secret Shopper/Systemic Education, Modeling, Secret Shopper/Systemic

Behaviors, “Push-Pull” factorsBehaviors, “Push-Pull” factors Internal/external controls and buy-in from key Internal/external controls and buy-in from key

stakeholdersstakeholders

Increasing Cultural Competence Increasing Cultural Competence in Healthcarein Healthcare

Dearth of research and quantitative Dearth of research and quantitative data: cultural diversity awareness data: cultural diversity awareness research is in its infancy.research is in its infancy.

Need for research, best practice Need for research, best practice database, systemic maturity, patient-database, systemic maturity, patient-centered care, patient safety, etc.centered care, patient safety, etc.

Measuring Staff competence to deal Measuring Staff competence to deal with cultural diversitywith cultural diversity Example: The CMS H-CAHP Survey,

in USA

Commonwealth FundCommonwealth Fund

““Evidence to support that cultural and linguistic Evidence to support that cultural and linguistic competence would result in decreased system costs, is not competence would result in decreased system costs, is not currently in the literature.” currently in the literature.”

-- Source: Commonwealth Fund, 2006

Joint Commission: Joint Commission: Cultural Competence and CommunicationCultural Competence and Communication

Joint Commission, March, 2007

Institute of Medicine (IOM)Institute of Medicine (IOM)

““To Err is Human,To Err is Human,” IOM report 1999” IOM report 1999 48,000 to 98,000 preventable hospital patient 48,000 to 98,000 preventable hospital patient

deaths per year caused by medical errors.deaths per year caused by medical errors. 2007 Updated data – 100,000 preventable patient 2007 Updated data – 100,000 preventable patient

deaths from Medication Errors alone.deaths from Medication Errors alone. ““Ineffective Communication”: Top cause of all Ineffective Communication”: Top cause of all

errorserrors

-- Source: Institute Of Medicine, 2007

2007 Joint Commission: New Standards 2007 Joint Commission: New Standards “Crosswalk” on Cultural Competence“Crosswalk” on Cultural Competence

Rights Responsibilities and EthicsRights Responsibilities and Ethics Provision of Care, Treatment and ServicesProvision of Care, Treatment and Services LeadershipLeadership Management of Human ResourcesManagement of Human Resources Improving Organizational PerformanceImproving Organizational Performance Management of InformationManagement of Information

-- Source: Joint Commission, 2007

Joint Commission: Joint Commission: 2007 “Do Not Use” List2007 “Do Not Use” List

cccc IU IU qd qd QOD, q.o.d., qod, QOD, q.o.d., qod, andand

QD, q.d., qd QD, q.d., qd UU MSOMSO44, MgSO, MgSO44, MS, MS Abbreviations for Drug Abbreviations for Drug

NamesNames

> > oror < < Apothecary UnitsApothecary Units @@ Q6PM Q6PM X3DX3D No zero before decimal No zero before decimal

dose dose Zero after decimal doseZero after decimal dose µµgg

-- Source: Joint Commission, 2007

Que?????? – Health LiteracyQue?????? – Health Literacy

"Mr. Smith is 55 years old and was admitted for LUQ "Mr. Smith is 55 years old and was admitted for LUQ pain, which was also associated with maybe EG or CP. pain, which was also associated with maybe EG or CP. Possibly he may have ACS or LLL consolid but the only Possibly he may have ACS or LLL consolid but the only

thing against it is he has NVBS. We did a CE profile thing against it is he has NVBS. We did a CE profile which is negative, we may have to do a ABDCT. Put which is negative, we may have to do a ABDCT. Put

him on ampnafgent to cover for any GNB”him on ampnafgent to cover for any GNB”

-- Source: Coney Island Hospital, 2006

Cultural Competence & Health LiteracyCultural Competence & Health Literacy

Challenges that Broach Cultures Challenges that Broach Cultures Culture-Unique Health Literacy Challenges: Example: Culture-Unique Health Literacy Challenges: Example:

LGBT and Unique needs of patient populationsLGBT and Unique needs of patient populations Healthcare: Comfort within our own “culture of Healthcare: Comfort within our own “culture of

complexity” – Need to re-think our methodscomplexity” – Need to re-think our methods Health literacy & cultural competenceHealth literacy & cultural competence Engaging the Community: a Source of Information and Engaging the Community: a Source of Information and

Linkage Linkage

Health Literacy: “What Did The Doctor Say?”Health Literacy: “What Did The Doctor Say?”

““The safety of patients cannot be assured without The safety of patients cannot be assured without mitigating the negative effects of low health literacy mitigating the negative effects of low health literacy and ineffective communication on patient care.”and ineffective communication on patient care.”

Source: “What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety”

– Joint Commission 2007

2007 U.S. National 2007 U.S. National Cultural Competence StandardsCultural Competence Standards

U.S. National Cultural and Linguistically U.S. National Cultural and Linguistically Appropriate Services (CLAS) Standards Appropriate Services (CLAS) Standards

14 Key Standards in providing quality 14 Key Standards in providing quality carecare

Standardized manner in which to Provide Standardized manner in which to Provide Culturally Appropriate Healthcare Culturally Appropriate Healthcare ServicesServices

-- Source: U.S. Department of HHS, 2005


3. Meeting the Challenge3. Meeting the Challenge

Coney Island Hospital Coney Island Hospital NYC Health & Hospitals CorporationNYC Health & Hospitals Corporation

11 acute-care hospitals, 100 different languages spoken11 acute-care hospitals, 100 different languages spoken 400K uninsured accessed care, 5 million out-patient 400K uninsured accessed care, 5 million out-patient

visits per yearvisits per year TEMIS (U.N. Style translation system), on-site TEMIS (U.N. Style translation system), on-site

interpreters, impact of 9/11interpreters, impact of 9/11

-- Source: NYC Health & Hospitals Corporation, 2007

Building Culturally Competent OrganizationsBuilding Culturally Competent Organizations

View from Coney Island HospitalView from Coney Island Hospital

How adults learn – How adults learn – Literacy challengesLiteracy challenges

How organizations learn How organizations learn ““Cultural” challengesCultural” challenges

Teaching Healthcare Workers to be Culturally Teaching Healthcare Workers to be Culturally Competent and SensitiveCompetent and Sensitive

Reinforcement – Building a Culture of SafetyReinforcement – Building a Culture of Safety

Cultural Diversity and Sensitivity Training: Cultural Diversity and Sensitivity Training: Coney Island HospitalConey Island Hospital

Organization’s Patient Safety FocusOrganization’s Patient Safety Focus Leadership Support and ExigenceLeadership Support and Exigence All Employees & SystemsAll Employees & Systems Mandated In-Service Training Mandated In-Service Training New Employee Orientation ProgramNew Employee Orientation Program Evidence of training effectiveness: Patient Satisfaction Evidence of training effectiveness: Patient Satisfaction

Rates, Error Reduction RatesRates, Error Reduction Rates Department and Team Training Department and Team Training

““Good Good Great Great””

““Good to Great”: by Jim Collins and the Culture of Good to Great”: by Jim Collins and the Culture of ExcellenceExcellence

““Good” is the enemy of “Great”?Good” is the enemy of “Great”? Is “Cultural Competence” enemy of “Cultural Is “Cultural Competence” enemy of “Cultural

Excellence”? Excellence”? Are you “On” or “Off” the bus?Are you “On” or “Off” the bus?

-- Source: “Good to Great”, Jim Collins, 2005

““Good to GreatGood to Great”: ”: Jim CollinsJim Collins

Get on the Bus with Culturally Get on the Bus with Culturally CompetentCompetent//ExcellentExcellent Care Care for all Patientsfor all Patients


3. Tools for Change3. Tools for Change

““Conceptual Framework for Conceptual Framework for Cultural Excellence”Cultural Excellence”

Inter-connections in Cultural ExcellenceInter-connections in Cultural Excellence

Awareness of Awareness of Cultural Cultural

DiversityDiversity

Action/Action/Behaviors that Behaviors that

Reflect Reflect AwarenessAwareness

Teamwork and Teamwork and Customer Customer serviceservice

Medical/Medical/Healthcare Healthcare ExcellenceExcellence

Empathy & Empathy & SensitivitySensitivity

Critical Critical Awareness and Awareness and

Continued Continued AnalysisAnalysis

Culturally Culturally ExcellentExcellent

Healthcare Healthcare OrganizationOrganization


““Tools for Change”Tools for Change”

1.1. Cultural Excellence Assessment Profile ToolCultural Excellence Assessment Profile Tool

2.2. ““DiSC” Behavior Profile ToolDiSC” Behavior Profile Tool

3.3. ““Secret Shopper Tool”Secret Shopper Tool”

4.4. Patient & Community Involvement ToolPatient & Community Involvement Tool

Tool #1Tool #1

Cultural Excellence Cultural Excellence

Assessment ProfileAssessment Profile

Tool for assessing organizational valuesTool for assessing organizational values GovernanceGovernance Planning & MonitoringPlanning & Monitoring CommunicationCommunication Staff DevelopmentStaff Development Infrastructure & ServiceInfrastructure & Service

http://www.hrsa.gov/culturalcompetence/indicators/default.htm#components

-- Source: U.S. HHS – HRSA, 2007

Tool #2Tool #2

““DiSC DiSC ProfileProfile”” Tool for assessing and highlighting individual health Tool for assessing and highlighting individual health

worker behavior patternsworker behavior patterns LearningLearning from what we from what we dodo Strengths & WeaknessesStrengths & Weaknesses Strategies for Behavior ChangeStrategies for Behavior Change

-- Source: DiSC Profile Program, Carlson Company, 2004

Tool #3Tool #3

““Secret ShopperSecret Shopper”” Proactive uncovering of risk areasProactive uncovering of risk areas Highlights organizational culture and challengesHighlights organizational culture and challenges Identifies opportunities for systemic change and Identifies opportunities for systemic change and

tracking tracking Proactive involvement of cross-section of organizationProactive involvement of cross-section of organization

-- Source: Peak Performance Consulting, 2003 and Coney Island Hospital, 2007

Tool #4Tool #4

Patient & Community Involvement InitiativePatient & Community Involvement Initiative

Partnership Programs: Example: Coney Island Hospital Partnership Programs: Example: Coney Island Hospital & Shorefront YM-YWHA, Partner: Sue Fox& Shorefront YM-YWHA, Partner: Sue Fox

Interactive Learning Sessions – Learning from Interactive Learning Sessions – Learning from “Stories”“Stories”

Celebration of Diversity and LearningCelebration of Diversity and Learning Personalization of ChallengesPersonalization of Challenges


Trends in Trends in Cultural ExcellenceCultural Excellence

Need for more research Need for more research Need for measurable impact of cultural Need for measurable impact of cultural

competency interventionscompetency interventions Public health response to increasingly Public health response to increasingly

diversifying patient base: education & diversifying patient base: education & advocacyadvocacy

Changing competencies for healthcare Changing competencies for healthcare workers and organizationsworkers and organizations


4. Next Steps4. Next Steps

Cultural Excellence: What is Needed NowCultural Excellence: What is Needed Now

Role of AdvocacyRole of Advocacy Active Patient InvolvementActive Patient Involvement Developing hospital-based learning Developing hospital-based learning

modelsmodels Constant pursuit of Excellence in Constant pursuit of Excellence in

HealthcareHealthcare Exchange of ideas for creation of Exchange of ideas for creation of

“Best Practice“Best Practice Databases”Databases” and and “Resource Banks”“Resource Banks” for culturally for culturally excellent healthcare deliveryexcellent healthcare delivery

Action PlanAction Plan for Follow Up for Follow Up

Developing Developing Cultural ExcellenceCultural Excellence

Urgent need for researchUrgent need for research is is NotNot a call for a call for Non-ActionNon-Action No single “magic bullet” solutionNo single “magic bullet” solution Cultural excellence developed through myriad efforts Cultural excellence developed through myriad efforts

of many key stakeholdersof many key stakeholders Enough data to launch innovative projects across our Enough data to launch innovative projects across our

bordersborders Important ingredients: partnerships, humble service, Important ingredients: partnerships, humble service,

shared experiences, action based on knowledge, shared experiences, action based on knowledge, rewarded accomplishments, teamwork, managing rewarded accomplishments, teamwork, managing change, patient involvement and common groundchange, patient involvement and common ground

ConclusionsConclusions

1.1. Recognize complexity and “multifaceted-Recognize complexity and “multifaceted-ness” of challengesness” of challenges

2.2. Launch collaborations and partnerships to Launch collaborations and partnerships to build new tools and conduct new research build new tools and conduct new research for cultural excellencefor cultural excellence

3.3. Support non-parentalistic systems that Support non-parentalistic systems that fundamentally involve patients in their own fundamentally involve patients in their own carecare

4.4. Resources and action must follow new Resources and action must follow new knowledge for developing cultural knowledge for developing cultural excellenceexcellence

5.5. ““Be the Change”Be the Change”

THANK YOU!THANK YOU!

“cultural competency”: healthcare meeting the challenges of diverse societies “tools for...

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